[
  {
    "id": "multiclinsum_gs_en_27.txt",
    "fulltext": "A 20-year-old woman was followed up since the age of eight for idiopathic NS inaugurated by cerebral venous thrombosis extended to the right jugular vein with a massive pulmonary embolism. The patient did not have any sequelae. She had no other medical or surgical history. A family history of thrombosis has not been reported. The patient was not biopsied because she had no kidney failure nor gross hematuria, or hypertension at first presentation; added to that, she had no extra renal signs suggestive of a secondary nephrotic syndrome. She was accordingly put on anticoagulant therapy (Oral vitamin K antagonist) and oral corticosteroid therapy with good evolution. Thereafter, the patient received several cures of high-dose corticosteroids for steroid-dependent relapses of NS. She was, hence, put on mycophenolate mofetil (MMF) as a background therapy to avoid corticosteroids and ensure normal growth. An exhaustive assessment of thrombophilia was performed and did not show any abnormality. Homocysteine rate, blood fibrinogen rate, Protein C, protein S, antithrombin III, factor V Leiden mutation, JAK-2 mutation, cryoglobulins, anticardiolipin antibodies, lupus anticoagulant and beta-1-glycoprotein antibodies were normal. The anticoagulant treatment was stopped after nine years. The evolution was enameled by the occurrence of several relapses of her disease controlled by oral corticosteroid therapy. Remission of NS has been noted since 2017, so MMF was gradually stopped in 2019 and the patient remained asymptomatic and without any relapse.\n\nOne year later, the patient came up to our emergency department for acute intense diffuse abdominal pain without any particular irradiation associated with postprandial vomiting and bilateral lower limb edema for the last six hours. The physical examination revealed an intense epigastric tenderness with normal vital signs (arterial pressure of 120/70 mm Hg, heart rate of 83 bpm, and oxygen saturation at 100% on room air). The patient was afebrile with normal consciousness. The rest of the physical examination was unremarkable. The urinalysis with labstix revealed proteinuria. The hemogasanalysis results showed metabolic acidosis with respiratory compensation. Further laboratory tests revealed hypoalbuminemia, hypercholesterolemia, a prothrombin time at 90%, high levels of D-dimer, lactate dehydrogenase, and creatine phosphokinase as well as a biological inflammatory syndrome with a CRP of 37 mg/L, and leucocytosis at 26.4 x 103/µL. Renal and liver functions were normal.\n\nThe patient was hospitalized in an intensive care unit with close monitoring of vital signs and initiation of resuscitation measures. An abdominal ultrasound was performed urgently showing an intra-abdominal effusion of low to moderate abundance. An abdominal CT scan revealed acute thrombosis of the superior mesenteric artery with acute mesenteric ischemia. The patient was immediately routed to the operating room. Intraoperative exploration confirmed mesenteric ischemia with extensive necrosis of almost entirely of the small bowel making their resections incompatible with life shown in Figure 3. The patient died after 48 hours.",
    "summary": "We present the case of a 20-year-old woman with a 12-year history of idiopathic NS revealed by extensive cerebral venous thrombosis with pulmonary embolism treated with anticoagulation therapy and oral corticosteroid therapy followed by mycophenolate mofetil (MMF). The thrombophilia assessment did not show any abnormalities. The evolution was marked by the occurrence of several NS relapses controlled by oral corticosteroid therapy until 2017. Subsequently, the patient had not presented a relapse of her disease. The anticoagulant treatment and the MMF were therefore stopped. One year later, the patient presented with severe diffuse acute abdominal pain associated with postprandial vomiting and bilateral lower limb edema. Laboratory results confirmed a NS relapse. An abdominal CT scan revealed acute thrombosis of the superior mesenteric artery with acute mesenteric ischemia. Intraoperative exploration showed mesenteric ischemia with extensive necrosis of the small intestine making their resections incompatible with life. The patient died after 48 hours."
  },
  {
    "id": "multiclinsum_gs_en_523.txt",
    "fulltext": "We present the case of a 34-year-old woman, eight weeks pregnant with no other personal history of interest, who presents to the emergency department with generalized convulsions with dysarthria in the postcritical period, which resolve progressively in less than two hours. On physical examination, she is conscious, oriented, with no language or motor or sensory deficits. Only signs of a right lateral tongue bite are observed.\n\nThe complementary tests, such as blood tests or the electrocardiogram, are normal. Given that the episode corresponds with a first epileptic seizure and the patient is pregnant, an urgent magnetic resonance of the skull is requested.\n\nThe usual protocol was performed and 3D T1 sequences without and with intravenous contrast were obtained in axial, coronal and sagital planes, axial FLAIR, axial T2, VEN BOLD and magnetic susceptibility sequences, as well as axial diffusion and apparent diffusion coefficient map. The MRI identified multiple venous cortico-medullary vascular structures converging centripetally to a large central venous structure draining through the inferior anastomotic vein into the left transverse sinus, forming the classic ‘Medusa head’ sign. In the T1 sequences, the drainage vein was seen to be increased in signal with central hyphocaptation after contrast administration, suggesting partial thrombosis versus slow flow. In addition, in T2 and FLAIR sequences, the brain tissue surrounding the drainage vein was seen to be hyperintense, without diffusion restriction and compatible with edema.\n\nThese findings are suggestive of a venous anomaly of development with signs of partial peripheral thrombosis and slow flow more proximal, which cause edema of the surrounding tissue. She is started on clexane 60 mg/12 hours and levetiracetam 500 mg/12 hours and the patient shows improvement and symptomatic stability after one week.\n",
    "summary": "A 34-year-old pregnant woman presents with seizures and dysarthria and is urgently referred for a cranial MRI. The classic ‘Medusa head’ sign is seen and the diagnosis is made as a venous anomaly of development with peripheral partial thrombosis and proximal slow flow.\n"
  },
  {
    "id": "multiclinsum_gs_en_587.txt",
    "fulltext": "A 22-year-old woman came to the Department of Oral Medicine with complaints of mouth ulcers causing pain and eating and drinking difficulty persisting for a duration of one month. This condition begins with a fever and appears like pimples on the lips. Based on the anamnesis, it was discovered that she had been using pod-type vapes for about a year but had never experienced complaints like when she came for treatment. She had never smoked traditional cigarettes before starting to vape. She said the reason for trying vaping was out of curiosity, and she quite often tried different types of e-liquid with different flavors. Before her complaint, she had simply changed the type of e-liquid to a different flavor without mentioning the brand. She vapes almost every day, but not all day, only in her free time or with friends. She was a healthy individual, and before this condition appeared, she had no history of taking medications, including antibiotics, analgesics, anticonvulsants, non-steroidal anti-inflammatory drugs, and antifungals. She also had no history of drug or food allergies, but the patient has unhealthy eating habits (eating irregularly and not consuming vegetables and fruit). Extraoral examination showed no lesions on other parts of the body, while the lips of the patient had serosanguineous crusts and an erosive area at the corner of the mouth, and tended to bleed. Intraoral examination revealed white ulcers with yellowish edges, irregular, varying sizes, and pain on the labial, buccal, lateral, and ventral mucosa of the tongue and floor of the mouth.\n\nBased on the medical history of the patient and physical examination, which revealed oral mucosal involvement but no symptoms elsewhere in the body, as well as the non-reactive anti-HSV1 IgG results, the diagnosis of vaping-related oral erythema multiforme was established. The medical condition has been classified as minor erythema multiforme. The oral conditions were treated with 0.9% NaCl, which was moistened in gauze and placed on the lips three times a day. The patient was instructed to gargle 1 mg of dexamethasone in 10 mL of hyaluronic acid three times a day and avoid eating or drinking for at least 30 minutes after gargling. She was also given 2% miconazole cream applied to the wound in the right corner of the mouth twice a day, as well as vaseline album cream for dry lips. To maintain good oral hygiene, she was advised to brush her teeth and tongue twice a day, after breakfast and before bed. She was also instructed to stop vaping and avoid foods containing monosodium glutamate (MSG). The control was carried out after a week following therapy and showed that oral condition had improved. Written informed consent for the publication of details was obtained from the patient. This case report conformed with the Helsinki Declaration. The publication of this case report has also been approved by the institution.",
    "summary": "A 22-year-old woman came to the Oral Medicine Department with complaints of stomatitis causing pain, eating, and drinking difficulty, which started with fever and pimple-like on the lips. She was an active vape user for one year. Extraoral examination revealed no lesions on other body parts. The serosanguinolent crusts on the lips, an erosive area on the labial commissures and tended to bleed. Intraoral examination revealed white ulcers with yellowish edges and irregular, varying sizes in several parts of the oral mucosa. The anti-HSV-1 IgG laboratory results showed non-reactive, leading to a diagnosis of oral erythema multiforme. Management of oral conditions using 0.9% NaCl compress, dexamethasone mouthwash, and hyaluronic acid, applying 2% miconazole cream on labial commissures and vaseline album cream on the dry lips, and stopping vaping. Oral condition improved in a week of therapy."
  },
  {
    "id": "multiclinsum_gs_en_274.txt",
    "fulltext": "A 29-year-old gravida V par IV (all alive, 3 spontaneous vaginal deliveries, and the last child was delivered by cesarean section for the indication of a failed induction 4 years prior to the current pregnancy) came for ANC follow-up at a gestational age of 32 weeks from her LNMP.\n\nAfter taking a medical history, it was discovered that all four of her children are healthy, doing well in school, and have no known history of genetic or seizure disorders. She was investigated with the Venereal Disease Research Laboratory (VDRL), Hepatitis B surface antigen (HBSag), and urine analysis, all of which were negative. All cell lines in the CBC were normal, her blood group is A, and Rh is positive, according to the Complete Blood Count (CBC), blood group, and RH. Obstetric ultrasound was also performed showing normal anatomical scan of the all body parts of the fetus except the heart. Detailed fetal echocardiography evaluation was done with findings of: both atria have comparable size and normal situs. Both atrioventricular and semilunar valves are normally positioned with normal opening and closure. Both ventricles are comparable in size and contractility; in both 2D and color flow, the left ventricle forms the apex of the heart without any ventricular septal defect. But on the papillary muscles of the left ventricle there were two circumscribed, round, echogenic mass measuring 18.2 mm by 8.3mm and 13.5mm by 8.3 mm. Upon evaluation of the outflow tract, both the LVOT (left ventricular outflow tract) and RVOT (right ventricular outflow tract) have normal anatomy and function using 2D and CF ultrasound evaluation. According to the fetal echo finding, a diagnosis of cardiac rhabdomyoma was made. Since there is a high chance of tuberous sclerosis in cardiac rhabdomyoma, detailed neurosonography and other system exams were done to look for other signs of tuberous sclerosis. Despite searching for the other features of tuberous sclerosis, no other sign of it was found other than the tumor. She had regular ANC follow-up from 32 weeks of gestation up to 39 weeks without any complications.\n\nAt gestational age of 39 weeks plus 1 day, she underwent a cesarean section for the indication of full-term pregnancy plus a request for a repeat cesarean section, with the outcome of a 3200-gram female with an APGAR score of 10 and 10 at the 1st and 5th minutes. Both the mother and the neonate had a smooth post-operative period and were discharged on the third day.\n\nAfter delivery, the neonate was evaluated on the 1st, 7th, and 30th days for any regression or increment of the mass, emergence of skin lesions, or seizure. All physical examination results were normal, and the mass size was similar to the antepartal evaluation.\n\nAt her 7th month, the child was evaluated again, and upon history inquiries, the infant was doing great developmentally for her age group. The infant was examined for neurodevelopmental delay, and the child was growing appropriately for her age. An echocardiography study by a pediatric cardiologist revealed well-circumscribed hyperechoic masses on both left ventricular papillary muscles, each measuring 21.8 mm by 9.2 mm and 14.7 mm by 8.5 mm and creating no left ventricular inflow obstruction.\n\nA history from the family was obtained, and a physical examination with anthropometric measurements was performed to assess her developmental condition during her first-year evaluation. The child was developing normally, as other children her age were. Except for the heart, all of the systems examined were unremarkable. An echocardiography study has revealed well-circumscribed hyperechoic masses on both left ventricular papillary muscles with no size increment and creating no left ventricular inflow obstruction.",
    "summary": "We are reporting an isolated, asymptomatic fetal intra-cardiac mass (rhabdomyoma) that was discovered at 32 weeks of gestation and was followed as an outpatient until 39 weeks plus one day, at which point a cesarean section was performed. After delivery, the child underwent evaluations at the 1st day, 7th day, 30th day, 7th month, and 12th month of age. Following a checkup, the child's anthropometric and neurobehavioral growth were both healthy. Except for the tumor, which was neither growing nor shrinking in size, none of the clinical diagnostic criteria for tuberous sclerosis complex were met for this child up to the age of one year."
  },
  {
    "id": "multiclinsum_gs_en_124.txt",
    "fulltext": "13-year-old boy from Cusco with a history of laryngeal papillomatosis since the age of two (at the age of three he required a tracheostomy) and a mother with a history of genital papilloma. The patient was admitted to the San Borja National Institute of Child Health in Lima, after a 16-day illness characterised by respiratory difficulties predominantly at night, inspiratory laryngeal stridor and moderate dysphonia; he previously received azithromycin and oxygen support, without improvement.\n\nThe physical examination revealed mild subcostal retraction, decreased vesicular murmurs in the left hemithorax and scanty wheezy breath sounds with predominance in the right hemithorax, which required oxygen support with a binasal cannula at 4 liters. The rest of the evaluation had no relevant findings. At the laboratory level, leukocytes were found at 8.03 × 103/u, platelets 209 × 103/u, hemoglobin 13.2 g/dL, C-reactive protein at 36.6 mg/L. As part of the imaging studies, a chest radiograph and a head and neck tomography were performed.\n\n48 hours after admission, she presented with increased stridor and respiratory difficulty, so admission to the emergency operating room for tracheostomy, microsurgery and excision of papillomatosis lesions was decided. An appendicular tumour of papillomatose appearance with ventricular bands in the epiglottis, glottic face, vocal cords, subglottis and trachea up to ring 5 was evident. The anatomopathological report reported coilocitic atypia due to HPV and mild focal dysplasia.\n\nIn the immediate postoperative period, he was transferred to the paediatric intensive care unit for respiratory monitoring, with weaning from oxygen at 48 hours. He received a single dose of bevacizumab 400 mg intravenous and subsequently improved clinically. The patient remained hospitalised for seven days, achieving clinical stability through normalisation of oxygen saturation levels and progressive weaning from oxygen, and was subsequently referred to the hospital in Breña to continue his management. Telemonitoring was carried out after eight months and the family indicated that there was no evidence of relapse or other intercurrences.\n",
    "summary": "A 13-year-old boy with a history of laryngeal papillomatosis since the age of two years was presented. The patient presented respiratory distress and multiple stenosing nodules in the larynx and trachea, and several pulmonary cysts were visualized on a chest tomography. The patient underwent exeresis of the papillomatosis lesions and tracheostomy. He received a single dose of 400 mg bevacizumab intravenous and respiratory therapy with a favorable evolution, without recurrence in the follow-up.\n"
  },
  {
    "id": "multiclinsum_gs_en_412.txt",
    "fulltext": "A 54-year-old male who had a medical history of membranous nephropathy II with nephrotic syndrome was administered with long-term oral glucocorticoids and immunosuppressants. The patient had a 20 pack-year history of smoking, and denied a family history of hereditary diseases. Chest x-ray demonstrated normal findings at one month before admission. On August 8, 2016, the patient was hospitalized for fever accompanied by progressive dyspnea, cough, and expectoration for 5 days. On admission, the BMI of the patient was 24.5 kg/m2, and his body temperature was 39.0°C. Furthermore, the patient had symptoms of tachypnea (35 bpm) and severe hypoxemia (SaO2 86%). On auscultation, the patient had good air entrance bilaterally with scattered diffuse crackles and rhonchi. Furthermore, the chest CT scan revealed multiple ground-glass opacities, and laboratory tests revealed normal white blood cell (WBC) count, but with elevated neutrophil count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and (1→3)-β-D-glucan. The patient was diagnosed as RSV infection on the fourth day of hospitalization when positive RSV-Ab was detected.\n\nOn admission, the patient was immediately given respiratory monitoring and supplemental oxygen to improve the low oxygen saturation, as well as antibiotics (moxifloxacin for 4 days, followed by cefminoxine for 8 days), and antifungal therapy (voriconazole for 10 days). The dose of the glucocorticoids and immunosuppressants remained largely unchanged. After 10 days of treatment, the patient's condition became worse. Chest CT revealed the progression of the disease, and oxygen partial pressure was further decreased. The patient was transferred to the Emergency Intensive Care Unit, where the patient was intensively treated, including noninvasive mechanical ventilation, broad-spectrum antibiotics (i.v. meropenem, oral moxifloxacin, and cotrimoxazole), antifungal therapy (micafungin), corticosteroids (methylprednisolone 40 mg bid iv) to relieve the inflammation, and other supportive treatment. Ganciclovir was also prescribed due to a possibility of viral infection, such as cytomegalovirus. Five days later, the patient's condition was further aggravated based on the chest x-ray evaluation. Despite receiving another round of treatments, including invasive ventilator-assisted ventilation therapy, methylprednisolone (80 mg bid), antibacterial agents (cefoperazone sulbactam, tigecycline, and cotrimoxazole) and antifungal (micafungin) therapy, the patient eventually died after 2 days.",
    "summary": "Patient concerns:\nA 54-year-old male patient with chronic nephropathy, who received long-term immunosuppressants, was admitted to the Department of Respiratory Medicine due to the symptoms of fever, cough, expectoration, and dyspnea.\n\nDiagnoses:\nPulmonary radiology revealed multiple bilateral ground-glass opacity. Laboratory tests revealed elevated inflammation indicators, implying infection with bacteria, viruses, and/or fungi. Furthermore, the patient was positive for RSV antibodies, without positive results for other pathogens. Moreover, the patient was immunocompromised due to the long-term use of corticosteroids and immunosuppressants, as evidenced by decreased total IgG levels and reduced CD4 and CD8 T-lymphocyte counts.\n\nInterventions and outcome:\nDespite the intensive anti-infection treatment and respiratory support, the patient developed rapid progression, and subsequently died of respiratory failure."
  },
  {
    "id": "multiclinsum_gs_en_301.txt",
    "fulltext": "A 34-year-old patient with a disease duration of four weeks. Two months earlier, she had a cesarean section in the 37th week of pregnancy and had persistent bleeding from the surgical wound. She denied a history of bleeding in childhood or adolescence. Three years earlier, she had given birth to her first child (also by cesarean section), who died due to a chromosome disorder (referred to by the patient). She also stated that she was allergic to tramadol.\n\nThe clinical picture began with lower back pain due to bilateral renal lithiasis. Subsequently, he managed to expel a stone and after that he presented haematuria for three days, for which he received tranexamic acid c/12 h. Three weeks later, he presented pain in the lower region of the left thigh that increased in intensity, with hardening of the area. Due to persistence of the symptoms, he was given diclofenac intramuscularly, which caused ecchymosis and bleeding in the gluteal area and persists despite the compression with gauze.\n\nThe patient underwent a particular Doppler ultrasound that revealed deep venous thrombosis of the left lower limb, and went to the hospital in her locality with these results. She was given anticoagulation with enoxaparin 30 mg/24 h subcutaneously, in addition to morphine for pain management and was hospitalized. The next day, she presented epigastralgia, blurred vision, heart rate of 117 beats/min, blood pressure of 113/85 mmHg and saturation of 93%. It was decided to discontinue enoxaparin. The blood count revealed a hemoglobin of 6.4 g/dl, which represented a difference of 4 g/dl from the result one day before admission, which was 10.4 g/dl. Because of the above, two blood transfusions were given. Due to the suspicion of vasculitis, methylprednisolone was indicated and she was referred to our hospital for further study.\n\nOn admission, the physical examination revealed severe pallor, extensive ecchymosis on the left thigh and lateral knee, and a haematoma on the right thigh. The haemogram showed moderate anaemia (Hb = 9.8 g/dl), normocytic and normochromic. The biochemical examination showed glucose values of 160 mg/dl. The liver enzymes AST and ALT were at 52 U/L and 86 U/L, respectively. The coagulation profile showed a prolonged activated partial thromboplastin time (APTT) of 91.2 s. The rest of the haemogram, biochemical, electrolyte, liver profile and coagulation profile were normal. The ultrasound of soft parts of the right gluteal region revealed a collection at the level of the subcutaneous cellular tissue (TCSC) and oedema up to the upper third of the thigh. The Doppler ultrasound in the left lower limb showed adequate flowometry without signs of thrombosis in the common femoral vein, superficial and deep.\n\nSymptomatic treatment was initiated and blood and urine cultures were requested and were negative. Antinuclear antibody (ANA) values, complement C3 and C4 and ferritin were within the reference range.\n\nIn the face of suspected acquired haemophilia, studies were requested for confirmation, where a partial correction of aPTT was found in the mixing test. Factor VIII was measured and its activity was found to be decreased (<1.0 U/dl) and the presence of a factor VIII inhibitor was demonstrated: 8.64 Bethesda units/ml. The above allowed the diagnosis of acquired haemophilia to be confirmed, which was related to the postpartum period due to the onset of symptoms.\n\nPrednisone 50 mg orally at breakfast and 10 mg orally at lunch, cyclophosphamide 50 mg 2 tablets orally every 24 hours and anti-inhibitor coagulant complex for haemophilia (FEIBA) were initiated. Five days later, the latter was discontinued due to chest tightness, dyspnoea and nausea (possible adverse drug reaction) and replaced with activated recombinant factor VII (NovoSeven).\n\nThe patient's clinical evolution was favorable, with a decrease in ecchymosis and no other symptoms, so she was discharged from the hospital.\n",
    "summary": "A 34-year-old female patient presented with lower back pain, haematuria and a haematoma in the right gluteal region, with no previous history of bleeding. Due to the extent of the haemorrhagic manifestations, she was transferred to the emergency department. The coagulation profile, mixing test and measurement of the factor VIII inhibitor titres confirmed the diagnosis.\n"
  },
  {
    "id": "multiclinsum_gs_en_47.txt",
    "fulltext": "We present here the case of a two-day old neonate with in-born right scrotal swelling admitted at Children’s hospital. The patient was born at term via cesarean section at a private hospital. He was kept in the nursery for one day. The examining doctor referred them for urgent surgical care, but it took them one day to arrive at our hospital. Upon arrival in the emergency department, he was well hydrated, pink at room temperature with good perfusion. Upon examination, the right testis was found to be enlarged, tense, non-tender visibly reddish with overlying skin excoriation. Trans-illumination was negative in the right but positive in the contralateral testis. Both hernial orifices were normal. All the laboratory investigations were performed with an urgent Doppler ultrasound of the inguinoscrotal area. The ultrasound examination found the right testis to be enlarged (15.6*9.4 mm) and showed heterogeneous hypoechoic texture with prominent rete testis and no flow on color Doppler analysis. Left testis appeared normal in size, shape and echotexture with minimal hydrocele. An urgent scrotal exploration was undertaken. Intra-operatively, there was frank necrotic right testis with intravaginal torsion of the testis with minimal hydrocele. A right orchidectomy and contralateral orchidopexy was then performed.",
    "summary": "We present here the case of a two-day old neonate with in-born right scrotal swelling admitted at Children’s hospital. The patient was born at term via cesarean section at a private hospital. Upon arrival in the emergency department, he was well hydrated, pink at room temperature with good perfusion. Upon examination, the right testis was found to be enlarged, tense, non-tender visibly reddish with overlying skin excoriation. Trans-illumination was negative in right but positive in the contralateral testis. Both hernial orifices were normal. Doppler ultrasound of the inguinoscrotal area found the right testis to be enlarged (15.6*9.4 mm) and showed heterogeneous hypoechoic texture with prominent rete testis and no flow on color doppler analysis. An urgent scrotal exploration was undertaken. Intra-operatively there was frank necrotic right testis with intravaginal torsion of the testis and minimal hydrocele. A right orchidectomy and contralateral orchidopexy were performed."
  },
  {
    "id": "multiclinsum_gs_en_289.txt",
    "fulltext": "4-year-old male patient with a history of nasal impetigo two weeks before admission (treated with topical mupirocin and oral cefadroxil; dose, duration and adherence to treatment unknown), with no other morbid history, who presented macroscopic glomerular haematuria associated with oedema of the lower extremities of 5 days' evolution, with the last 12 hours prior to the consultation adding headaches, nausea and vomiting. He went to the emergency department (ED) in convulsive status, after 20 minutes of generalised tonic-clonic convulsions.\n\nOn admission to the ED, the patient was afebrile, with non-evaluable blood pressure, with quantitative consciousness impairment associated with generalized hypertonia and bilateral and pretibial oedema. Endotracheal intubation was decided and phenobarbital (10 mg/kg) was administered to manage the convulsive status.\n\nOn physical examination in the intensive care unit (ICU), blood pressure was 134/94 mmHg (BP 110 mmHg) (p95 for patient 108/66 mmHg, p95+12 120/78 mmHg).\n\nInitial laboratory parameters included: complete urine with haematuria (> 100 erythrocytes per field), proteinuria 3+ and leucocyturia 10-25 per field, creatinemia 0.3 mg/dL, anaemia with haematocrit (HTO) 21%, haemoglobin (Hb) 7 g/dL, with normal mean corpuscular volume (VCM) and mean corpuscular haemoglobin concentration (CHCM), leukocytosis of 23,900 cells/mm3, thrombocytosis of 756,000/mm3, without elevation of acute phase reactants, hypocomplementemia with complement C3 level at 25 mg/dL (normal value, VN: 80-150 mg/dL) and normal C4. The rapid antigen test for Streptococcus beta-haemolytic group A (Streptococcus pyogenes) in pharynx was positive and the Anti-streptolysin O (ASO) was (+). The non-contrast brain computed tomography showed no acute changes. The renal ultrasound concluded bilateral nephromegaly with increased cortical echogenicity and decreased corticomedullar differentiation.\n\nThe patient was diagnosed with nephritic syndrome due to complicated GNAPE with hypertensive emergency - convulsive status.\n\nWithin the first 24 hours of his ICU stay, the patient required mechanical ventilation (MV) and anticonvulsant therapy with phenobarbital. He progressed without seizures, with a normal electroencephalogram (EEG) (on the day following admission) and a normal cerebrospinal fluid study. Antibiotic therapy was initiated for eradication of Streptococcus pyogenes with cefotaxime and diuretic therapy with furosemide.\n\nThe next day, he developed renal impairment with creatinine elevation to 0.99 mg/dL, hypertension and 24 hour proteinuria of 36.6 mg/m2/h, without oliguria. He initiated antihypertensive therapy with amlodipine and intravenous labetalol, with good initial control.\n\nWith favorable evolution, extubation was performed at 48 hours, which was well tolerated from the ventilatory point of view. However, after 24 hours of extubation, the patient's consciousness deteriorated, with both ocular opening and withdrawal of limb only in response to painful stimulus and poor verbal response (Glasgow Coma Scale 8), and developed blood pressure figures > p95+12 despite receiving therapy with labetalol in continuous infusion (up to 3 mg/kg/h), amlodipine (10 mg/day) and furosemide, which required the reintroduction of mechanical ventilation and infusion of sodium nitroprusside (up to 3 mcg/kg/min), with the aim of achieving gradual reduction of blood pressure figures (25% daily) to prevent secondary neurological damage. Given the presence of acute neurological symptomatology associated with HTA in a patient with glomerulonephritis, the diagnosis of PRES was suspected, which was confirmed by magnetic resonance imaging (MRI) of the brain (day 5), which showed an increase in the subcortical signal in bilateral and symmetric occipital region, without restriction in diffusion, which was compatible with vasogenic edema (PRES). Ophthalmological evaluation was normal and a new EEG evidenced occasional episodes of generalized voltage depression.\n\nAdding enalapril to the treatment. Finally, after 10 days with a slow pharmacological weaning, normalization of blood pressure was achieved. The control MRI (day 12) revealed regression of the previously described findings. Successful extubation was achieved after 5 days.\n\nDuring his stay in the ICU, the hemoglobin level dropped to 5 g/dL, with normal mean corpuscular volume and mean corpuscular hemoglobin concentration, without plateletopenia, so hemolytic anemia was suspected given a positive direct Coombs test and hemoglobinuria. He required red blood cell transfusions twice. Steroid therapy with methylprednisolone (1 mg/kg/d) was initiated for 72 hours. The coproculture was negative, as was the urinary antigen for Streptococcus pneumoniae. Epstein-Barr virus and Parvovirus B19 serology, extractable nuclear antigen (ENA) profile, anti-neutrophil cytoplasmic antibodies (ANCA), anti-DNA antibodies, anti-B2 glycoprotein 1 antibodies, anti-cardiolipin antibodies and lupus anticoagulant were all negative. All cultures were negative (blood cultures, urine cultures, cultures of endotracheal aspirate and pharyngeal cultures). ANA (antinuclear antibodies) was positive 1/160.\n\nThe patient improved with blood pressure normalization, increased complement levels, and a urine test without proteinuria or hematuria. The direct Coombs test remained positive on the 9th day of hospitalization.\n\nOn day 31, the patient was discharged normotensive, without anaemia, with preserved renal function, without proteinuria or haematuria, with normalisation of C3 levels and asymptomatic from the neurological point of view. He was discharged with pharmacological therapy with prednisone, amlodipine, enalapril and folic acid. The patient did not present recurrence and remained asymptomatic 6 months after discharge.\n",
    "summary": "4-year-old male patient with a history of 5 days of haematuria and oedema, with additional headaches, nausea and vomiting, who entered a convulsive state and hypertensive crisis. Laboratory tests showed hypocomplementemia C3 and elevated Anti-Streptolysin O titers, which was interpreted as GNAPE. He developed encephalopathy, which led to suspicion of secondary PRES due to hypertensive emergency, which was finally confirmed by magnetic resonance of the brain. He also developed autoimmune haemolytic anaemia with haemoglobin up to 5 g/dL. His treatment was based on antihypertensive therapy, neuroprotection measures and steroid treatment. He was discharged after 31 days of hospitalisation, asymptomatic 6 months after discharge.\n"
  },
  {
    "id": "multiclinsum_gs_en_564.txt",
    "fulltext": "A 69-year-old male with prior history of CABG presented with severe dyspnea at mild exertion (NYHA III) of 2 months duration was admitted in our center. The electrocardiogram showed ST depression in leads II, III, aVF, and V4-6, and blood examination revealed elevation of plasma N-terminal pro-B-type natriuretic peptide levels (2640 pg/mL). Echocardiogram showed left ventricular systolic dysfunction and low left ventricular ejection fraction (30%). The patient had inferior ST-segment-elevation myocardial infarction in 2009, when he was 59 years old, with angiographic evidence of severe 3 vessels disease (coronary angiography showed CTO in proximal left anterior descending artery (LAD), 90% stenosis in mid and distal left circumflex artery, and 95% stenosis in mid RCA. The patient underwent CABG with left internal mammary artery (LIMA) to LAD, and sequential SVG to 1st obtuse marginal branch (OM1), 2nd obtuse marginal branch (OM2), and posterolateral branch (PL) in 2009.\n\nCoronary angiography was performed via 6 French (Fr) left radial artery access and demonstrated patency of LIMA to LAD and SVG to OM1, OM2 conduits, but a complete occlusion of sequential SVG to PL conduit. Native left main coronary artery was occluded in ostium and native RCA was occluded in the mid portion with bridging collaterals. We decided to treat the native RCA CTO. Dual arterial access was achieved with another 6 Fr sheath in right femoral artery. The left and right coronary arteries were intubated with 6 Fr AL 0.75 (Launcher; Medtronic; USA) and 6 Fr EBU 3.5 (Launcher; Medtronic; USA) guide catheters, respectively. An antegrade approach via left radial artery was attempted; however, neither Fielder XTR wire (Asahi Intec, Japan) nor Gaia 3 wire (Asahi Intec, Japan) with Finecross microcatheter (Terumo, Japan) reached the true lumen in distal RCA. Then, parallel wire technique with Crusade microcatheter (Kaneka, Japan) and two Gaia 3 wires (Asahi Intec, Japan) were attempted, but also failed. We therefore switched to the retrograde approach using septal channel from LAD through occluded left coronary artery. Gaia 3 wire (Asahi Intec, Japan) crossed occluded left main (LM) and LAD, and finally reached true lumen in distal LAD. Sion wire was exchanged by Finecross microcatheter (Terumo, Japan) into dital LAD, and dilation of LM and proximal LAD with a 2.0 × 15 mm balloon was performed. Then, septal surfing technique (SST) was used for septal crossing. We tried different septal channels originating from proximal to distal LAD, and delivered Sion wire (Asahi Intec, Japan) retrogradely through distal septal branch into distal RCA supported by a 150-cm Finecross microcatheter (Terumo, Japan). Gaia 3 wire (Asahi Intec, Japan) crossed CTO lesion retrogradely into the true lumen in proximal RCA, and was advanced into Guidezilla guide extension catheter (Boston Scientific, USA) positioned in the antegrade guiding catheter. The Finecross microcatheter (Terumo, Japan) was delivered to the antegrade catheter and a RG3 wire (Asahi Intec, Japan) was externalized. The CTO was then predilated by a 2.0 × 15 mm balloon and stented with 2 overlapping drug-eluting stents (2.5 × 38 mm and 3.0 × 38 mm) with excellent angiographic result and TIMI3 flow in all distal branches.\n\nDyspnea was relieved at discharge. At 6-month follow-up, the patient had no recurrence of dyspnea.",
    "summary": "Patient concerns:\nThis is a 69-year-old male with prior history of coronary artery bypass grafting presented with severe dyspnea at mild exertion (NYHA III) of 2 months duration.\n\nDiagnosis:\nThe patient was diagnosed as heart failure caused by ischemia after SVG failure (SVG to right coronary artery) according to electrocardiogram, plasma N-terminal pro-B-type natriuretic peptide levels, and coronary angiogram.\n\nInterventions:\nWe recanalized native right coronary artery CTO by retrograde approach using septal collaterals by surfing technique after recanalization of totally occluded left coronary artery.\n\nOutcomes:\nDyspnea was relieved at discharge. At 6-month follow-up, the patient had no recurrence of dyspnea."
  },
  {
    "id": "multiclinsum_gs_en_399.txt",
    "fulltext": "A 51-year-old male patient presented to us with acute painful visual loss of his left eye (LE) from 3 days ago. The best-corrected distance visual acuity (BCDVA) was 20/20, and hand motion (HM) detection for the right eye (RE) and LE, respectively. The ocular movement was normal in both eyes. Anterior segment examination was unremarkable for both eyes. The LE fundus examination showed ONH swelling, choroidal bulging, multiple patches of subretinal fluid accumulation, and retinal pigment epithelial (RPE) corrugations. Fundus examination of the RE was unremarkable.\n\nWe used multimodal imaging including Optical coherence tomography (OCT) (OptoVue, Inc., Fremont, CA, USA, software version: 2018,0,0,18), fundus blue-autofluorescence (BAF), fluorescein angiography (FA) (Heidelberg Eye Explorer version 1.9.13.0, Spectralis Viewing Module 6.5.2.0; Heidelberg Engineering), Indocyanin green angiography (ICGA), and B-scan ultrasonography for further evaluation. Besides, orbital and brain MRIs with gadolinium enhancement were ordered. The OCT image revealed a mild RPE and choroidal bulging, RPE hyper-reflectivity with back shadowing, subretinal and intraretinal fluid accumulation, and mild retinal thickening. A geographic area of macular hypocyanescence was apparent in the ICGA image of the left eye. BAF showed a geographic area with a speckled autofluorescence pattern at the macula. Optic nerve enlargement was found in the B-scan ultrasonography. In FA images, vascular leakage was apparent at the ONH (hot disc). Besides, a geographic patchy hypofluorescent area with speckled hyperfluorescent margins with a size of three disc diameters (DD) was detected. Orbital and brain MRI showed a retrobulbar nodular mass with gadolinium enhancement at the junction of the optic nerve and sclera. An oncology consultation was done with no remarkable finding.\n\nConsidering the suspicion of malignancy and the presence of an enhancing nodular mass in the orbit, the patient underwent transconjunctival lateral orbitotomy one week after the presentation. A pink localized scleral nodule with edematous tenon was found. Sub-tenon triamcinolone acetonide was injected with the clinical diagnosis of nodular posterior scleritis. The patient refused admission and intravenous corticosteroid injection as the treatment order. Oral prednisolone 50 mg/Kg was started. Rheumatology consultation and screening lab results, including PPD test (tuberculosis), chest X-ray, serum ACE level (sarcoidosis), and C-ANCA level (Wegner granulomatosis), were unremarkable. At the last follow-up examination (one week after the surgery), the patient’s BCDVA was 20/20, and counting fingers at 2 meters for the RE and LE, respectively. Furthermore, SRF was absorbed, and the macula became atrophic. Oral prednisolone was tapered off slowly for three months.",
    "summary": "A 51-year-old male patient presented to us with acute painful visual loss of his left eye (LE) from 3 days ago. The best-corrected distance visual acuity (BCDVA) was 20/20 and hand motion (HM) for the right eye (RE) and LE, respectively. Fundus examination of the LE showed ONH swelling, choroidal bulging, multiple patches of subretinal fluid accumulation, and retinal pigment epithelial (RPE) corrugations. Orbital and brain MRI showed a retrobulbar nodular mass with gadolinium enhancement at the optic nerve and sclera junction. Oncology and rheumatology work-ups were unremarkable. With the clinical diagnosis of nodular posterior scleritis oral prednisolone 50 mg/Kg was started."
  },
  {
    "id": "multiclinsum_gs_en_55.txt",
    "fulltext": "An elderly 78-year-old patient from the Amhara region of Ethiopia, who has had a permanent cardiac pacemaker for 7 years, was scheduled for retropubic prostatectomy due to benign prostatic hyperplasia (BPH). This condition developed following a previous transurethral resection of the prostate 3 months earlier. The patient in the preoperative anesthesia evaluation was fully evaluated, and all the routine investigations required for the proposed surgery, which were within normal limits, were investigated. The patient presented with a history of frequency, urgency, nocturia, and dribbling for the past 2 months. Additionally, the patient had been known to have hypertension for the past 16 years and was taking amlodipine 5 mg orally daily, enalapril 10 mg orally twice daily (BID), and atorvastatin 10 mg orally daily. He had also been known to have type II diabetes mellitus for the past 25 years and was on metformin 500 mg orally BID and neutral protamine Hagedorn (NPH) 20 IU and 10 IU. He was admitted to a hospital for further evaluation, and complete bundle branch block (BBB) was detected via electrocardiogram (ECG). In an electrophysiology study, the patient was diagnosed with left ventricular hypertrophy secondary to hypertensive heart disease, mild diastolic dysfunction, and an ejection fraction of 62%. Abdominal ultrasound revealed an enlarged prostate size of 82 ml; anterior–posterior (AP) chest X-ray revealed a normal chest region with a left-side pacemaker in situ, and all the other blood parameters, including electrolytes and serum troponin levels, were within normal limits.\n\nA cardiologist was involved preoperatively as a multidisciplinary approach and risk determination tool for cardiac risk assessment. The patient had a frailty score of 5.5 with a poor functional cardiopulmonary reserve of metabolic equivalent (MET) = 3.4 and Revised Cardiac Risk Index (RCRI) class III, which accounts for 10.1% of major cardiac adverse events (myocardial infarction [MI], cardiac arrest, or death) within 30 days of the postoperative period, and intermediate risk on the basis of surgery type and patient risk factors. After preoperative evaluation and risk disclosure regarding the un-reprogrammed pacemaker and the associated complications during anesthesia and surgery, the patient was unable to afford the necessary health coverage for pacemaker reprogramming. This is because the cardiac surgery was performed in Addis Ababa, Ethiopia, which has a long waiting list with few cardiac surgeons for millions of people and is a considerable distance from the patient’s home institution, and there is a period of monitoring after pacemaker reprogramming for considerable post-reprogramming complication. As a result, the patient chose to proceed with the surgery, accepting the potential risks and harm associated with the situation. Continuous cardiac monitoring during the intraoperative period is highly advocated. Despite these factors, the patient did not experience cardiorespiratory failure, and he was stable. The patient continued on medication until the day of surgery, which included amlodipine, enalapril, atorvastatin, and a morning lower dose of two-thirds of the NPH. He also took 5 mg of diazepam orally for anxiolytics at midnight before the day of surgery.\n\nOn the day of surgery, the patient’s random blood sugar (RBS) was measured, and sliding scale glycemic control was implemented. Communication among the anesthetist, surgeon, and nurses was emphasized, ensuring that the cautery pad was placed away from the pacemaker, and that emergency drugs and a defibrillator were ready. The patient was premedicated with dexamethasone for nausea prophylaxis and paracetamol for pain relief as preemptive analgesia. American Society of Anesthesiology (ASA) standard monitoring was applied, and baseline parameters were recorded. Combined epidural–spinal anesthesia was administered via 0.5% isobaric bupivacaine (12.5 mg) and 50 µg fentanyl at the L3–L4 interspace. The block achieved anesthesia up to the umbilicus, and the sensory block was performed at T7. The surgery involved a midline incision below the umbilicus, with monopolar cautery used at low voltage (20 mA). Hemostasis was achieved through bipolar low-voltage cautery. Throughout the procedure, the patient’s vital signs remained stable. The patient’s vital signs did not change by more than 10% from the baseline vital signs. The intravenous fluid was resuscitated intraoperatively. During the postoperative period, the patient was transferred to the postanesthesia care unit (PACU) with vigilant monitoring, and 10 ml of 0.125% epidural top-up analgesia was given. Postop investigations were within normal limits. The patient was observed in the PACU for 12 hours and later transferred to the ward in stable condition with regular follow-up with the cardiology team. After 88th day of postsurgery the patient was discharged and advised to have regular checkups for pacemaker’s in situ status.",
    "summary": "A 78-year-old male from the Amhara region, Ethiopia, with a permanent pacemaker for complete heart block was scheduled for retropubic prostatectomy. Preoperative assessments by the anesthetist and cardiologist recommended reprogramming the pacemaker to asynchronous mode to reduce risks related to its dual-chamber, rate-modulated mode setting. However, the patient could not afford reprogramming and opted to proceed with the existing perioperative plan. Informed consent was obtained, and case report publication permission was obtained after operation. The patient received combined epidural-spinal anesthesia with 2.50 ml of 0.5% isobaric bupivacaine and 50 µg fentanyl at the L3-L4 interspace. Standard American Society of Anesthesiology monitoring was applied, with a focus on cardiac stability. The patient remained stable with minimal vital sign fluctuations and maintained adequate blood pressure using isotonic saline. Postoperatively, the patient was transferred to the postanesthesia care unit, receiving analgesia after 4 hours and an epidural top-up. After 6 hours, he was transferred to the ward in stable condition. Epidural analgesia was continued for 72 hours, and the patient was discharged on the 88th postoperative hour in stable condition."
  },
  {
    "id": "multiclinsum_gs_en_317.txt",
    "fulltext": "A 52-year-old woman referred to the urology clinic with urinary complaints. Her symptoms began three years ago with frequency, dysuria and dribbling. She also mentioned the frequent passage of red and black thread-like substances in her urine. Moreover, during these discharges, she had headache, fever and chills. Intermittent periurethral and genital itching was another complaint of hers. She had been treated by several specialists with the diagnosis of recurrent urinary tract infections, with no clinical improvement. The patient denied recent travel, camping, hiking, farming, swimming and insect bites. She had positive history of pilonidal sinus surgery and hysterectomy, 8 and 7 years earlier, respectively. Two years prior to the current visit, she had been hospitalized for assessment. On physical examination, she was well-appearing with normal vital signs. All her laboratory tests, including cell blood count, urine analysis and biochemistries were in normal ranges. Abdominopelvic computed tomography (CT) scan revealed no abnormalities. Hence, she underwent cystoscopy, which demonstrated erythema and hyperemia of the bladder mucosa, suspended debris, and dilation of the left ureteral orifice. During consultation with an infectious diseases’ specialist, schistosomiasis was suspected, Therefore, she was treated with Praziquantel with the appropriate dose and duration and was discharged from the hospital.\n\nHowever, her symptoms did not subside. She was revisited by another infectious disease specialist, who prescribed her ivermectin due to suspicion to urinary myiasis. Nevertheless, no improvement was observed. She was readmitted to undergo bladder irrigation with polyethylene glycol, but the bladder washfluid did not contain any visible larvae. This procedure was followed by a two-day hematuria with spontaneous cessation. She was discharged home and advised to repeat the urine analysis one months later. Her random urine analysis was normal, so she collected her 24-h urine and sent it to the laboratory for analysis, in which a live larva was demonstrated under light microscope by the pathologist. The larva was isolated and sent to an entomologist to be identified morphologically. Finally, it was determined that the larva belonged to the species Sarcophaga. The patient was advised to take personal hygiene and consume at least 3 L of water daily.",
    "summary": "We report a 52-year-old woman with persistent dysuria, frequency despite multiple treatments for suspected infections. Cystoscopy revealed erythema and debris, but imaging and laboratory tests were unremarkable. A live larva was identified in urine analysis, confirming the diagnosis. Treatment involved improved hygiene and hydration."
  },
  {
    "id": "multiclinsum_gs_en_79.txt",
    "fulltext": "A 36-year-old female patient with a history of ulcerative colitis and good disease control on sulfasalazine, ferrous fumarate and intermittent prednisone for flare-ups is presented.\n\nHe was admitted to the emergency unit with a 1 week history of progressive oppressive precordial pain associated with dyspnea and neurovegetative symptoms. On admission, an electrocardiogram was performed in sinus rhythm, with finding of supradesnivel of the ST segment in the lower wall.\n\nThe patient reported a 6-month history of general disorders, fatigue and night sweats. She had previously presented episodes of precordial pain in relation to effort that progressed to rest. The physical examination was without murmurs or alterations of the peripheral pulses.\n\nAn emergency coronary angiography was performed, which revealed severe 2-vessel disease: severe ostial lesion 90% in the left coronary trunk and severe subocclusive lesion 99-100% at the ostial level in the right coronary artery (culprit vessel). Primary angioplasty of the right coronary artery was performed with successful installation of a medicated stent. The hemodynamicist was impressed by a possible aortitis due to involvement of the arch and friability of the vessels when the balloon was advanced, so he suggested an etiological study oriented to inflammatory disease, prior to surgical resolution of the lesion of the left coronary trunk.\n\nLaboratory tests showed mild anaemia (haemoglobin: 11.6 g/dL), mild leukocytosis (13,800/mm3), elevated erythrocyte sedimentation rate (ESR): 42 mm/h and C-reactive protein (CRP): 4.9 mg/L (normal value <1) and elevated ultrasensitive troponin. From the autoimmunity study, normal levels of complement C3 and C4, negative anti-nuclear antibodies (ANA), anti-DNA, negative extracellular nuclear antigen (ENA) profile and non-reactive VDRL were rescued.\n\nCardiac magnetic resonance (MRI) with contrast was completed with findings of acute infarction of the left ventricular inferior wall non-transmural myocardium and subendocardial ischemia in the anteroseptoapical resting of the left ventricle. Mild aortic and mitral insufficiency. Preserved biventricular systolic function.\n\nComputed tomography angiography (CTA) of the chest, abdomen and pelvis showed periaortic fibrotic wall thickening involving the root, aortic arch and abdominal aorta with severe left coronary trunk stenosis and mild left subclavian, left vertebral artery stenosis and severe lower mesenteric artery stenosis. Immune globulin G (IgG) 4 deposition disease or Takayasu's arteritis was suggested.\n\nWithin the differential diagnosis study, IgG levels were performed at 1,600 mg/dl (reference values: 700-1,600), and its subclasses: IgG1: 1024 mg/dl (elevated), and the rest in normal range (IgG2: 456 mg/dl; IgG3: 98.8 mg/dl and IgG4: 13.6 mg/dl).\n\nTakayasu arteritis was diagnosed clinically and by imaging and treatment was initiated with prednisone 60 mg daily, methotrexate 20 mg weekly by injection and folic acid 1 mg daily. After 3 weeks of treatment she underwent myocardial revascularisation surgery with use of the left internal mammary artery (LIMA) as a graft to the descending anterior artery (DA) and aortocoronary bypass to circumflex artery. It was noted intraoperatively that the root of the aorta and the ascending aorta presented a healthy appearance. The patient is currently at home in good general condition and under ambulatory follow-up.\n",
    "summary": "A 36-year-old woman with ulcerative colitis presented with progressive precordial pain and neurovegetative symptoms. The electrocardiogram showed a ST segment elevation in the inferior wall. The patient had a history of fatigue and night sweats. She underwent a coronary angiography that revealed severe disease in two coronary arteries, with successful primary angioplasty of the culprit artery. Aortitis was suspected, which led to additional studies, including a mild elevation of inflammatory activity indices and a computed tomographic angiography with periaortic fibrotic thickening and significant stenosis in multiple arteries, suggesting Takayasu arteritis. She was treated with prednisone, methotrexate, and underwent delayed myocardial revascularization surgery with good results.\n"
  },
  {
    "id": "multiclinsum_gs_en_194.txt",
    "fulltext": "A 36-year-old female patient complained of dysphagia with longstanding cervical and upper thoracic pain. She also had a multinodular goiter with no other significant history. Esophagogastroduodenal transit was performed. It showed a posterior and lateral right impression of the proximal esophagus after ingestion of baryte, extending 3.5 cm cephalocaudal. A maximum esophageal stenosis of 60% was estimated. A cervical and thoracic CT scan revealed a congenital anomaly of the aortic arch: a mirror image of the right aortic arch. The aortic arch originates from the root of the aorta and runs above the right stem bronchus, giving rise to the three supra-aortic trunks as follows: the first is the left brachiocephalic artery (which gives rise to the left common carotid artery and the left subclavian artery); the second is the right common carotid artery; and the third is the right subclavian artery. The aortic arch then enters posteriorly to the esophagus and gives rise to a small anterior saccule of 1.3 cm, known as the Kommerell diverticulum. This configuration forms a ring around the tracheo-esophageal pair, whose edges are formed posterior-lateral to the right by the aortic arch, posterior-lateral to the left by the Kommerell diverticulum, lateral to the left by the arteriosum ligamentum (or arterial ligament), and anteriorly by the left brachiocephalic artery. A gastroscopy confirmed the endoluminal impact of extrinsic compression. In view of minimal clinical repercussions and the absence of nutritional disorders, no surgical cure was ultimately performed. The evolution was favorable with, according to the patient, a spontaneous amelioration of symptoms.\n",
    "summary": "We report the case of a 36-year-old female patient whose dysphagia presented a congenital anomaly of the thoracic aorta: the right aortic arch with mirror image. This is a rare anomaly of embryonic development where the aorta winds around the right stem bronchus and the supra-aortic trunks emerge from the crown in the reverse and opposite order to normal. The vast majority of patients are asymptomatic unless there is a compression of the mediastinal structures. Major compression of the esophagus or trachea, aneurysmal disease, thoracic aortic dissection or the presence of a Kommerell diverticulum of more than 2 cm may warrant surgical intervention. There is no standard treatment and it must be adapted to the clinical presentation and anatomical configuration of the patient. Our patient did not receive any treatment for her condition.\n"
  },
  {
    "id": "multiclinsum_gs_en_419.txt",
    "fulltext": "A 62-year-old Tunisian Arab postmenopausal female diagnosed with Von Hippel–Lindau disease in 2021 presented with various manifestations related to the disease. She had a history of multiple surgeries, primarily for renal, adrenal, and pancreatic tumors, with incidental findings of ovarian masses.\n\nThe patient was asymptomatic from a gynecological standpoint, but primarily complained of headaches before undergoing brain surgery. She had no significant family or psychosocial history.\n\nHer surgical history included\n2021: A non-operable tumor (6 cm) of the left petrous bone endolymphatic sac, managed with radiotherapy.\n\n2021: Left adrenalectomy for a 6 cm pheochromocytoma. Pathological examination revealed pheochromocytoma.\n\n2021: Left nephrectomy for a ruptured left renal tumor. Microscopy showed multifocal clear-cell renal carcinoma of nuclear grade 2.\n\n2022: Cephalic duodenopancreatectomy for a mass in the pancreas. Histological examination confirmed three serous cystadenomas and two well-differentiated neuroendocrine tumors.\n\nIn January 2021, during postoperative surveillance with an abdominal–pelvic computed tomography (CT) scan, a 4 cm solid cystic left adnexal mass was incidentally discovered, which raised suspicion of malignancy. The mass was confirmed by transvaginal ultrasound and pelvic MRI, classified as Ovarian-Adnexal Reporting and Data System (O-RADS) 5 (high suspicion for malignancy).\n\nGynecological examination and surgical history\nPhysical examination: No abdominal–pelvic mass detected.\n\nSpeculum examination: Healthy cervix observed.\n\nSurgical scars from previous left nephrectomy and cephalic duodenopancreatectomy were noted.\n\nA multidisciplinary staff meeting concluded that surgery was necessary. A laparotomy was performed via a midline incision below the umbilicus, revealing a well-defined solid cystic mass in the left adnexa. No ascites or signs of peritoneal carcinomatosis were present, and the right adnexa appeared normal, with no macroscopic signs of malignancy observed intraoperatively, including the absence of exocystic vegetations.\n\nCytology was performed along with left adnexectomy, and the specimen was sent for frozen section examination. The results were inconclusive, raising the possibility of borderline tumors or tumors specific to Von Hippel–Lindau syndrome. Considering the patient’s postmenopausal status, a right adnexectomy and total hysterectomy were performed.\n\nHistological examination later revealed bilateral clear-cell papillary cystadenomas of the Fallopian Tubes and broad ligament, characteristic of Von Hippel–Lindau disease (0.5 cm on the right side and 4 cm on the left side).The tumors consisted of tightly packed papillae with fibrous cores, covered by monolayered epithelium.\n\nThe immediate postoperative period was uneventful, and at the 1-month follow-up, no abnormalities were detected. The patient has since been followed up with every 4 months with normal pelvic ultrasounds. During these 2 years of follow-up, no complications have arisen, but the patient was recently readmitted to the neurosurgery department for recurrence of a brain tumor.",
    "summary": "A 62-year-old white North African woman diagnosed with Von Hippel-Lindau disease in 2021 presented with multiple manifestations, including a left petrous bone tumor, left pheochromocytoma, left renal cell carcinoma, multi-cystic right kidney, and pancreatic masses. She underwent various treatments, including radiotherapy, adrenalectomy, nephrectomy, and cephalic duodenopancreatectomy. Ultrasonographic and magnetic resonance imaging examinations revealed a solid cystic mass in the left adnexal region. Laparoscopy identified cystic tumors in the right and left mesosalpinx. Following a hysterectomy with bilateral adnexectomy, histological examination revealed bilateral clear-cell papillary cystadenomas of the mesosalpinx and broad ligament, consistent with Von Hippel-Lindau disease."
  },
  {
    "id": "multiclinsum_gs_en_30.txt",
    "fulltext": "The patient was a 59-year-old Japanese man with a 28-year history of type 1 diabetes. He visited our hospital monthly for management of diabetes with intensive therapy employing multiple-dose insulin injections. His height and body weight were 168 cm and 52 kg (body mass index: 18.4 kg/m2), respectively. He showed depleted insulin secretion (serum C-peptide level was below the limit of detection), such that his blood glucose levels fluctuated severely, and his hemoglobin A1c (HbA1c) level was around 9.0% despite intensive insulin therapy. He had been diagnosed with asymptomatic chronic severe (grade III) aortic regurgitation (AR) 16 years before the current presentation but had declined follow-up for the AR. He had never undergone surgery nor the implantation of any prosthetic devices.\n\nEight days after his regular hospital visit, he visited an emergency clinic complaining of breathing difficulty and had a fever above 38℃. Until that day, he had not noticed any fever, chills, weakness, or any other symptoms. His blood pressure and pulse rate were 192/82 mmHg and 118/min, respectively. He showed orthopnea, and his oxygen saturation (SpO2) was 80%. He was transported to the emergency department of our hospital. A physical examination revealed a Levine 3/6 systolic murmur, although his cardiac murmur had not been checked at regular hospital visits. No physical findings suggesting IE, such as Osler nodes, Janeway lesions, or conjunctival petechiae, were recognized. His white blood cell (WBC) count was markedly increased to 20,800 /μL, and his C-reactive protein (CRP) was elevated to 6.06 mg/dL. Serum creatine phosphokinase MB was within the normal range, at 6.0 IU/L, and troponin T was negative. Chest X-ray showed pulmonary congestion with cardiac enlargement (cardiothoracic ratio: 55%). Electrocardiography revealed ST elevation on V1-V4, but emergency echocardiography showed no dysfunction of cardiac contractility. He was diagnosed with acute heart failure due to valvular disease, and treatment with non-invasive positive pressure ventilation and nitrates was initiated.\n\nAfter hospital admission, a detailed examination by transthoracic echocardiography showed severe aortic regurgitation, severe mitral regurgitation, and a mobile vegetation on the mitral valve. Transesophageal echocardiography revealed a 16.5×6-mm mobile vegetation on the anterior leaflet of the mitral valve and an 11.2×5-mm nonmobile vegetation on the noncoronary cusp of the aortic valve. These findings raised strong suspicion of NVE. In this case, head computed tomography (CT) and magnetic resonance imaging revealed no cerebral infarction or hemorrhaging, although a mobile vegetation was detected.\n\nOn reviewing the clinical course until hospitalization, we noted that at the visit four months before admission, his WBC count had been slightly elevated. The following month, his albumin (Alb) level decreased to 3.0 g/dL, and his hemoglobin (Hb) level had shown a gradual decline over the 2 months prior to admission. During this period, he had experienced a 4-kg weight loss. Esophagogastroduodenoscopy and whole-body CT were performed, but no abnormalities were detected. One month later, he had regained some weight, and the laboratory findings had nearly normalized, except for a slightly elevated CRP level (0.54 mg/dL). At the last visit (8 days before admission), his WBC count had again risen to 9,300 /μL, while his Hb and Alb levels had again decreased to 13.1 g/dL and 3.0 g/dL, respectively. Furthermore, his CRP level had increased to 4.18 mg/dL. At that time, his diastolic blood pressure has shown an obvious decrease. Thus far, he had not experienced a fever or any symptoms other than weight loss. We suspected diseases of infectious and/or malignant origin and initiated comprehensive examinations to identify the source of his clinical findings.\n\nAfter heart failure treatment had been started, his clinical symptoms showed rapid improvement, and his hemodynamic stability was maintained during the first six hours. He initially received empirical intravenous antibiotic therapy consisting of 12 g/day of ampicillin sulbactam (ABPC/S) and 120 mg/day of gentamycin (GM). Three blood culture sets were obtained on the admission, and all were positive for S. warneri [minimum inhibitory concentration (MIC) to ABPC/S ≤8 μg/mL; MIC to GM ≤1 μg/mL; MIC to cefazolin (CEZ) ≤2 μg/mL]. Thus, IE caused by this organism was diagnosed.\n\nAccording to the clinical guideline established by the Japanese Circulation Society, emergency surgery is generally recommended for heart failure of NYHA III to IV or urgent surgery for NVE mobile vegetation exceeding 10 mm and severe valve dysfunction. In this case, however, his heart failure was successfully improved. Based on the guideline, the risk of embolism was considered to have been reduced by the administration of appropriate antibiotic therapy. In addition, the patient had type 1 diabetes, and his glycemic control was so poor that we were concerned that double-valve surgery would be a high-risk procedure. Therefore, we planned elective surgery after sufficient control of both infection and diabetes.\n\nBased on the blood culture results, the antibiotic regimen was switched to 6 g/day of CEZ. A detailed dental examination revealed no abnormalities, such as periodontitis. After four weeks of antibiotic therapy, he underwent surgical therapy. His aortic valve was found to be bicuspid, and the aortic and mitral annuli were intact without abscess formation. Large vegetations were exenterated, and the mitral and aortic valves were both replaced with mechanical valves. He experienced no postoperative complications and was discharged on the 22nd day after the operation without apparent embolism. He has not had any recurrence in over two years since the operation.",
    "summary": "A 59-year-old man with type 1 diabetes presented with heart failure. Echocardiography showed large vegetations on the mitral and aortic valves. Blood bacterial culture was positive for Staphylococcus warneri, a coagulase-negative staphylococcus (CoNS) family member. He was diagnosed with native valve endocarditis (NVE) induced by the resident bacteria and ultimately underwent double valve replacement. Retrospectively, slight laboratory data abnormalities and weight loss beginning four months before may have been signs of NVE. He had no history of immunosuppressive therapies or medical device implantation. "
  },
  {
    "id": "multiclinsum_gs_en_383.txt",
    "fulltext": "A 27-year-old woman with multiple colorectal cancers on a background of FAP was presented to our department. Notably, a large lesion was detected in the ascending, transverse, and sigmoid colon and the upper rectum, and pathological examination confirmed some of them as adenocarcinoma. Preoperative computed tomography revealed multiple lymph node swellings along the inferior mesenteric artery (IMA) and middle colic artery, without any evidence of distant metastases. After a comprehensive evaluation by a multidisciplinary cancer board, we decided to perform TPC with lymph node dissection of the entire colorectal region, using the Hugo RAS system as a surgical device.\n\nRobot-assisted TPC using the Hugo RAS system was approved by the Evaluating Committee for Highly Difficult New Medical Technologies (approval number H-0051) and the Institutional Review Board at Kyoto University.\n\nUnder general anesthesia, the patient was placed in a lithotomy position with the arms tucked. After a 5-cm vertical skin incision was made at the umbilicus, a wound-protecting device was applied. After pneumoperitoneum, 4 robotic trocars and 2 assistant trocars were placed. The instruments used in robot-assisted TPC with Hugo were a camera, monopolar curved shears for the right hand, bipolar fenestrated forceps for the left hand, and Cadiere/double fenestrated forceps for the reserve arm. Robot-assisted TPC with Hugo consists of 3 distinct steps, followed by transanal specimen extraction, ileal pouch construction through a small laparotomy, and ileal pouch-anus anastomosis (IPAA). Two table positions, Trendelenburg and flat, were required, each with specific docking tilts but the same angles of the arm carts throughout the robotic procedure. The detailed operative procedure is presented in Supplementary Videos.\n\nStep 1: Ascending colon complete mesocolic excision (CME)\n\nThe ascending colon CME from the caudal approach proceeded until the completion of the hepatic flexure mobilization (Supplementary Video S1).\n\nStep 2: Central vessel ligation (CVL) of the IMA, descending colon CME, and total mesorectal excision (TME)\n\nAfter CVL of the IMA, descending colon CME proceeded until the completion of splenic flexure mobilization, followed by TME until the intersphincteric space was fully exposed (Supplementary Video S2).\n\nStep 3: CVL along the superior mesenteric artery (SMA)\n\nAfter undocking all the robotic arms, the patient was placed in a flat position. Then, CVL along the SMA was performed to ligate the ileocolic, right colic, and middle colic vessels (Supplementary Video S3). The final step of this procedure was the ligation of the inferior mesenteric vein (IMV) at its root, which was exposed in Step 2.\n\nTransanal and small laparotomy procedures\nAfter transection of the terminal ileum, we extracted the specimen transanally by excising the rectal mucosa entirely from just below the dentate line because of multiple adenomas in the anal canal. After constructing the ileal pouch through the small umbilical incision and confirming that the ileal pouch could reach the bottom of the anal canal for anastomosis, transanal hand-sewn IPAA was performed. A diverting ileostomy was not performed.\n\nAll 3 steps were completed without conversion to open surgery. After undocking Hugo when we finished Step 3, we performed a laparoscopy to confirm hemostasis, specimen extraction, and appropriate anastomosis. The operative time was 632 min (36 min for Step 1, 160 min for Step 2, 188 min for Step 3, and 248 min for other procedures such as positioning, docking, specimen extraction, and anastomosis), with a minimal intraoperative estimated blood loss of 20 mL. The patient exhibited an uneventful postoperative recovery, with gas passage and initiation of liquid nutrition on postoperative day 1 (POD 1) and a solid diet on POD 3 with a functional ileal pouch and satisfactory anal function. Pathological examination revealed 2 sigmoid colon cancers (S1, Type 0-Ip, 55 × 50 mm, tub1, T1b, ly0, v0; S2, Type 0-Isp, 55 × 50 mm, tub1, Tis, ly0, v0) and 1 rectal cancer (R1, Type 0-Ip, 40 × 35 mm, tub1, Tis, ly0, v0). It also revealed 18 out of 89 positive lymph nodes, all of which belonged to the sigmoid colon and rectosigmoid lesions (stations #241, 242, and 251), resulting in UICC pT1bN2b stage.",
    "summary": "A 27-year-old woman with multiple colorectal cancers with a background of familial adenomatous polyposis underwent robot-assisted TPC, including lymph node dissection of the entire colorectal region using the Hugo RAS system. The robotic procedure was divided into 3 steps: 1) Trendelenburg position to perform ascending colon complete mesocolic excision (CME) to the hepatic flexure, 2) descending colon CME and total mesorectal excision with D3 lymph node dissection, and 3) flat position to perform central vessel ligation along the superior mesenteric artery. After undocking, the specimen was extracted transanally, and an ileal pouch was constructed from a small laparotomy at the umbilical incision, followed by ileal pouch-anal anastomosis. The operative time was 632 min, and the estimated blood loss was minimal. The postoperative period was uneventful."
  },
  {
    "id": "multiclinsum_gs_en_462.txt",
    "fulltext": "A 65-year-old male presented with swelling and boutonniere deformity on the right middle finger for six months after a motorcycle accident on January 1st, 2023. Initially, he managed the injury with painkillers and did not seek medical attention. After six months of persistent symptoms, including an inability to fully extend the finger and noticeable edema, he sought treatment.\n\nClinical findings\nThe inspection of the right hand showed the presence of deformity with edema. The active range of motion (ROM) was impaired in PIP joint in digiti III of the right hand. The active ROM of PIP joint digiti III of the right hand 45–110 degrees. The passive ROM of PIP joint digiti III of the right hand within normal.\n\nDiagnostic assessment\nWe performed X-ray of the right hand AP/Lateral which showed there are no abnormality in the bone and we diagnosed the deformity from soft tissue which is central slip injury.\n\nSurgical technique\nA central slip defect reconstruction utilizing partial ulnar side of flexor digitorum superficial tendon was performed. Under anesthesia, the patient was positioned supine with a tourniquet applied to the upper arm. A midlateral incision was made on the ulnar aspect of the right middle phalanx, centered at the PIP joint. The incision extended dorsally in an oblique manner. A transverse incision was made over the MCP joint flexion crease, just proximal to the A1 pulley. The procedure involves identifying and protecting the ulnar digital neurovascular bundle, exposing the central slip and extensor tendon to the PIPJ, full-thickness dorsal flaps are elevated. Scar tissue and pseudotendinous tissue is identified and excised. The central slip cannot be repaired primarily, so the ulnar slip of the FDS tendon is used for reconstruction. The ulnar neurovascular bundle is mobilized to visualize the periosteal insertion of the A3 pulley.\n\nThe extensor tendon is mobilized and tenolyzed, followed by incision of the dorsal capsule of the PIP joint and removal of interposed tissue. The A3 pulley's periosteal insertion is incised longitudinally, and the PIP joint's volar capsule is incised longitudinally. The ulnar slip of the FDS tendon is identified and a 2–0 non-absorbable, monofilament suture is placed around it. A transverse incision is made at the MCP joint flexion crease, proximal to the A1 pulley revealing the flexor tendon sheath. The tendon sheath and A1 pulley are incised longitudinally. The FDS tendon is identified. The ulnar slip of the FDS tendon is isolated and transected to release the ulnar slip, avoiding entrapment or catching of the radial slip. The 2–0 suture that was placed around the ulnar slip at the level of the PIP joint is used to release distally based FDS tendon slip and deliver the ulnar slip of the FDS tendon distally.\n\nA 2.8-mm drill is used to create a vertically oriented bone tunnel dorsal to volar. An elevator is placed between the flexor digitorum profundus tendon, volar plate, and volar aspect of the base of the middle phalanx protecting the volar anatomic structures. The FDS tendon slip passes through the tunnel while maintaining the PIP joint in extension and reduced position. The FDS tendon slip passed through the intact proximal section of the central slip and extensor tendon. A tendon weaver completes a Pulvertaft weave, confirming the appropriate tension with the PIPJ in the reduced, full extension position. A 3–0 non-absorbable suture secures the pulvertaft weave. The margins of the capsule and central slip reconstruction are approximated across the PIP joint, and adhesions are released and the lateral bands mobilized.\n\nThe overall posture, stability, and motion with tenodesis assessed. All the incisions are copiously irrigated. The tourniquet is deflated and hemostasis is obtained. Capillary refill of all fingers is assessed. The skin is closed using horizontal mattress stiches. A sterile dressing is applied with an appropriately padded PIP joint extension splint to allow for early DIP joint and MCP joint motion.\n\nFollow-up and outcomes\nFirst follow-up was done 4 days after for wound treatment. The patient was given oral meloxicam 7,5 mg twice a day and doxycycline 100 mg twice a day for 3 days. The second follow-up was done 3 days after for wound treatment. After 2 weeks, we remove the back slab, remove the external suture and begin the active and passive ROM exercise. After 3 weeks, the wound was healed, and we found the ROM of PIP joint 0 to 90 degrees. And after a month, the patient came with improved ROM of PIP joint 0 to 100 degrees, and improved functional outcome. After 7 weeks of physical rehabilitation, patients already back to work with improve ROM of PIP joint 0 to 110 degrees. The function of the patient's right hand is evaluated with DASH score, which improves significantly from 50 to 4.2.",
    "summary": "A 65-year-old male patient presented with swelling and boutonniere deformity on the digiti III of the right hand. The patient had previously fallen from a motorcycle, and the patient's right middle finger got was by a motorcycle six months ago. After the incident, the patient's right middle finger cannot be fully extended. The patient's right hand showed edema with flexion of the interphalangeal (PIP) joint and hyperextension of the distal interphalangeal (DIP) joint. The Range of Motion (ROM) of the PIP joint right middle finger was 45-110 degrees. The X-ray of the right hand AP/oblique showed no bone involvement in the deformity. The patient underwent central slip defect reconstruction utilizing the partial ulnar side of the flexor digitorum superficial tendon. A PIP joint extension splint was applied for 2 weeks. Active and passive exercise of the ROM of the PIP joint began after 2 weeks of PIP extension joint splinting. The patient's ROM of the PIP joint (0-90 degrees) significantly improved 1 month after surgery. The patient's ROM of the PIP joint returned to normal after 2 months after surgery. The function of the patient's right hand is evaluated with the DASH score, which improves significantly from 50 to 4.2."
  },
  {
    "id": "multiclinsum_gs_en_382.txt",
    "fulltext": "A 23-year-old male patient presented to the emergency department with a sudden onset of severe frontal headache lasting for 2 h. He experienced associated symptoms of nausea, vomiting, and chest heaviness. He has a unremarkable medical record and denies the use of illicit drugs. However, he is a smoker with a history of 23 pack-years but does not consume alcohol.\n\nOn physical examination, the young male appeared distressed but was fully conscious and oriented to time, place, and person. Chest auscultation revealed normal vesicular breathing sounds, while cardiovascular and abdominal examinations were inconclusive. Neurological examinations demonstrated neck stiffness, dilated pupils reactive to light, normal plantar reflexes, and no focal neurological deficits.\n\nHis vital signs were as follows: blood pressure 178/103 mmHg, respiratory rate 26 breaths/min, temperature 38.9°C, heart rate 87 beats/min, and oxygen saturation of 94%.\n\nEmergency tests were initiated. An ECG revealed ST segment elevation >2 mm in leads V2-V5, consistent with STEMI as the top of our differential diagnosis, requiring confirmation by cardiac markers. With prompt referral to a tertiary cardiac centre implemented, the patient received a 300 mg aspirin load while being transferred to the catheter lab. Troponin levels were significantly elevated at 1.48 mg/dl (normal <0.16 mg/dl).\n\nPercutaneous coronary intervention was performed via the femoral artery, and the result showed normal coronary arteries with thrombolysis in myocardial infarction (TIMI) flow grade of 3.\n\nHis ECG after coronary angiography revealed normal sinus rhythm with left ventricular hypertrophy LVH. An echocardiogram was performed, revealing normal ventricular function with no regional wall motion abnormalities (RWMA).\n\nFollowing coronary intervention, he was admitted to the medical ward for further assessment and investigation. Blood samples were drawn for a complete blood count, random blood sugar, renal function tests, and CRP. The results revealed lymphocytosis and mildly elevated CRP.\n\nWe proceeded further with CT brain to exclude serious cause of headache. His brain CT showed cisternal subarachnoid haemorrhage SAH with extension anterior to the right temporal lobe. Abdominal ultrasound screening was performed to rule out polycystic kidney disease which was negative and cerebral CT angiography was scheduled to exclude cerebral aneurysm Nimodipine 60 mg every 4 h was initiated, with a target blood pressure of 160/100 mmHg.\n\nOn the second day, his condition suddenly deteriorated, culminating with cardiac arrest. Therefore, cardiopulmonary resuscitation (CPR), resulting in a Glasgow Coma Scale score (GCS) of 6. The patient was subsequently, intubated and placed on mechanical ventilation in the Intensive Care Unit (ICU). Due to his unstable condition in the ICU, we could not perform a repeated CT brain scan or the planned cerebral CT angiography.\n\nOver the next 7 days, we diligently monitored him with a strict multidisciplinary team. A nasogastric tube was inserted for feeding and fluid replacement. His medications included intravenous fluids, antibiotics, proton pump inhibitors, and nimodipine.\n\nOn the 8th day, he suddenly developed ventricular fibrillation, and despite CPR with more than five defibrillations, we were unable to revive him and death was the final outcome.39734686",
    "summary": "We present a case detailing the diagnostic challenges of a 23-year-old male presenting with a sudden severe headache, nausea, vomiting, and chest heaviness. Initial evaluation showed elevated blood pressure and respiratory rate. An emergency electrocardiogram (ECG) indicated ST-segment elevation myocardial infarction (STEMI), leading to immediate referral for percutaneous coronary intervention, which revealed normal coronary arteries. Further investigations identified a cisternal subarachnoid haemorrhage (SAH) on CT brain imaging. Despite multidisciplinary management, the patient's condition rapidly deteriorated, resulting in cardiac arrest and mortality."
  },
  {
    "id": "multiclinsum_gs_en_58.txt",
    "fulltext": "Patient A.P., female, born in 1979, has been diagnosed with dilatation cardiomyopathy in 1996. Anamnestically, disease started with tonsillitis, possible myocarditis (which was never proven), with pronounced symptoms of heart failure and general symptoms. She was hospitalized and after one month, the left ventricular ejection fraction was 10% with the aforementioned signs of congestive heart failure. She was hospitalized for 10 months and 9 days, with standard therapy for vitally endangered patient, oxygen support, numerous adjuvant therapy, and intensive monitoring. Therapy was administered (ACE inhibitor - ramipril, cardiotonic - digoxin, beta-blockers - metoprolol and combination of diuretics - furosemide and spironolactone), with the indication of heart transplantation. Clinical improvement occured with an ejection fraction that was gradually increasing and at the age of 21 she entered in remission or stabilization phase, with the ejection fraction value of 48-57% (regular echocardiography was performed every three months). For the following four years therapy remained the same, but in Jun 2004 (after an episode of low immunity), ejection fraction fell to 25%, with a clinical deterioration of the disease. The patient was hospitalized for a period of two months, and the condition stabilized, and she was discharged with therapy that was the same but without cardiotonic. Ejection fraction was stabilized, and in year 2006 it was 50%. At the age of 27, the patient decided on the first pregnancy that was successful with beta blocker (metoprolol) in therapy. After the first pregnancy, the ejection fraction was 40% and she was treated with the same therapy with eplerenone (25 mg) instead of spironolactone. The ejection fraction was controlled and did not fall below 45%. At the end of 2015 the patient became pregnant for the second time, and the pregnancy went neatly until eighth month (35 weeks), when she was urgently admitted to hospital, due to sense of suffocation and inability to walk. Ejection fraction decreased to 18% (brain natriuretic peptide (BNP) was 2600 pg/ mL (reference values are 100-400 pg/ mL)). During pregnancy she received only metoprolol in therapy. Physicians decide to continue with her pregnancy, in the 39th week they performed c-section, and the condition stabilized again after twenty days. In October 2016 new mode of therapy was administered, ramipril (2.5 mg, in the morning), metoprolol (47.5 mg, in the morning), spironolactone (50 mg, once a day) and ivabradine (5 mg, twice a day) with torasemide (5 mg, once a day). LifeVest Defibrillator was carried from 06 December 2016 until 27 February 2017 when it was removed. When removed and after examination (ejection fraction was 44%) she continued with ramipril therapy (1.25 mg) metoprolol (23.75 mg), torasemide (5 mg), spironolactone (25 mg) and ivabradine (7.5 mg, twice a day) with potassium supplements, and compliance with non-pharmacological measures (fluid intake restricted to 1.5 L/ day). The echocardiographic finding in March 2017 showed left ventricular dilatation with moderately reduced left ventricular function and left ventricular wall hypokinesia with ejection fraction of 44% (insignificant pericardial effusion was present, inferior vena cava with physiological flow, preserved valves function - Dopler sonography showed slight insufficiency of mitral valve with dilatation of anulus). Evaluation of a patient with ejection fraction 44% showed no indication for an implantable cardioverter defibrillator (ICD), and conservative procedure and medication therapy were recommended. Regular check-ups and body mass reduction, regular control of renal function parameters and electrolytes were recommended. She is led under the diagnosis of dilated cardiomyopathy and heart failure NYHA stage II without any indication for the ICD prophylactic implantation.",
    "summary": "Patient A.P., female, 38 years old, had symptoms of dilated cardiomyopathy (with possible infectious myocarditis in the background) at age 17. After hospitalization for ten months and ten days, while waiting for heart transplantation (with threatening death outcome), without a clearly pronounced threatening arrhythmia, but with a low ejection fraction and a poor general condition, remission occurred. The therapy focused primarily on the treatment of heart failure, prevention of arrhythmia and thromboembolism. Normalization of the disease by improving the function of the left ventricle (expected in 16% of patients) occurred and lasted for 4 years, followed by an exacerbation of the disease that lasted for two years. In the next few years the patient was stable, had a first child with normal pregnancy. During the second trimester of the second pregnancy, there was an exacerbation (postpartum dilatation cardiomyopathy) lasting for couple of months. At the time of case report (May 2017), the patient is stable on therapy (ACE inhibitor, beta blocker, diuretics, If channel blocker), without limitation of physical capacity, mother of two children, unemployed."
  },
  {
    "id": "multiclinsum_gs_en_81.txt",
    "fulltext": "27-year-old male patient with a history of fibrous dysplasia in the right proximal femur, which was managed prophylactically to reduce the risk of fracture 20 years ago by curettage (intralesional resection), application of bone graft and fixation with osteosynthesis material, which was removed one year after the fixation. Two weeks before admission to hospital, the patient experienced pain after a fall with low energy mechanism characterised by axial load and rotational component of the right hip, which resulted in pain intensity 8/10 on the visual analogue scale (VAS) at the level of the inguinal fold and right thigh, which incapacitated him for walking. Radiological control was performed at four weeks, observing all prosthetic components adequately. The patient was discharged clinically and haemodynamically stable, without the need for transfusion of blood products. During his follow-up in the postoperative period (612 weeks), the patient continued with partial support until day 20, in which he began with full support even accompanied by a walker. Radiological control was performed at four weeks, observing all prosthetic components adequately. The patient is currently carrying out daily activities with slight limitation due to claudicatio intermittens caused by the incision in the middle gluteus. However, he was able to participate in low-impact sports activities, such as walking and expressed great satisfaction with the functional outcome of the procedure.\n",
    "summary": "We present the case of a 27-year-old male patient who presented to the emergency department with a fracture of the right femur at the base of the neck in pathological ground Garden II Pauwells III AO 31B2.3r, after a low energy mechanism of injury characterized by axial load with rotational component of the right hip. The patient had a history of intralesional resection, application of bone graft and prophylactic fixation with unspecified osteosynthesis material in the pertrochanteric region 20 years ago; the biopsy later showed DF; one year later, the osteosynthesis material was removed. Due to the characteristics of the fracture and as a definitive and curative therapeutic method, it was decided to carry out a wide resection of the proximal femur and total arthroplasty of the hip with a modular prosthesis with placement of cerclage, as well as a excisional biopsy that later corroborated that it was the same DF treated in childhood.\n"
  },
  {
    "id": "multiclinsum_gs_en_280.txt",
    "fulltext": "A 4-year-old boy with stage IV neuroblastoma received four cycles of chemotherapy, including high-dose chemotherapy including busulfan and melphalan, followed by autologous peripheral blood stem cell transplantation with autologous bone marrow supplementation. After eight additional cycles of chemotherapy consisting of temozolomide and irinotecan, which led to stable disease, the patient underwent preparative conditioning with fludarabine (150 mg/m2), melphalan (140 mg/m2), and 12 Gy of TBI for subsequent allogeneic CBT. The patient received tacrolimus and a short-term course of methotrexate for GVHD prophylaxis. The patient underwent engraftment on day 17. He then developed grade 3 GVHD, which was managed by increasing the prednisolone dose and was later discharged on day 85. The patient also received proton beam therapy (39.6 Gy) from days 121 to 150 post-transplantation for a right supra-mediastinum tumor with residual I123-MIBG accumulation in the right adrenal gland.\n\nThe patient remained healthy with no evidence of GVHD until presentation at our hospital with a productive cough on day 159. As his older brother displayed similar cold symptoms, a rapid antigen test for RSV was performed, which revealed a positive result. His respiratory symptoms gradually worsened, and he revisited our hospital on day 194 with dyspnea and intercostal retractions. Upon admission, he was given 0.7-1.0 mg/kg of prednisolone, which failed to improve his respiratory condition. Chest computed tomography on day 231 revealed infiltration, ground-glass opacity, and septal thickening in the bilateral lung fields along with right pleural effusion. Echocardiography showed an elevated tricuspid regurgitation peak velocity of 4.1 m/s and an interventricular septum close to the isobaric, indicating the presence of PH. In addition, pericardial effusion was detected. On day 231, the patient was transferred to the pediatric intensive care unit, where mechanical ventilation and inhaled nitric oxide (NO) were initiated. Thoracoscopic lung biopsy on day 244 revealed diffuse intra-alveolar hemorrhage and edema on hematoxylin-eosin (HE)-stained samples. Elastica van Gieson staining revealed diffuse obstructive lesions due to fibrocellular components with plump endothelial cells in the pre-septal pulmonary veins and venules. While pulmonary muscular arteries and arterioles showed mild medial hypertrophy and focal intimal thickening (Heath-Edwards Grade 2), severe stenosis with concentric intimal fibrosis or plexiform lesions was present. Based on these results, the patient was diagnosed with PVOD with mild pulmonary arterial/arteriolar lesions. Of note, HE staining also revealed enlarged type II pneumocytes with multinucleated and giant cell-like features, indicating the presence of prior lung injury that was likely attributable to his preceding viral infection.",
    "summary": "A 4-year-old boy was diagnosed with metastatic neuroblastoma and underwent intensive chemotherapy, autologous HSCT, and allogeneic cord blood transplantation (CBT). He experienced PVOD on day 194 following CBT after displaying upper respiratory symptoms and positive RSV antigen test results approximately one month prior. Pathological examination of a lung biopsy specimen revealed lung injury suspected to be associated with viral infection in addition to PVOD-related findings, suggesting that RSV infection might have contributed to the onset of PVOD."
  },
  {
    "id": "multiclinsum_gs_en_160.txt",
    "fulltext": "65-year-old male with no personal or family history of pathology of relevance. His condition began in 2020 with productive cough that intensified and was accompanied by shortness of breath with small to medium effort; as well as loss of 10 kg of weight in a period of 4 months. He went to a doctor who requested a chest X-ray that showed massive, multilocular right pleural effusion with right bronchial obstruction and mediastinal lymphadenopathy. A thoracocentesis was performed with a biopsy of the right lung and parietal pleura. The histopathological study reported an adeno-squamous carcinoma. His evolution was bad, which is why he was referred to our institution. On admission, a physical examination found him cachectic, with right pulmonary hypoventilation, 92% oxygen saturation and pneumokoccal dysfunction, with no evidence of systemic or haemodynamic compromise. A chest X-ray was performed that showed complete opacity of the right hemithorax, and a pleural catheter was placed with a serohematic flow. In the histopathological study of the revision material, the lung parenchyma was replaced by a poorly differentiated neoplasm with a solid mantle and syncytia, surrounded by abundant lymphocytes and plasma cells. The neoplastic cells had large, ovoid nuclei, fine chromatin, prominent nucleolus and wide, poorly defined cytoplasm. An immunohistochemical study was performed that was positive for CKAE1/AE3, CK 5/6, p63, EBER ISH, and negative for Napsina A, TTF-1 and CK 7, which ruled out the reference diagnosis of adeno-squamous carcinoma and established the diagnosis of CTLP. Molecular study in the paraffin block was positive for PD-L1 (SP263) +++ in approximately 100% of the neoplastic cells, and negative for EGFR, K-RAS, ALK, ROS1. In order to confirm the pulmonary origin of the neoplasm, a nasopharyngeal examination was performed that was negative. In April 2021, a PET-CT was performed that reported a heterogeneous parahilary pulmonary lesion that compromised the main bronchus and caused atelectasis; as well as multiple cervical, mediastinal and peri-gastric lymphadenopathies. The catheter was removed due to partial resolution of the effusion and chemotherapy treatment with gemcitabine/cisplatin was initiated. He received 6 cycles, however, the patient reported hearing loss and AKIN I acute renal failure was documented, so cisplatin was changed to carboplatin, and maintenance durvalumab was continued. In December 2021, disease progression was documented and he died in January 2022 due to respiratory failure.\n",
    "summary": "We report the case of a 65-year-old man with a pulmonary lymphoepithelioma-like carcinoma, who presented with cough, dyspnea, and weight loss. A chest CT scan showed a poorly defined nodule located in the right lung. A trans-thoracic biopsy of the lesion was performed, and microscopic examination revealed large polygonal cells arranged in sheets, infiltrated by abundant lymphocytes and plasma cells, around the interstitium. The neoplastic cells were positive for cytokeratin 5/6 and p63, and negative for Napsina A and thyroid transcription factor 1 (TTF-1). PD-L1 expression was positive (approximately 100%) by immunohistochemistry; as was the nucleus of the neoplastic cells by in situ hybridization for Epstein-Barr virus-encoded RNA (EBER-ISH). The patient received six cycles of a combination chemotherapy regimen based on platinum (gemcitabine/cisplatin) plus durvalumab. He progressed and ultimately died 9 months after diagnosis.\n"
  },
  {
    "id": "multiclinsum_gs_en_436.txt",
    "fulltext": "A 13-year-old male patient was admitted to the Children’s Hospital in Damascus after noticing a palpable enlarged mass in the left inguinal region. His medical history was unremarkable except for a surgical intervention on his spine 6 years ago due to an accident, which resulted in the loss of motor function and sensation in both of his lower extremities.\n\nDue to the long period he had spent in bed, the patient developed decubitus sores on his left foot. The only finding on clinical examination was a mass in the left inguinal area, which was movable on deep structures and so was the overlaying skin on it. The mass was not tender on palpation, and no signs of local inflammation were observed.\n\nLaboratory tests revealed an Elevated ESR (119 mm/h in the first hour). Other Basic Laboratory tests including (Complete Blood Count, Liver function tests, electrolytes, Urea, Creatinine and LDH) were ordered and were within normal ranges for age. Ordering these tests was essential to rule out systemic diseases. Given the absence of indicative physical findings for systemic disorders or immunodeficiencies, additional tests like those for HIV or Direct Antiglobulin were deemed unnecessary.\n\nA CT of the abdomen, chest, and pelvis showed enlarged lymph nodes inferior to the inguinal ligament, with the largest measuring approximately (3.5 × 2.4 cm). Other organs and nodes were within normal limits.\n\nAll of the above-mentioned investigations were essential to rule other high-risk diagnosis including lymphoma and leukemia. However, these were not sufficient to reach the definite diagnosis, so a decision of surgical resection of the nodes was taken.\n\nTo confirm the diagnoses and exclude other potential differentials presenting with enlarged lymph nodes, surgical removal of all of these enlarged nodes was performed under general anesthesia, and biopsies were sent for microscopic study.\n\nThe biopsy showed hyperplastic nodal architecture with proliferation of histiocytes and plasma cells with vascular proliferation, consistent with Plasma cell subtype of Castleman’s Disease.\n\nThe patient was discharged from the hospital after 14-day period after ensuring that there were no remaining enlarged lymph nodes. The only recommendation was oral prednisolone. The patient underwent follow-up using a whole-body CT scan every three months. During each hospital visit, a comprehensive clinical examination and laboratory tests (e.g. Complete Blood Test, ESR, C-reactive protein, liver function tests, renal function tests) were performed in addition to the CT scan. After a 12-month follow-up period, the patient reported no new symptoms or enlarged lymph nodes. Additionally, no abnormalities were observed during clinical examination or in laboratory tests.",
    "summary": "We report a unique case of a 13-year-old boy who presented with a palpable enlarged mass in the left inguinal region without any constitutional symptoms. Surgical removal of this mass was essential to exclude worrying causes. Pathologic examination revealed proliferative changes consistent with Castleman's disease plasma cell type which is one of the rarest forms of the disease in children. To our knowledge, this case is the first reported case of Unicentric Castleman Disease (UCD) in the inguinal area. During a 12-month-period of follow-up, no additional lymph node enlargements or other symptoms were reported."
  },
  {
    "id": "multiclinsum_gs_en_116.txt",
    "fulltext": "The medical records of patients with a diagnosis of congenital myotonia studied and followed in the pediatric neurology consultation in a third-level hospital between 2015 and 2020 were reviewed. The inclusion criteria were to present a clinical diagnosis – myotonia, warm-up phenomenon, characteristic electromyographic pattern and/or family history – and/or a molecular diagnosis (mutation in the CLCN1 gene). The clinical signs and symptoms, as well as the results of the complementary explorations and the genetic mutation found, were collected by reviewing the medical record. Demographic variables (age and sex), course of the disease (age of onset, symptoms and signs, time elapsed until diagnosis and clinical evolution), family history and evaluation of the response to treatment were collected.\n\nFive cases with clinical diagnosis of congenital myotonia were identified (three with Becker's disease and two with Thomsen's disease). The incidence in relation to the number of births was estimated at 1:15,000 newborns for cases with Becker's phenotype and 1:21,000 newborns for Thomsen's phenotypes.\n\nMost of our patients were female, and the male was the only one who started before the age of six. The initial clinical presentation included myotonia in the lower limbs in four of the five patients and in the upper limbs in all but one. The age at onset ranged from 22 months to 12 years, with a median of 6 years. Genetic diagnosis was performed in all cases approximately two years after onset, and the family of one patient refused to have it performed. All had a worsening with cold, but the warming phenomenon was only in those with the Becker phenotype.\n\nPatients with recessive congenital myotonia showed some progression. As a family history, it is worth noting that patients 2 and 3 were sisters, without the parents showing any clinical signs, and that the mother of patient 1 showed mild clinical signs that were doubtful with the cold. The patient who refused the study had a history of myotonia in the maternal branch.\n\nBlood tests did not show elevated creatine kinase in any of the patients. The electromyogram was abnormal in all patients except the first one at 2.8/12 years of age. The test was not repeated later because it was not considered necessary.\n\nThe most used treatment initially was oxcarbazepine (in patients with recessive form), with a good response in general. In case 2 it lost efficacy with time and mexiletine was initiated. Patient 4 initiated several drugs without success due to loss of efficacy or side effects. Patient 5 rejected treatment due to mild clinical presentation.\n\nPatient 1 had a previously undescribed, likely pathogenic mutation (CLCN1: c.824T>C) inherited from his mother. Cases 1 to 3 had the Becker phenotype with composite heterozygosity mutations, and cases 4 and 5 had the Thomsen phenotype. Case 5 declined genetic testing.\n",
    "summary": "The medical records of patients with a diagnosis of congenital myotonia studied and followed in the pediatric neurology consultation in a third-level hospital between 2015 and 2020 were reviewed. Demographic variables (age and sex), course of the disease (age of onset, symptoms and signs, time elapsed until diagnosis and clinical evolution), family history and evaluation of the response to treatment were collected. Five cases with a clinical diagnosis of congenital myotonia were identified (three with Becker disease and two with Thomsen disease). The incidence in relation to the number of births was estimated at 1:15,000 newborns for cases with a Becker phenotype and 1:21,000 newborns for Thomsen phenotypes. We found a probably pathogenic mutation not previously described (CLCN1: c.824T>C).\n"
  },
  {
    "id": "multiclinsum_gs_en_322.txt",
    "fulltext": "A 67-year-old female patient presented with a six-year history of recurrent swelling in the left lower limb. One year prior, she was diagnosed with an AVM in the lower limb at another hospital. Two months before hospitalization, the patient underwent embolization treatment, which included the placement of two coils (20 mm x 40 cm, BSX, USA). Despite this intervention, the patient’s left lower limb swelling did not show any improvement. The patient has been experiencing fatigue and difficulty of breathing for a month. As these symptoms of heart failure progressed and worsened, the patient was transferred to Chengdu University of Traditional Chinese Medicine Hospital for further evaluation and treatment. The patient had no prior history of cardiovascular diseases, injuries, or surgeries. However, she reported a history of oral estrogen use for menopausal syndrome seven years ago.\n\nShe exhibited significant edema and skin sclerosis in the left lower limb. Additionally, absent pulses were observed in the popliteal artery and distal regions. A noticeable tremor was also present in the left thigh. The patient was seated during the examination. Echocardiography revealed cardiac enlargement, along with moderate mitral regurgitation and severe tricuspid regurgitation. The left ventricular ejection fraction (EF) was measured at 60%, and there was an elevation in b-type natriuretic peptide (BNP) levels to 2853 ng/L. The electrocardiogram showed a sinus rhythm with a heart rate of 105 beats per minute and evidence of left atrial enlargement. Chest CT scans confirmed cardiac enlargement, while no respiratory system abnormalities were detected. Preoperative computed tomography angiography (CTA) provided further insights, revealing a left iliac artery aneurysm, a significantly enlarged femoral artery, and complex AVMs in the superficial femoral artery. Additionally, the femoral and superficial veins appeared significantly enlarged on arterial phase imaging. Notably, the left lower limb popliteal artery and anterior tibial artery were not visualized. Based on these findings, the patient was diagnosed with complex congenital lower limb AVMs, acute exacerbation of chronic heart failure, and classified as NYHA Class IV.\n\nThe patient exhibits distinct symptoms of acute heart failure, and preoperative ultrasound assessment has revealed a volume flow of 3400 ml/min in the CFA. Given that embolization using coils may not effectively reduce the flow rate of the AVMs, the utilization of covered stents is a viable option. These stents effectively decrease the flow of lower limb AVMs, thereby improving the patient’s heart failure condition. Additionally, staged embolization treatment can further enhance the treatment outcome by improving the nidus of the lower limb AVMs.\n\nCTA of the patient revealed significant dilatation of blood vessels, with a maximum diameter of 32 mm for the iliac artery, 27 mm for the common femoral artery (CFA), and 22 mm for the superficial femoral artery (SFA). To minimize access site complications, antegrade access was achieved through a surgical approach of the CFA. Under general anesthesia, intravascular covered stents were inserted through an open femoral artery approach, utilizing 14 F (Cook Medical, USA) catheter sheaths intraoperatively. complex AVMs were visualized in the superficial femoral artery and profunda femoris artery, accompanied by early visualization of an enlarged femoral vein.\n\nPreoperative CTA measurements indicated a diameter of 19 mm for the middle segment of the SFA, leading to the selection of a 20 mm–12 mm/120 mm aorto-uni-iliac covered stent (MicroPort, China). A 0.035 guidewire, in conjunction with a single-curve catheter, was used to access the popliteal artery. Subsequently, it was replaced with a 0.035 super-hard guidewire to provide support during the implantation of the stent graft. The stent was deployed precisely at the distal end of the superficial femoral artery, the location with the highest concentration of AVMs. Completion angiography revealed a significant reduction in venous opacification around the stent and clear visualization of the popliteal artery. Postoperatively, the left femoral artery was sutured using a 6 − 0 vascular risk suture, resulting in a significant improvement in the patient’s heart failure symptoms. The patient has heart failure, so the surgery duration should not be excessive. It is planned to perform embolization treatment in the second phase.\n\nOne week post-treatment, ultrasound examination revealed a reduction in volume flow to 1600 ml/min in the CFA, with a BNP level of 1198ug/l. Targeting the nidus with embolization therapy is expected to further decrease the flow velocity of arteriovenous malformations. The right CFA was punctured, allowing the insertion of a 5 F arterial sheath and a 5 F catheter for angiographic examination. Guided by ultrasound, the drainage vein of the AVM was punctured, and a 5 F vascular sheath was introduced. The contrast agent confirmed the presence of a nidus and its draining veins. The embolization procedure of the draining veins involved the use of a coil (18–20 mm x 40 cm, BSX, USA), two microcoils (4 mm x 42 mm, 5 mm x 10 mm, USA), 3% polidocanol (6 mL Kruelle, Germany), and 99% anhydrous ethanol (10 mL).\n\nCompletion angiography showed a significant reduction in the visualization of AVMs and draining veins, indicating their disappearance. During the one-year follow-up, the patient exhibited notable improvement in lower limb swelling and cardiac function. The volume flow in the CFA decreased to 780 ml/min. Echocardiography revealed minor enlargement of the left and right atria, slight mitral and tricuspid regurgitation, and a left ventricular ejection fraction (EF) of 71%. Notably, BNP levels decreased significantly.",
    "summary": "We present a case involving a patient with congenital AVMs in the lower limb, who had suffered from prolonged swelling in the left lower limb and recently developed symptoms of heart failure. At the age of 67, the patient was definitively diagnosed with a complex congenital AVMs in the lower limb. This article delves into the practical experiences and limitations encountered in employing an abdominal aortic stent graft, coupled with embolization, to address acute heart failure caused by complex congenital AVMs in the lower limb."
  },
  {
    "id": "multiclinsum_gs_en_384.txt",
    "fulltext": "28-year-old male patient with no significant history presented to the dermatology department with a 48-hour history of a skin condition characterized by two erythematous plaques with central vesicles and superficial ulceration located on the flexor surface of the right arm and forearm equidistant from the elbow crease, accompanied by a burning sensation and pruritus at the site of the lesions. He did not have systemic symptoms or self-medicate. As a background, he reported that he was on vacation in the coastal region of Ecuador at the time of the lesions. An incisional biopsy was performed that reported epidermis with acanthosis, parakeratosis and spongiosis, neutrophils in the stratum corneum and perivascular lymphocyte infiltration in the superficial, middle and deep dermis. Based on the clinical characteristics, the background of travel to a tropical region and the histological findings, a diagnosis of Paederus dermatitis was made. Treatment with antihistamines, topical steroids and cold compresses was indicated. After 8 days of treatment, the lesions resolved, leaving a post-inflammatory hyperpigmentation.\n",
    "summary": "The case of a 28-year-old male patient who presented to the dermatology department with a 48-hour history of two erythematous plaques with central vesicles and superficial ulceration located on the flexor surface of the right arm and forearm, accompanied by a burning sensation and pruritus at the site of the lesions, without accompanying symptoms, is reported. As a background, he stated that he was on vacation in the coastal region of Ecuador at the time of the lesions. An incisional biopsy was performed and, due to the clinical characteristics and the background of travel to a tropical region, the diagnosis was made as dermatitis by Paederus and treatment with antihistamines, topical steroids and cold compresses was indicated. After 8 days of treatment, the lesions subsided, leaving a post-inflammatory hyperpigmentation.\n"
  },
  {
    "id": "multiclinsum_gs_en_268.txt",
    "fulltext": "Technique\nInformation about the procedure of TFD.\nThe patient receives intravenous photosensitizer (Photogen®, King of Prussia, PA, USA - 1.5 mg/kg) 24 h before the procedure. Its peak light absorption is at the wavelength of 630 nm. The procedure begins with standard duodenoscopy (Olympus TJF-180) under general anesthesia. After the identification of the greater duodenal papilla and the retrograde cannulation, the digital cholangioscope (SpyGlassTM DS, Boston Scientific, Natick, MA) is introduced into the common bile duct. Then the cholangioscopic examination helps to identify the neoplastic stenosis. Under direct visualization, the illumination catheter (Medlight S.A., RD10-323, Switzerland) is advanced through the cholangioscope. This consists of a typical three-way cannula. The first port has a 1 cm long cylindrical light diffuser at the end. Two black radiopaque marks demarcate the limits of the diffuser. The second port accommodates a 0.025 inch guidewire and the third is a portal for injection. After positioning under cholangioscopic guidance, illumination is initiated. The dose is 90 J/cm², with a power of 70 mW/cm². Repositioning is recommended every centimeter to cover the entire stenosed area. At the end of the procedure, new cholangioscopy evaluates the bile duct for immediate outcome and adverse events.\n\nPost-procedure care\nThe patient is fasted for the next 24 h. If no adverse event is detected, oral diet is initiated. Discharge from hospital is done under strict guidance on photoprotection (prevention of exposure to light and use of sunglasses), especially during the first week after the session of TFD.\n\nRESULTS\nThis procedure was performed in an 82-year-old man who presented to our tertiary center with obstructive jaundice and weight loss over the previous two months. Endoscopic ultrasound (EUS) revealed severe dilation of the common bile duct associated with choledocholithiasis. ERCP confirmed these findings but was unable to remove the stones due to the disproportionate dilation of the common bile duct. Therefore, a plastic biliary stent was chosen. The patient showed improvement in his clinical condition, but the cholestasis returned 45 days after the first procedure. Two other ERCPs failed to remove the stones. During the third procedure, a long irregular stenosis of the common hepatic duct was apparent and he was referred for another echoendoscopic evaluation.\n\nIn addition to the choledocholithiasis, the new EUS revealed a dilated common hepatic duct with a well-circumscribed hypoechoic solid mass measuring 1.8x2 cm, which was compressing the common hepatic duct. The mass appeared to also involve the common hepatic artery. An ultrasound-guided needle biopsy confirmed the diagnosis of moderately differentiated cholangiocarcinoma (Bismuth I).\n\nAfter staging, the mass was considered inoperable and the patient was referred for palliative treatment. After a multidisciplinary meeting with the oncology team, adjunctive PDT was proposed to treat the recurrent biliary obstruction. The procedure went without complications and lasted 150 minutes. At the end, a biliary drainage was performed with a 10 Fr plastic stent, since a self-expanding metal stent was not available at that time.\n\nThe patient showed no signs or symptoms of photosensitivity in the following week. There was, however, early recurrence of cholestasis complicated with cholangitis. ERCP revealed obstruction of the stent with debris and biliary sludge secondary to tumor necrosis. A biliary scan followed by new drainage resolved the patient's acute condition. Subsequently, he remained asymptomatic for three months, the longest period since the onset of the disease. At his next recurrence, he was drained with a self-expanding metal stent. He continued with systemic treatment and eventually required a duodenal stent for palliation of dysphagia. He died due to complications of pulmonary metastases two years after the onset of symptoms and 15 months after the session of TFD.\n",
    "summary": "Patient receives intravenous photosensitizer 24 h before the procedure which begins with regular duodenoscopy. After identification of the main papilla and retrograde cannulation, the digital cholangioscope is introduced into the common bile duct. Then the cholangioscopic examination helps to identify neoplastic stenosis. Under direct visualization, the illumination catheter is advanced through the cholangioscope. Repositioning is done every centimeter. At the end of cholangioscopy, the bile duct is evaluated for immediate outcome and adverse events.\n\nResult: This procedure was performed in an 82-year-old man with obstructive jaundice for the past two months. EUS and ERCP revealed severe dilation of the common bile duct associated with choledocholithiasis. In addition, there was dilation of the hepatic duct to a well-circumscribed hypoechoic solid mass measuring 1.8x2 cm, compressing the common hepatic duct. It was considered inoperable and the patient was referred for palliative treatment with PDT, which remained asymptomatic for three months. He died of complications 15 months after the PDT session.\n"
  },
  {
    "id": "multiclinsum_gs_en_201.txt",
    "fulltext": "A 77-year-old woman with haematemesis presented to the emergency room. Her medical history included only hypertension and dyslipidaemia. When she presented to the emergency room, her vital signs indicated shock (heart rate: 100 beats/min, blood pressure: 79/56 mmHg), and blood tests revealed anaemia (haemoglobin: 9.6 g/dL), which suggested upper gastrointestinal bleeding.\n\nNon-contrast-enhanced CT was performed immediately because of renal dysfunction. CT revealed that the third part of the duodenum flexed steeply on the right side of the aorta and ran caudally, without crossing anterior to the aorta. The jejunum was located on the patient’s right side. The second part of the duodenum and the stomach were dilated, and there were high-density gastric contents that were considered to indicate a haematoma.\n\nUpper gastrointestinal endoscopy was performed following the CT examination, which revealed a mucosal laceration at the gastric cardia. Bleeding from lacerations of the cardia of the stomach as a result of forceful vomiting was first reported by Mallory and Weiss in 1929.1 In our case, the third part of the duodenum flexed steeply, and the lumen was narrowed, which caused an obstruction. As a result, repeat vomiting was considered to have caused Mallory–Weiss syndrome.\n\nOn the basis of the CT findings showing that the duodenal-jejunal junction was located in the right hemi-abdomen, intestinal malrotation was suspected.2 However, 7 days later, when CT was repeated, spontaneous resolution of the malpositioned jejunum was seen. The patient was then discharged from the hospital. However, months later, she was rushed to the emergency room for repeat haematemesis. Dynamic CT was performed before upper gastrointestinal endoscopy, on admission, and revealed contrast extravasation in the dilated stomach. Additionally, the third part of the duodenum was flexed on the right side of the aorta, and the duodenal-jejunal junction and jejunum were again located in the right hemi-abdomen. Upper gastrointestinal endoscopy revealed a laceration at the gastric cardia, as in the previous endoscopy, which was considered Mallory–Weiss syndrome.\n\nTwo months after the second episode of haematemesis, the patient presented to the emergency room with nausea. Non-contrast-enhanced CT revealed no abnormalities in the duodenal positioning, but there was oedematous wall thickening in the second part of the duodenum. If we had not had previous CT images, we would have suspected duodenitis, but on the basis of all of the CT findings, we suspected the possibility of an underlying condition after the right-sided deviation of the small intestine had resolved spontaneously.\n\nIn summary, CT was performed 4 times over 5 months. The third and fourth parts of the duodenum and the jejunum deviated repeatedly, but this resolved spontaneously, which is not indicative of intestinal malrotation. Therefore, we diagnosed dysplasia of the ligament of Treitz.\n\nClinical outcomes\nThe patient underwent laparotomy, which revealed no abnormalities in the relative position of the duodenum to the jejunum. Additionally, the jejunum was located on the patient’s left side, and there was no intestinal malrotation. The ligament of Treitz was formed; however, its fixation in the upper jejunum was incomplete as it was attached only to the duodenum. The duodenal-jejunal junction was not fixed to the retroperitoneum, and the jejunum folded easily with the ligament of Treitz as a fulcrum. Surgically, the upper jejunum was fixed with 4 sutures to the retroperitoneum on the patient’s left side. The postoperative course was good, and the patient has remained symptom-free.",
    "summary": "A 77-year-old woman underwent CT to evaluate haematemesis. The images showed that the third part of the duodenum flexed steeply on the right side of the aorta and ran caudally, without crossing anterior to the aorta. The duodenal-jejunal junction and jejunum were located on the patient's right side. Upper gastrointestinal endoscopy revealed a laceration at the gastric cardia, and a diagnosis of Mallory-Weiss syndrome was made. Repeat CT 7 days later revealed that the abnormal positioning of the intestinal tract had resolved spontaneously. Two months later, the patient experienced another episode of haematemesis, and CT revealed repeat deviation of the duodenal-jejunal junction and jejunum to her right side. Upper gastrointestinal endoscopy revealed another laceration at the gastric cardia, as in the previous study. On the basis of the initial CT findings showing the duodenal-jejunal junction in the right hemi-abdomen, intestinal malrotation was suspected. However, because the jejunum deviated repeatedly to the right side but resolved spontaneously, we diagnosed dysplasia of the ligament of Treitz. Laparotomy revealed a formed ligament of Treitz; however, fixation in the upper jejunum was incomplete. Additionally, CT revealed that the anterior pararenal space was loosely fixed and mobile. These factors may have caused the right-sided deviation of the small intestine."
  },
  {
    "id": "multiclinsum_gs_en_24.txt",
    "fulltext": "Patient and observation\nPatient information (presentation of the patient): he is a 28-year-old single man without children, an active military. He has been present for 5 weeks with progressive abdominal pain, more marked in the epigastrium and the right hypochondrium, followed shortly after by a non-quantified fever, chills, profuse sweats in a context of anorexia and weight loss of 6 kg. Note that the patient is not a drinker or smoker, vaccinated with BCG and has no other contributing personal or family history.\n\nClinical findings: On admission, the physical examination found the patient in a general altered state, asthenic with a weight loss of 6 kg in one month. A clinical systemic inflammatory response syndrome was present with the following elements: a fever of 39.1 °C, tachycardia (124 beats/min), polypnea (22 cycles/min). The pulmonary examination and exploration of the superficial lymph node areas were without particularity. In the abdominal area, moderate sensitivity in the right hypochondrium with hepatomegaly was found.\n\nChronology: dates back to February 2022 with the onset of diffuse abdominal pain with diarrhea-constipation transit disorder, all in a context of preservation of general condition with low-grade fever predominantly at night. A syntagmatic treatment was unsuccessfully initiated. The evolution is marked by the persistence of low-grade fever associated with anorexia and progressive weight loss of 12 kg over three months. In the face of this transit disorder with unexplained fever and the deterioration of the general condition, the patient will be admitted to the emergency department for further investigation.\n\nDiagnostic approach: upon admission, a biological infectious syndrome was reported with a neutrophilic predominant hyperleucocytosis (17800 cells/mm3) and a high C-reactive protein of 323 mg/L.\n\nIn the face of his abdominal pain, the lipase and troponin tests were normal at 38 IU/L (VN: <3 78 IU/L) and 4 ng/L (VN: 2 to 16 ng/L) respectively. The liver function was stable with ALT (alanine amino transferase) at 22 IU/L (VN: < 40UI/L), AST (aspartate amino transferase) at 17 IU/L (VN: < 35UI/L), GGT (gamma glutamyl transferase) at 42 IU/L (VN: < 50UI/L), PAL (alkaline phosphatase) at 115 IU/L (VN: 40- 150 IU/L) and normal bilirubinemia. The liver function was normal with a prothrombin rate of 78% and an albuminemia of 39 g/L. The blood ionogram and renal function were normal. The chest radiograph and abdominal ultrasound were without particularity.\n\nWith a procalcitonin positive at 4.1 ng/L, an infectious disease assessment to search for the infectious focus was initiated, including a cytobacteriological examination of urine and blood cultures during the febrile peaks at 39°C, which were both negative. The hepatitis viral B, C and HIV serologies, as well as the syphilis serology performed in hospital were all negative. The lactate dehydrogenase (LDH) and beta-2 microglobulin were normal at 231 IU/L and 2.28 mg/L respectively. The GeneXpert to search for the Mycobacterium on these bioptic pieces was negative. The quantiferon was negative. The search for the Mycobacterium on the morning expectorations of 3 consecutive days was negative.\n\nOn the morphological level, a thoraco-abdomino-pelvic scan showed an enlarged liver (hepatic arrow at 17 cm), the site of multiple, well-defined, rounded hypodensities, which were not enhanced after injection of the contrast agent. The largest lesions were in segment I (21 x 16 mm) and segment V (36 x 27 mm). No suspicious lesions were detected in the thoracic and pelvic levels. The first liver biopsies obtained by echo-guided puncture revealed subacute, fibro-inflammatory liver lesions, with no histological evidence of specificity or malignancy.\n\nA liver MRI following the scan objectified a dysmorphic liver, the site of lesions in heterogeneous signal T2 surrounded by a wall in hyper signal T2, enhanced in the periphery after injection of the contrast agent, the largest of which is located in segment I (20 x 22 mm) and in segment V (33 x 31 mm). No deep lymphadenopathy had been objectified, either in the scan or in the MRI. A diagnostic laparoscopy performed on the hepatic nodules, the histological examination found epithelioid and gigantocellular granulomas of varying size with caseous necrosis in favour of a hepatic tuberculosis.\n\nTherapeutic intervention: the patient was put on anti-tuberculosis treatment according to the standard protocol for months: Phase 1: quadritherapy (Isoniazide + Rifampicine + Pyrazinamide + Ethambutol) in a single oral intake each morning on an empty stomach for 2 months. Phase 2: bithrapia (Isoniazide + Rifampicine) in a single oral intake each morning on an empty stomach for 4 months\n\nFollow-up and results of therapeutic interventions: from the first days of treatment, a good response was obtained with disappearance of the inflammatory syndrome with systemic response both clinically and biologically. After three months of treatment, a control scan of the liver showed a decrease in the number and volume of liver lesions.\n",
    "summary": "This clinical case was reported in a young Moroccan, presenting a picture of hepatic colic that had been developing for a month, associated with subtle signs of tuberculous infection. Non-specific hepatic nodular lesions were revealed on the scanner and on the hepatic magnetic resonance imaging (MRI). The diagnosis of focal hepatic tuberculosis was confirmed after pathological analysis of hepatic nodule biopsies obtained after a laparoscopy. After the start of well-conducted anti-bacillary treatment, a good clinical-biological improvement was obtained.\n"
  },
  {
    "id": "multiclinsum_gs_en_40.txt",
    "fulltext": "A 12-year-old boy with Down Syndrome and motoric disorders was referred from the Pediatric Department to the Oral Medicine Department of RS Hasan Sadikin Bandung. The patient was diagnosed with Down Syndrome and myeloradiculopathy. The patient’s mother said that the patient was admitted to the hospital because of weakness in both patient’s hands and feet. The patient had a history of falling down about one year ago. The patient’s mother also had a difficulty in cleaning the patient’s oral cavity regularly.\n\nIn the extraoral examination, the patient had a dysmorphic face. The patient also had a cracking and desquamative condition of the vermillion border of the lips. Lymph node examination could not be assessed because the patient wore a cervical collar. The intraoral examination showed an irregular ulcer with 1×0.7 cm in diameter, indurated margin, and white-yellowish base at the right lateral border of the tongue. There was dentinal caries on 63 tooth and also the tooth remnants on 55, 62, 74, and 85 teeth. The upper and lower tooth remnants were suggested to be extracted by pediatric dentist. The space of the extracted teeth will be maintained using a space maintainer. The 55 tooth was sharp and caused an occlusion trauma to the right lateral border of the tongue.\n\nLaboratory examination showed a decrease in sodium value (130 mEq/L) and an increase in lymphocyte value (46%). The MRI examination was performed in the Radiology Department to determine the presence of abnormalities in the cervical spine. The results of the MRI examination showed a dislocation of the patient’s cervical spine. The patient’s mother provided informed consent to publish the patient’s case details and any accompanying images.\n\nBased on the history review, the clinical examination, and appropriate investigation, the patient was diagnosed with a chronic traumatic ulcer mimicking OSCC, exfoliative cheilitis, reversible pulpitis of 63 teeth, and radix gangrene on 55, 62, 74, and 85 teeth. The diagnosis of the chronic ulcer was based on clinical examination. There was an indurated margin in the traumatic lesion, which mimicked Oral Squamous Cell Carcinoma clinically. The patient has been hospitalized for 4 days and was given paracetamol 120 mg/5 mL oral suspension and amoxicillin 125 mg/5 mL oral suspension from the Pediatric Department. The patient also was given sodium chloride 0.9% solution, povidone-iodine mouthwash 1%, and petroleum jelly from the Oral Medicine Department. The patient’s mother was instructed to clean the patient’s oral cavity using gauze soaked in sodium chloride 0.9% solution, compress the ulcer using povidone-iodine mouthwashes 1% three times a day as an antiseptic and anti-inflammatory agent to the oral ulcer, and apply petroleum jelly to moisturize the patient’s lips. The patient was also suggested to extract the 55, 62, 74, and 85 teeth.\n\nIn the second visit (3 days follow-up), oral lesions already showed improvement. In the third visit (1-week follow-up), the size of the oral ulcer at the lateral border of the tongue was getting smaller and the lesion of the lips had some improvement.\n\nIn the fourth visit (10 days follow-up), the size of the oral ulcer at the lateral border of the tongue already had significant improvement. Two days after the fourth visit, the patient underwent neurosurgery. The patient was observed in the Pediatric Intensive Care Unit postoperatively. After two weeks of observation in the Pediatric Intensive Care Unit, the experienced respiratory failure and was declared dead.",
    "summary": "A 12-year-old boy with Down Syndrome and motoric disorders was referred to Oral Medicine Department. In the extraoral examination, the patient had a dysmorphic face and dry lips. Lymph node examination could not be assessed because the patient wore a cervical collar. The intraoral examination showed an irregular ulcer with 1×0.7 cm in diameter, indurated margin, and white-yellowish base at the right lateral border of the tongue. The 55 teeth were sharp and caused an occlusion trauma to the right lateral border of the tongue. The patient was diagnosed with a chronic traumatic ulcer mimicking OSCC based on clinical examination. The medication given to the patient were sodium chloride 0.9%, povidone-iodine mouthwash 1%, and petroleum jelly."
  },
  {
    "id": "multiclinsum_gs_en_3.txt",
    "fulltext": "We present a case of a 59-year-old lady with a twelve-year history of secondary progressive multiple sclerosis who was referred to ophthalmology with a few weeks’ history of bilateral blurring of vision.\n\nThe patient had no past ophthalmic history and no drug history other than the anti-epileptic medications related to her multiple sclerosis. Previously documented ophthalmic examinations did not reveal any signs of Fuchs' endothelial corneal dystrophy, and the patient has no family history of corneal pathology.\n\nThe patient had been on amantadine therapy at a dose of 100mg twice daily for the past 7 years and was started on levetiracetam 250mg twice daily as an add-on agent. Visual deterioration was experienced shortly after commencement of levetiracetam therapy for a breakthrough seizure.\n\nOn examination, the patient’s best corrected visual acuity was 0.5 logMAR right eye and 0.5 logMAR left eye. Slit-lamp examination revealed corneal edema involving both eyes and absence of uveitis. Corrected intraocular pressures were 16mmHg right eye and 18mmHg left eye. Corneal topography was performed which confirmed bilateral significant corneal thickening with a right central corneal thickness of 936μm and left central corneal thickness of 1134μm. The rest of the eye examination was normal.\n\nSince amantadine is a known cause of corneal edema, it was agreed with the patient and her caring neurologist to switch from amantadine to lamotrigine. Levetiracetam therapy was continued at this stage. No improvement in vision was noted two months after this change in treatment. The patient expressed the wish to temporarily stop levetiracetam on a trial basis in view of the direct temporal association between the onset of symptoms and the commencement of the medication.\n\nAmantadine was re-introduced, while levetiracetam dose was tapered. Improvement in vision was noted a few days after levetiracetam dose reduction. Levetiracetam was stopped altogether, and the patient remained on amantadine and lamotrigine. A provisional diagnosis of levetiracetam-induced corneal edema was made at this stage. Her vision normalized and repeat corneal topography six months after stopping the levetiracetam showed a right central corneal thickness of 567μm and a left central corneal thickness of 573μm, and a visual acuity of 0.2 logMAR both eyes. Slit-lamp examination confirmed clear cornea and the absence of corneal guttata in either eye.\n\nThe patient was examined again thirteen months after the first presentation. No further changes in her medications were made, and her vision had remained stable at 0.2 logMAR in both eyes. Repeat corneal topography showed no further changes.",
    "summary": "A 59-year-old woman was referred to the ophthalmology department with a few weeks’ history of bilateral blurring of vision. She is a known case of secondary progressive multiple sclerosis, and she was started on levetiracetam by her neurologist a few weeks prior to referral in view of new seizure activity. Examination revealed bilateral clinically evident corneal edema, which was documented on corneal topography.\n\nResults\nUpon levetiracetam dose reduction, symptoms started to improve and eventually the medication was stopped altogether. The patient’s vision and corneal edema normalized on follow-up."
  },
  {
    "id": "multiclinsum_gs_en_362.txt",
    "fulltext": "A 77-year-old male patient presented with a history of moderate cognitive impairment. The patient was admitted to the emergency department for a tonic-clonic seizure at home. The patient presented hemodynamically unstable in the context of a postcritical state and suspected intrapelvic bleeding. The code for a polytraumatized patient was activated, not because of the mechanism of injury, but because of the patient's hemodynamic status.  He was stabilized and optimized in the emergency department with intravenous fluid and transfusion of packed red blood cells. A pelvic girdle was placed. Once hemodynamic stability was achieved, a physical examination was performed. Clinically, the patient presented a shortening of the lower limb compared to the contralateral limb, external rotation and joint blockage when performing the log roll test in both limbs. He presented functional impotence in both hips. Given the patient's condition when he arrived at the emergency department, it was not possible to assess the neurological status. He had no signs of external injuries or bruises. Distal pulses were present at the foot level. He could move his upper limbs. A chest and anteroposterior pelvic radiograph was performed as part of the code for a polytraumatized patient, pending completion of an abdominal-pelvic computed tomography (CT) study. A bilateral femoral dislocation was diagnosed in the pelvic radiograph. The patient underwent a procedure to correct the dislocation.\n\n\n\nComputed tomography angiography to rule out vascular lesions given the instability in hemodynamic that presented itself on admission. Vascular lesions were ruled out after the angiography. In the 3D-CT reconstruction of the pelvis, a bilateral transverse acetabular fracture was found, according to the classification of Letournel and a bilateral longitudinal fracture of the iliac wing was found, along with intrapelvic protrusion of both femoral heads. After initial evaluation, supracondylar traction was placed on the femoral head in both extremities and the pelvic traction was removed. The patient was admitted to the recovery unit until surgery, where he remained with the traction supracondylar femoral head in both extremities and the pelvic traction was removed. The patient was operated on the eighth day of admission. In our service, the acetabular fractures were ruled out after seven days waiting for the formation of a fibrosis in the focus of fracture and the decrease of intraoperative bleeding during surgical procedures. It was decided to perform the surgery in two stages due to the long duration of each intervention. Both surgeries were performed with general anaesthesia, tranexamic acid was administered to prevent intraoperative bleeding and decrease blood transfusions in relation to the surgeries; and antibiotic (cefazolin 2 g preoperatively and 1 g of cefazolin every 8 hours postoperatively for 24 hours) as an intrahospital protocol. During the postoperative period, enoxaparin 40 mg was administered subcutaneously every 24 hours for seven weeks. Initially, the surgery of the left hemipelvis was performed since, at the radiographic level, it presented greater pelvic protrusion and it was not desirable that a hematoma in the soft tissue phase could generate complications at the time of extraction of the femoral head (vascular injuries, intraoperative bleeding). The supracondylar traction was removed. The patient was placed in lateral decubitus, and a posterior lateral approach was performed with a Moore's autograft in the acetabular background (fracture focus). Subsequently, the anti-protrusion ring was implanted (Burch SchneiderTM Reinforcement Cage, Zimmer Biomet) anchored to the ischium and ilium. Prior to the implantation of the ring, it was necessary to perform dissection of the gluteal musculature (gluteus minimus and medius) to correctly place the femoral head. The medial ischial fracture of the ring was also anchored with screws. The check was performed under the control of a scope to verify the correct implantation. Subsequently, a double mobility cementaed acetabular ring was implanted and then the non-cemented femoral stem was implanted. After finishing the placement of the components, the capsule and pelvic musculature were closed by means of transosseous trochanteric points. The surgery of the right hemipelvis was performed seven days later. The patient was placed in lateral decubitus. To address the longitudinal fracture of the iliac wing, the first window of the ilio-inguinal approach was performed. It was synthesised with a six-hole anatomical plate. Subsequently, the same procedure as the previous surgery was performed, using an anti-protrusion ring with a double mobility cemented femoral stem and non-cemented femoral stem. This type of anti-protrusion rings are used when there are acetabular fractures that could be equivalent to a pelvic disjunction (type IV classification of acetabular defects of the AAOS) and an anchorage in the ischium and ilium of the ring is needed to support the ring. They are not indicated for isolated fractures of the anterior or posterior wall of the acetabulum where there is no involvement of the acetabular background. During admission, the patient remained in bed and was mobilised to avoid decubitus ulcers. Once the second intervention was performed and when the patient tolerated it clinically, he began to transfer with the use of a wheelchair. In bed he was allowed to have a full range of motion without restriction. The patient was discharged four weeks later and did not begin to load or walk until six weeks. He began to load with the use of a walking stick. We decided to delay loading because, despite the use of arthroplasty as a treatment, it was decided to wait until there was an initial consolidation of the graft in the acetabular background that provided better support for the ring. It was also added that the patient presented bilateral involvement and it would be difficult to start partial loading, given that he did not have a healthy hip to support. During the follow-up of the patient, at 12 months of the intervention he was already doing full load with the use of a walking stick, with a Harris hip score of 79 in the left hip and 77 in the right hip; and a score of 12 on the WOMAC scale. He has not presented any postoperative complications to date. The patient is satisfied clinically, he reports occasional discomfort and a slight limp of the right side. He has a full range of motion in the examination and does not report having had any episode of instability since the surgery.\n",
    "summary": "77-year-old patient with a history of moderate cognitive impairment who suffered bilateral central dislocation of the hip in the context of a generalized convulsive seizure. Clinically, upon arrival in the emergency department, the patient presented a shortening of the lower right limb compared to the contralateral limb, external rotation and joint blockage when performing the log roll test in both limbs. Imaging and clinical optimization study was performed prior to surgery. It was performed in two stages: first the left hip on the eighth day of admission and the right hip on the fifteenth. In both surgeries the same procedure was performed by implanting an anti-protrusive ring and prosthesis with double mobility acetabulum with non-cemented femoral stem. In the immediate postoperative period, the patient did not present any complications associated with the surgery. In the 12-month follow-up, the patient performed a full load with a Harris hip score (HHS) of 77 in the right hip and 79 in the left; 12 points in the WOMAC scale. He has not presented any postoperative complications to date.\n"
  },
  {
    "id": "multiclinsum_gs_en_346.txt",
    "fulltext": "A 19-month-old boy was admitted to the Emergency Department because he fell from his baby feeding highchair. This fall occurred in apparent well-being, without the presence of anticipatory signs or symptoms. First, he fell on his gluteus and then he banged his head (occiput) on the ground. He presented with vomiting (three episodes) and he was very irritable. His respiratory rate and heart rate were >60 breaths and >150 beats per minute, while oxygen saturation was <80%. Upon physical examination, the child was hydrated and conscious, but irritable. More importantly, we noted subcostal retractions, and, at the auscultation, decreased breath sounds in the left basal part of chest. The patient was ventilated with an AMBU balloon connected to an oxygen source and monitored with a pulse oximeter. Despite our intervention, oxygen saturation fell below 70% and the more we ventilated, the more the saturation dropped down. The lung ultrasound showed the absence of the typical A lines and the consolidation of the lung, which was directly visualized as a solid parenchyma. On the basis of the poor clinical condition, the patient underwent orotracheal intubation with a cuffed endotracheal tube. After the baby was stabilized, he underwent a chest computed tomography (CT) showing complete atelectasis of the left lung with an interruption of the main left bronchus at 12 cm from bronchial bifurcation. An FBA was suspected as the mother also stated that the baby in the previous days had an intensive cough attack and disappeared within 24 h without any treatment. Therefore, a rigid bronchoscopy was performed and an almond of 2 cm in diameter in the main left bronchus was found and promptly removed.\n\nThe patient had never consumed almonds or other nuts before and in this circumstance ingested the almond by chance.\n\nThe baby had a progressive clinical improvement, and after 24 h, he was extubated and discharged from intensive care to be admitted to the general pediatrics ward for a few days with gradual and a total respiratory function recovery.",
    "summary": "We describe the case of a 19-month-old boy who accessed the emergency room initially for a head trauma. The clinical evaluation, however, revealed an unexplained serious respiratory distress needing tracheal intubation. After our evaluation, we hypothesized that the severe respiratory distress determined an altered state of consciousness with following head trauma. The radiological findings raised the suspicion of foreign body aspiration for the presence of an atelectasis of the entire left lung. The computed tomography showed an abrupt interruption of the main bronchus at 12 mm from the hull. The following bronchoscopy identified an almond of 2 cm."
  },
  {
    "id": "multiclinsum_gs_en_151.txt",
    "fulltext": "The patient was a 4-month-old male from central Mexico with two healthy male siblings. His mother was hypothyroid during the first trimester of pregnancy and took drugs. The infant was born with normal weight and size, was breast-fed, and received the BCG vaccine with no scarring. The mother of the patient was a prisoner in a jail cell with the infant in a crowded cell with two others.At 4 months, the patient was medically evaluated for a painful tumor in the left axilla. A chest X-ray showed suggestive images of rib fractures; the mother was suspected of child abuse, and the infant was admitted to a pediatric hospital. The infant was weighed (4,190 g) and measured (58 cm) below the third percentile, oxygen saturation of 70%, fever, cough, increased volume in the left axilla, and pain, redness, and warmth. The blood count showed: hemoglobin of 8.8 g/dL (11.0-12.6), 29.3 × 109 leukocytes/L (6.0-17.5), 18.4 × 109 neutrophils/L (1.0-8.5), 7.0 × 109 lymphocytes/L (4.0-13.5), 3.5 × 109 monocytes/L, 459 × 109 platelets/L (150-350), and C-reactive protein of 16 mg/L (< 3.0). The first thoracoabdominal tomography showed an abscess in the left axilla, lytic lesions in ribs 3-6, left apical pneumonia, pulmonary nodules in both lungs, and enlarged cervical and mediastinal lymph nodes. The biopsy of the left axilla abscess reported myositis and suppurative panniculitis. Only the culture for bacteria from the bronchoalveolar liquid was negative, and the PCR for the Mycobacterium tuberculosis complex was negative. After 41 days of hospitalization and receiving two antimicrobial regimens of ceftriaxone-clindamycin and cefepime-vancomycin, the patient was discharged.\n\nTwo months later, at eight months of age, he was readmitted to hospital with a fever, irritability and a suppurating abscess in the left scapula. The blood count showed haemoglobin of 10.8 g/dl (10.5-12), 21.2 × 109 leukocytes/L (6-17), 12.2 × 109 neutrophils/L (1.5-8.5), 7.5 × 109 lymphocytes/L (4-10.5), 1.2 × 109 monocytes/L (600), and 583 × 109 platelets/L (150-350); the serum test for HIV was negative. A left apical consolidation, bronchiectasis, lytic lesions in ribs 2-7 and dorsal vertebrae 2-7, and a multilocular fluid collection were observed on a chest scan; ultrasound showed a fistula associated with the scapular abscess. The patient received piperacillin-tazobactam, which was later replaced with voriconazole after Aspergillus fumigatus was detected in the secretion sample culture. Given the recurrence and severity of the infection, an innate immunity defect was suspected. The dihydrorhodamine test showed no production of reactive oxygen species and the gp91phox expression in neutrophils was absent, establishing a diagnosis of X-linked chronic granulomatous disease. The pathogenic variant detected by next-generation sequencing was c.80_83del/Y (p.Val27Glyfs*33) in CYBB. The mother was a carrier of the variant (c.80_83del/WT). The two older male siblings, who were apparently healthy, could not be genetically tested. The patient was discharged after 65 days of hospitalisation and 28 days of voriconazole treatment. Daily antibiotic prophylaxis with trimethoprim-sulfamethoxazole and antifungal prophylaxis with fluconazole twice a week were initiated. Two months later, at one year of age, the infant was readmitted due to multifocal pneumonia, for which mechanical respiratory assistance was required. The galactomannan antigen was detected in the serum and A. fumigatus was detected in the culture of the lavage fluid, so treatment with voriconazole was initiated again. The patient suffered a multiple organ failure and died one month after admission.\n",
    "summary": "A case of infant with chronic granulomatous disease and invasive aspergillosis is reported. The infant was a 4-month-old male infant living with his mother in a prison cell. The infant had tumors in the left axillary region and a chest X-ray suggested rib fractures; he was hospitalized on suspicion of child abuse. A chest X-ray showed an axillary abscess, osteolysis of ribs, pneumonia and pulmonary nodules; the patient received broad spectrum antibiotics and was discharged. At 8 months, he was readmitted with fever and extension of the purulent abscess to the left shoulder region; a chest X-ray showed worsening of the condition. Aspergillus fumigatus was isolated from the secretion of the abscess and invasive aspergillosis was diagnosed; voriconazole was initiated for 28 days. A dihydro rhodamine test was performed and a diagnosis of chronic granulomatous disease caused by the pathogenic variant c.80_83del/Y of the CYBB gene, carried by the mother (c.80_83del/WT), was made. At 12 months, the patient was readmitted with invasive aspergillosis, resistant to treatment, with fatal outcome.\n"
  },
  {
    "id": "multiclinsum_gs_en_133.txt",
    "fulltext": "Male patient, 25 years old, Sundanese, presented at the Dental Hospital of the Faculty of Dentistry Universitas Padjadjaran with the chief complaint of mouth sores, which are painful on the upper and lower lips and exacerbated when eating and talking. Initially, four days ago, canker sores started in the oral cavity, then appeared on the lips two days later. The patient tried to self-medicate by applying petroleum jelly which he used to relieve his symptoms, but it did not improve. The patient replaced the drug with triamcinolone acetonide 0.1% in orabase ointment purchased at the pharmacy and applied it once a day. Canker sores were getting better but did not cure.\n\nThe patient had history a of fever for about a week before the canker sores appeared and there were no lesions on other parts of the body. He stated that the workload was quite heavy and he had not consumed a balanced nutritional diet for about one and a half months. He had no medical history, history of food allergies, or history of taking medication. He had no history of alcohol consumption or smoking, but he had a frequent habit of licking his lips. He also had a history of chickenpox when he was a child.\n\nThe patient had no fever with all vital signs within normal limits on general examination. Extra-oral examination showed no abnormalities in the lymph nodes. There were serosanguineous crusts that felt painful and bleed easily on the lips. Intra-oral examination revealed erythematous lesions, irregular in shape, and had diffuse borders, accompanied by pain in the upper and lower labial mucosa. Hyperkeratotic white plaque that could not be scraped off, irregular in shape, has diffuse borders, without pain in the region of tooth 38 left buccal mucosa. Yellowish-white plaques were seen on 1/3 of the posterior surface of the dorsal tongue, which could be scraped off without leaving an erythematous area, and there were indentations in the form of dental impressions without pain on the lateral right and left sides of the tongue. A painless hard nodule about 2×1 x 0.5 cm in size was seen in the midline of the hard palate. Several teeth were found in caries, radix, and edentulous conditions in all regions. The oral hygiene was poor.\n\nExamination of psychological conditions was evaluated using the DASS-21 questionnaire and showed normal depression level (score 0), normal anxiety level (score 6), and normal stress level (score 6). Based on history and clinical examination, the working diagnosis was suspected HAEM, accompanied by the coated tongue, frictional keratosis, crenated tongue, torus palatinus, reversible pulpitis of tooth 18, irreversible pulpitis of tooth 47, chronic apical periodontitis et causa radix of tooth 15, and edentulous teeth 28, 37, 36, and 46. The differential diagnosis of suspected HAEM lesions on the lips was exfoliative cheilitis. However, exfoliative cheilitis did not have herpes virus involvement. The patient was indicated for serological testing (IgG anti-HSV-1) to confirm the diagnosis. Oral health-related quality of life was measured, and the results of the OHIP-14 examination at the first visit were 35 (moderate OHRQol).\n\nThe non-pharmacological therapy included instruction to maintain oral hygiene by brushing the teeth and tongue using a soft-bristled toothbrush two times a day and using non-detergent toothpaste. Education was given such as increasing the intake of water by at least two liters per day, consuming a balanced nutritional diet, avoiding acidic, spicy, hard, and monosodium glutamate-containing foods, and stopping the bad habit of licking and peeling the skin of the lips. The pharmacological therapy included topical and systemic medications. The topical medications included instructions to compress the lips with gauze moistened with 0.9% NaCl solution at least three times a day and to apply a thin layer of triamcinolone acetonide 0.1% in orabase to the lips three times a day. The systemic medications included instruction to take a multivitamin once a day.\n\nThe progress of improvement was visible in the first follow-up, two days after the initial visit. The pain in the lips was reduced, but the canker sores have not healed. Extra-oral examination revealed serosanguinous crusts on the lips which were still painful and bled easily. The serological test result (IgG anti-HSV-1) was positive with a ratio of: 6.32 (positive: ratio > 1.1). The definitive diagnosis was established based on the history, clinical examination, and serological tests as HAEM. The non-pharmacological and pharmacological therapy was continued, and systemic medication was added in the form of instructions to consume acyclovir 200 mg tablets five times a day for one week.\n\nSignificant improvement was visible in the second follow-up, five days after the previous visit, showing excellent healing in all of the patient’s oral lesions. The OHIP-14 result at the last visit was 4 (good OHRQoL). The patient’s physical, psychological, and social conditions showed improvement and returned to normal after 7 days of treatment. Patient was referred to continue dental and oral care in the periodontics, dental conservation, oral surgery, and prosthodontics departments. The patient has approved and written informed consent for the case details to be published included publication of the images, and the institution has also approved for publication. This case had complied with the Declaration of Helsinki.",
    "summary": "A 25-year-old male patient came to the Department of Oral Medicine with the chief complaint of painful canker sores on the lips. Extra-oral examination revealed serosanguineous crusts on the lips that were painful and easily bleed. Intra-oral examination showed diffused and painful irregular erythematous lesions on the upper and lower labial mucosa. The anti-HSV1 IgG test was positive. The patient was diagnosed with HAEM.\n\nCase management: Pharmacological therapy included triamcinolone acetonide 0.1% in orabase, acyclovir tablets, multivitamins, and 0.9% NaCl. Non-pharmacological therapy included advice on maintaining good oral hygiene, avoiding spicy and sour foods, and breaking the bad habit of licking the lips."
  },
  {
    "id": "multiclinsum_gs_en_83.txt",
    "fulltext": "A 29-year-old woman, Para 1, with abnormal vaginal bleeding of one-month duration presented to the gynecology outpatient department of a level 2 hospital. She was HIV positive, commenced on antiretroviral treatment following diagnosis, but had defaulted the antiretroviral treatment for one month when she became ill with vaginal bleeding, resulting in virological and immunological failures (viral load 37400 copies/mL and CD4 count 26 cells/μL). Of note, it was unclear when the patient first started showing HIV symptoms. However, she was diagnosed with HIV about a year prior to presentation. Physical examination revealed a large mass on the cervix measuring 8 × 8 cm extending to the parametrium and to the pelvic side walls bilaterally. There was bleeding on contact and foul-smelling vaginal discharge. Ultrasonography detected a bulky cervix and bilateral hydronephrosis. The patient was clinically diagnosed with cervical malignancy stage 3B. She was recommenced on antiretroviral therapy with a treatment change from TLD (Tenofovir-Lamivudine-Dolutegravir combination) to a preferable renal friendly regimen (Lamivudine-Abacavir-Dolutegravir combination). A punch biopsy of the cervix was performed, and the histopathological report revealed the diagnosis of an extra-nodal BL. The immunohistochemical and in situ hybridization confirmed the diagnosis, with CD20, CD75a, CD10, PAX5 and Bcl-6 positive. In addition, the CD44 and c-Myc were positive, with the EBER-ISH demonstrating focal positivity. The Ki67 demonstrated a proliferation index of almost 100% and PAX5 moderately positive BCL6. She had white cell count of 2.67 x109/L, haemoglobin of 5.7g/dl and platelet count of 71 × 109/L. Results of other investigations were serum creatinine 187 mmol/L, urea 11.1 mmol/l, albumin 21 g/l, aspartate transaminase 41 U/l and alkaline phosphatase 100 U/l.\n\nFollowing histological confirmation of the diagnosis and review at an oncology multidisciplinary meeting, she spent 43 days waiting to start treatment at oncology unit. The delay was due to long waiting list. This delay exceeded the 48 hours waiting period during which oncological treatment for BL should commence following diagnosis. The treatment plan was chemo-radiation therapy, and the patient gave written informed consent for the case to be published. However, she demised in the gynaecological ward on the 43rd day while waiting to start the treatment. During the 43 days, further imaging could not be performed due to poor functionality of the available CT and MRI machines. In addition to antiretroviral therapy, the patient received other supportive care such as blood transfusion and analgesia. Again, the number of days between the diagnosis of the BL and her death was 43 days. Histopathological postmortem was not performed as the diagnoses (BL and retroviral disease) were known. We reckon that the main primary cause of death is challenging to assign because of the multiple principal diagnoses. Because BL has rapid progression and high mortality rate in persons living with HIV particularly with high viral load, the attending physician certifying the death assigned BL as the most likely cause of death. However, the secondary cause of death was multiple organ failure (renal and haematological inclusive).",
    "summary": "The patient was a 29-year-old woman, Para 1, with abnormal vaginal bleeding for a month and living with HIV and had a CD4 of 26 cells/μL. The histological examination of the cervical biopsy confirmed an extra-nodal BL. She had International Federation of Gynecology and Obstetrics (FIGO) stage 3B cervical cancer based on presence of hydronephrosis and pelvic wall involvement. The patient was reviewed at the oncology multidisciplinary meeting and required chemoradiation. There was delay in her management due to a long waiting list for chemoradiation at oncology unit in the referral center and the patient demised 43 days after diagnosis and did not receive the treatment."
  },
  {
    "id": "multiclinsum_gs_en_164.txt",
    "fulltext": "A 56-year-old female patient presented with complaints of dyspnea that required oxygen supplementation. Her medical history dates back to July 2013 when she was hospitalized in the chest ward for dyspnea and cough with yellow sputum. She was subsequently diagnosed with Sjogren’s syndrome complicated with interstitial lung disease (ILD) and PAH (Table I). Her chest X-ray at that time showed vascular markings with interstitial thickening, costophrenic (CP) angle blunting and cardiomegaly. An echocardiogram revealed a pulmonary arterial (PA) systolic pressure of 99 mmHg, enlargement of the right atrium and ventricle, D-shaped left ventricle (LV), and severe tricuspid regurgitation. Chest CNYCT showed no filling defects, excluding pulmonary embolism; it also displayed an enlarged pulmonary trunk, right atrium (RA), and right ventricle (RV), further evidencing pulmonary hypertension. Symptoms of dry mouth, dry eyes, and cracked tongue mucosa, with a Schirmer’s test showing <5 cm, oculus uterque (OU). A positive minor salivary gland biopsy, nuclear medicine scan showing impaired salivary gland function, and a positive anti-Ro test, confirmed Sjogren’s syndrome. She started on Revatio (Sildenafil) 20 mg three times a day (TID) for pulmonary hypertension control, adding Tracleer (Bosentan) in 2016 due to disease progression. A right heart catheterization (RHC) revealed a mean pulmonary arterial pressure (PAP) of 39 mmHg, pulmonary vascular resistance (PVR) nearly 15 Woods, and a wedge pressure of 4, indicating pre-capillary type, group I, CTD-related PAH in 2017. The right heart catheterization (RHC) report allowed for insurance coverage of Opsumit (Macitentan) 10 mg once a day (QD), replacing Tracleer (Bosentan) in 2017. From 2017 to 2020, she was hospitalized multiple times for steroid treatments to manage her underlying Sjogren’s syndrome.\n\nPulmonary hypertension treatment is risk-based, and until 2017, the patient was considered low to intermediate risk, controlled with two medications (Sildenafil + Macitentan). Her condition remained stable until October 2020, when she experienced worsened dyspnea accompanied by cough and expectoration of white sputum, suggestive of infection. On November 10, 2020, the patient experienced severe dyspnea, cold sweats, and cyanosis, with SpO2 dropping to 70%, necessitating 100% O2 via face tent. Blood gas and lab tests revealed a lactate level of 5.2 mmol/l and brain natriuretic peptide (BNP) over 10,000 pg/ml, strongly suggesting cardiogenic shock. She was prepped for intensive care unit (ICU) admission, intubated, and initiated on four pulmonary hypertension medications. Her condition stabilized and showed improvement, preventing further deterioration. On November 12, 2020, evaluation for heart-lung transplantation began. Her condition continued to improve with off vasopressors on November 13, 2020, and extubating on November 14, 2020, and transferred to a general ward on November 21, 2020, with O2 tapered to nasal cannula 2l/min. A follow-up RHC continued to show elevated pulmonary artery pressure, likely attributed to chronic hypertension leading to right heart strain and eventual failure. After intensive care unit (ICU) treatment, she was referred to National Taiwan University Hospital for evaluation for heart-lung transplant.\n\nReviewing the records since the onset of her illness, it was evident that pulmonary artery pressure had steadily increased, and the distance covered in the 6-minute walk test was progressively shortened. Currently, the patient is classified as high risk. She continues regular hospitalizations for control. Despite the relatively stable condition, her chief complaint during the admission is still dyspnea. The physical examination revealed mild rhonchi ILD and a pansystolic murmur indicative of severe valvular heart disease, with no other significant findings. Ventavis (Iloprost) 10 mcg/ml 2 ml was added in 2020. Molecular hydrogen therapy (1 capsule/day) was initiated in May 2023. Hydrogen capsules (PURE HYDROGEN) were purchased from HoHo Biotech Co., Ltd. (Taipei, Taiwan, ROC). Each capsule contained 170 mg of hydrogen-rich coral calcium containing 1.7×1,021 molecules of hydrogen, which is equivalent to 24 cups of water with 1,200 ppb of hydrogen or 0.6 mM of hydrogen per 200 ml of water. Adjuvant therapy with hydrogen capsules resulted in increased CD127 + Treg, decreased anti-Ro antibody, decreased B cell subsets, and stabilization of clinical symptoms and signs was observed following the addition of hydrogen therapy in this patient. No adverse reactions or events were observed following the administration of hydrogen capsules. Flow cytometry and serological examination were employed for whole-blood analysis to assess changes in immune cells and autoantibody before and after hydrogen therapy. For subsequent whole-blood analysis via flow cytometry, blood samples were prepared using standard fluorescent dye preparation methods and fluorescent antibody reagent kits with dried reagents (Beckman Coulter, Brea, CA, USA). The methods, steps, immunophenotypic analysis, and cell gating were conducted following previously described procedures. Our analysis of immunophenotypic markers before and after hydrogen therapy revealed increased CD127 + Treg and decreased B cell subsets after treatment. Moreover, this study adheres to the CARE reporting guidelines (2013 CARE Checklist).",
    "summary": "We present the case of a 56-year-old female with CTD-PAH, diagnosed in 2013 with Sjogren’s syndrome complicated by interstitial lung disease (ILD) and PAH. Despite treatment with sildenafil, bosentan, macitentan, iloprost, and corticosteroids, her condition deteriorated, resulting in severe dyspnea and cardiogenic shock in 2020. In May 2023, molecular hydrogen therapy was initiated as an adjuvant treatment. The patient received daily hydrogen capsules, which led to increased CD127+ Treg cells, reduced anti-Ro antibodies, and decreased B cell subsets. Her clinical symptoms stabilized without adverse effects."
  },
  {
    "id": "multiclinsum_gs_en_354.txt",
    "fulltext": "The patient was a 45-year-old male born in Pakistan who had resided in Portugal for 7 years. He had a history of grade 3 obesity, with no other known personal history or usual pharmacological therapy.\n\nThe patient sought emergency care for fever, dry cough, dyspnea, chest pain, dysgeusia, headache and myalgia with 4 days of evolution. In the summary neurological examination at admission, there were no reported changes. In the evaluation of the respiratory system, tachypnea and pulmonary auscultation with bilateral rough vesicular murmur, without other adventitious sounds, were noted. The remainder of the objective examination showed no changes.\n\nOf the complementary diagnostic tests performed at admission, there was a slight increase in inflammatory parameters and in arterial blood gases under an inspired oxygen fraction (FiO2) of 21%, with type 1 respiratory failure and extensive predominant bilateral, peripheral and basal opacities on chest teleradiography. After a positive reverse-transcription real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2 (nasal and oropharyngeal exudate) and negative tests for influenza A and B, Streptococcus pneumoniae and Legionella pneumophila, a diagnosis of pneumonia by SARS-CoV-2 infection was established.\n\nOver the first 48 hours, progressive worsening of fatigue, dyspnea and type 1 respiratory failure, requiring an increase in supplemental oxygen therapy, were observed. Due to the lack of improvement, noninvasive mechanical ventilation was initiated; however, due to poor adherence, high-flow oxygen therapy was initiated through a nasal cannula, without a response to therapy.\n\nIn this context, the patient was admitted to the intensive care unit (ICU), level III, where he underwent sedoanalgesia and orotracheal intubation with connection to invasive mechanical ventilation.\n\nOn the eleventh day of hospitalization, treatment with remdesivir, dexamethasone, enoxaparin and empirical antibiotic therapy with amoxicillin/clavulanic acid and azithromycin, administered on suspicion of bacterial overinfection, was continued. During this period, sustained fever was observed, with a weak response to antipyretic therapy, with improvements in inflammatory parameters after the third day of hospitalization in the ICU.\n\nTo exclude any concomitant infectious etiology, intravenous devices were replaced, and blood cultures, cultures of the tip of the central catheter and bronchial secretions, urinalysis, urine culture and transthoracic echocardiography were performed. Among the cultures, the blood culture yielded the only positive result, i.e., Klebsiella pneumoniae, which is sensitive to amoxicillin/clavulanic acid, which the patient was already receiving. The summary echocardiogram did not reveal valve changes suggestive of endocarditis, but the patient presented hypokinesia of the lateral wall and left ventricular apex, as well as poor biventricular function. A slight increase in troponins (1.8ng/mL) and ST-segment depression in leads I and aVL were confirmed, suggesting the existence of acute coronary syndrome or septic cardiomyopathy.\n\nOther noninfectious causes of febrile symptoms in the critically ill patient were excluded, including treatment with neuroleptics or altered thyroid function.\n\nNotably, there was a need for inotropic support with dobutamine in the ventilatory weaning phase as well as noninvasive ventilatory support after orotracheal extubation, which occurred on the fifteenth day of hospitalization.\n\nOn the sixteenth day of hospitalization (nineteenth day of confirmed disease), there was an episode of altered state of consciousness, conjugated deviation of gaze to the right and myoclonus of the face and thoracic region to the left followed by a generalized tonic-clonic seizure crisis, which ceased after midazolam therapy. The hypothesis that the seizure occurred in the context of a hypoxic-ischemic event was excluded because the patient remained normotensive, there was never a peri-event or hypoxemia, serum lactate level was normal, and diuresis remained preserved. Any ionic or glycemic disorders that could explain the inaugural seizure episode were excluded.\n\nIn the post-critical period, there was an absence of eye opening, no verbal response, failure to localize to pain (coma scale of Glasgow 7), and persistent left hemiparesis grade 3 out of 5. Due to the need for airway protection, the patient was sedated, subjected to orotracheal intubation and started on anticonvulsant therapy.\n\nIn the process of diagnosis of the convulsive episode, after cranial computed tomography confirmed no changes, the patient was subjected to lumbar puncture, with turbid CSF output and mild proteinorrachia but without pleocytosis and with normal opening pressure. In the CSF, neurotropic virus and venereal disease research laboratory (VDRL), acid-alcohol resistant bacteria tests and an RT-PCR test for SARS-CoV-2 were requested, and samples were collected for culture. Electroencephalography was performed 1 hour after propofol suspension and under fentanyl, with a single record and total duration of 13 minutes; the findings indicated no changes.\n\nAfter confirmation of a positive RT-PCR test for SARS-CoV-2 RNA in the CSF, without CSF pleiocytosis, the hypothesis of bacterial but nonviral meningitis was excluded, considering the hypothesis of encephalitis. Magnetic resonance imaging (MRI) performed on the seventeenth day of hospitalization showed multiple image artifacts associated with patient movement during the procedure, suggesting the need to repeat the examination.\n\nAfter discontinuation of sedoanalgesia, a change in consciousness was observed, with a Glasgow coma scale score of 14, persistent left hemiparesis with muscle strength grade 4 in 5 and an absence of involuntary movements, allowing safe orotracheal extubation in 24 hours. Given the favorable clinical outcome, brain biopsy was excluded. On the twenty-first day of hospitalization, the patient was transferred to the ward.\n\nThe patient maintained apyrexia without altered state of consciousness. No new episodes of involuntary movements were observed, and on the twenty-sixth day of hospitalization, he underwent a reassessment MRI, which revealed no pathological changes. As he maintained a favorable clinical evolution, the patient was discharged on the thirty-first day of hospitalization without antiepileptic drugs and with an appointment for follow-up with the internal medicine department.\n",
    "summary": "The authors present the clinical case of a 45-year-old man admitted for pneumonia with a positive result for SARS-CoV-2, with no neurological history, who, on the 16th day of admission, presented a sudden change in consciousness accompanied by a conjugate deviation of the gaze to the right and myoclonia of the face and thoracic region to the left, followed by a generalized tonic-clonic convulsive seizure, associated with persistent left hemiparesis. From the study carried out, the existence of RT-PCR for SARS-CoV-2 in the cerebrospinal fluid is highlighted. The patient presented a clinical evolution with gradual improvement, and the outcome was favourable.\n"
  },
  {
    "id": "multiclinsum_gs_en_491.txt",
    "fulltext": "This is a 32-year-old patient, a baker, from Bamako, who was admitted to the Infectious and Tropical Diseases department of the CHU du Point G (Bamako, Mali) on 27 April 2023 for chronic productive cough, otalgia and a chronic right-sided purulent otorrhea.\n\nThe symptomatology would be of progressive installation in 1 month, initially treated in a medical center with artésunate, paracetamol and unspecified antibiotics for confirmed malaria and acute otitis media, without success. He is immunosuppressed by a HIV1 infection, diagnosed and put on a tritherapy antiretroviral (TARV) Tenofovir/Lamivudine/Dolutégravir 7 months ago, not observed due to denial of his illness.\n\nThe general physical examination found a fever (38.2 °C), altered general condition, otalgia, purulent right foul-smelling otorrhea, a right basal pulmonary condensation syndrome, a normal neurological examination, without the involvement of the cranial nerves, mainly the facial nerve VII and the VIII cochleovestibular nerve.\n\nIn the ENT examination, the otoscopy of the right ear showed an inflammatory external auditory canal with purulent secretions and the presence of a single tympanic perforation in the anterior-inferior quadrant. The left ear is normal. The Rinne and Weber test is in favor of a right conductive hearing loss.\n\nImmuno-virological evaluation shows a CD4 count of 118 cells/pl and a viral load of 12,370 copies/ml at the time of diagnosis of HIV infection, compared to a viral load of 9,460 copies/ml and a CD4 lymphocyte count of 193 cells/pl at the 6th month of antiretroviral treatment. At the time of diagnosis of tuberculosis at the 7th month, the immuno-virological evaluation shows a CD4 count of 89 cells/pl and a viral load of 10,230 copies/ml.\n\nThe Ziehl Neelsen bacilloscopy was positive with a cross in the gastric washings on admission and 19 days later in the right ear swab because of the persistent otorrhea. The Xpert-MTB/GeneXpert test did not detect rifampicin-resistant Mycobacterium tuberculosis.\n\nThe frontal chest radiograph shows a more accentuated bronchovascular network at the base of the right lung.\n\nThe diagnosis of tuberculosis of the middle ear concomitant to a pulmonary localization in the field of immunosuppression by HIV1 is therefore retained.\n\nThe patient is put on oral first-line anti-tuberculosis for 6 months, a fixed dose of a quadra-therapy in the intensive phase of isoniazid, rifampicin, pyrazinamide and ethambutol for 2 months (2RHZE), followed by a bi-therapy in the maintenance phase of isoniazid and rifampicin for 4 months (4RH) at a dose of 3 tablets/day in the morning on an empty stomach, associated with vitamin B6 (1 tablet/day). He benefits from two sessions of therapeutic reinforcement with anti-retroviral drugs. The ART is restarted on 4 May 2023 with his consent, given the good tolerance of the anti-tuberculosis drugs, with the combination of tenofovir/lamivudine/dolutegravir at a dose of 1 tablet/day associated with dolutegravir 50 mg as a supplement (1 tablet/day) according to the protocol for the management of HIV/AIDS. A chemoprophylaxis with cotrimoxazole 960 mg (1 tablet/day) is undertaken as well as a cleaning of the external auditory canal by aspiration and the instillation of ciprofloxacin ear drops (2 drops 3 times a day) for 14 days.\n\nThe evolution is favorable after 14 days of treatment, marked by a pyrexia, a good general state, the amendment of the cough and otorrhea with the negativation of the bacilloscopy in the gastric tube liquid and the swab of the pus of the right ear. At the end of the maintenance anti-tuberculosis treatment, the clinical healing is complete with a normal ENT and neurological examination. The bacilloscopy associated with the Xpert-MTB/GeneXpert test at the end of the 2nd month of the intensive phase, during the 5th month and at the end of the 6th month of the maintenance phase were negative. The HIV viral load performed after 3 months of ART is 329 copies/ml.\n",
    "summary": "The patient presented with a chronic productive cough, otalgia and a chronic right-sided purulent otorrhea. The search for acid-fast bacilli was positive by direct examination in the gastric tube liquid and the swab of the auricular pus.\n\nAn anti-tuberculosis treatment of 6 months, associated with adjuvants, led to the patient's complete recovery.\n"
  },
  {
    "id": "multiclinsum_gs_en_423.txt",
    "fulltext": "A 23-month-old boy with hypoxic-ischaemic encephalopathy at birth with good brain motor potential and normal psychomotor development. He had a personal history of restrictive cardiomyopathy and was included in a cardiac transplant programme when he was 16 months old. He also required the implantation of an external Berlin Heart biventricular support device. In order to prevent embolic events, double antiplatelet and anticoagulant treatment was administered. When he was 23 month old presented with disconnection and right hemiparesis. A computerised tomography (CT) scan showed a hyperdense left middle cerebral artery (MCA), as well as a chronic right parietotemporal infarction. His blood analysis showed: red cells 4.16 × 106 µ/L; haemoglobin 11.4 g/gL; activated partial thromboplastin time (APTT) 93 seconds and international normalised ratio (INR) 1.08.\n\nIntravenous thrombolytic treatment was contraindicated due to double antiplatelet and anticoagulant treatment at full dose with heparin, so an intra-arterial thrombectomy was performed. Although the patient was 23 months old, he was in the third percentile of the weight curve (10 kg). Under general anaesthesia, the right femoral artery was punctured and an 11 cm long 4F sheath (Cordis, Ireland) was placed. A 4F vertebral Radiofocus catheter (Glidecath of Terumo, Belgium) was used to confirm the occlusion of the M1 segment of the left MCA. The artery was recanalised by mechanical thrombectomy with a stentriever using the 4F vertebral catheter as a tutor, positioning it in the petrous segment of the carotid artery. A 3 mm × 20 mm Trevo XP Pro Vue device (Stryker, The Netherlands) was used, with a straight Rapid Transit microcatheter (Codman Neurovascular, UK), opening the artery in one pass. The whole system was removed (tutor catheter, microcatheter and stentriever) simultaneously. In the control run, an iatrogenic dissection of the left internal carotid artery was detected, which had no clinical significance, however, as the left hemisphere was irrigated through the anterior communicant artery.\n\nOne month later, his heart transplant was carried out successfully. Neurologically, the only long-term sequel that came as a result of the stroke was a right upper limb spasticity.",
    "summary": "A 16-month-old boy with restrictive cardiomyopathy who was listed for a cardiac transplant. At 20 months he required an implantation of an external biventricular support device (Berlin Heart) and had a left hemisphere stroke at 23 months. An intra-arterial approach was used and produced good clinical results. One month later, a heart transplant was performed successfully."
  },
  {
    "id": "multiclinsum_gs_en_90.txt",
    "fulltext": "52-year-old male patient with no medical history, transferred from a lower-level hospital to our institution due to a tonic-clonic seizure secondary to alcohol withdrawal and non-reduced right LFGHP. He was evaluated by a traumatologist 24 hours after admission, and was found to be conscious, with bilateral ecchymosis of the shoulders and severe limitation of passive external rotation on both sides. In addition, the patient was restrained physically at this point, with both feet and his left hand held down by intermittent psychomotor agitation.\n\nThe initial evaluation included a thorough review of the patient's admission radiographs, which showed a right LFGHP and a left simple posterior dislocation. This second injury (simple posterior dislocation of the left shoulder) was not diagnosed at the referring facility, and took approximately 48 hours to be diagnosed at our facility.\n\nComputed tomography (CT) of both shoulders was requested to better characterize the injuries. These images showed a marked worsening of the left shoulder injury since the time of the first radiographic study, possibly secondary to the physical restraint of the patient. This evidence of progression from a simple left posterior glenohumeral dislocation on admission radiographs to a LFGHP on the CT taken 48 hours later.\n\n\nPlanning\n\nThe preoperative study of the right shoulder showed bone indemnity of the glenoid and 40% involvement of the articular surface of the humerus, but with a large fragment with the possibility of osteosynthesis in continuity with the lesser tuberosity, so it was planned to fix this fragment by spongeous screw 4.0 mm partial thread and high strength sutures. In the left shoulder, no significant bone defect was evidenced in the glenoid and the defect of the articular surface of the humerus was 20%, so it was planned to fill the defect with the fragment of the lesser tuberosity at the time of osteosynthesis (imitating the surgery of McLaughlin).\n\n\nSurgical technique\n\nOpen reduction and internal fixation with bilateral locked-plate is decided. The patient is placed in a beach chair position and the surgical fields are prepared in the usual way for the right shoulder. The fracture focus is accessed by a classic deltopectoral approach. A digital maneuver is performed to reduce the posterior fragment of the humeral head with a posterior mini-open incision of the size of a standard diagnostic arthroscopy portal. A provisional reduction of the fracture is achieved using high-strength sutures and needles. A partial 4.0 mm spongy screw and high-strength sutures are used to fix both fragments of the humeral head. Definitive fixation of the fracture with a Philos (Depuy Synthes®) plate achieves adequate reduction and stability of fragments. Fixation is increased with high-strength sutures to the tendons of the rotator cuff that are tied to the plate. Closure by planes of the right shoulder, healing and immobilization of the extremity with a universal shoulder immobilizer.\nThe surgical field of the left shoulder is immediately prepared. Classic deltopectoral approach is performed again to reach the fracture focus using an accessory posterior portal for digital manipulation and reduction of the humeral head. Fixation and osteosynthesis are performed in the same way as described for the right shoulder with the exception of the spongiosa screw, as the anterior fragment could be adequately fixed only with the use of high strength sutures.\nPostoperative management consisted of the use of bilateral shoulder immobilizer for four weeks. A pendular exercise of flexion-extension of the elbow and exercises of the fist were given to be performed from the second postoperative week to tolerance (according to the level of pain). In the radiographic control of the first month, loss of reduction of the greater left tuberosity was observed. It was decided to perform revision surgery achieving adequate fixation of the fragment with high-strength sutures.\nThe patient is left with a shoulder immobilizer for an additional four weeks on the left shoulder. The self-administered exercise regimen is restarted as described previously from the second postoperative week on a bilateral basis. At the sixth week after the revision surgery, face-to-face kinesiological therapy is initiated twice a week. After 30 sessions of kinesiological rehabilitation, the patient is able to return to work five months after the initial injury.\nFollow-up one year after the initial surgery shows that the patient has recovered strength and mobility in the right shoulder. The left shoulder still has severe limitations in the range of motion, especially in external rotation. At this point, it is decided to perform arthroscopic joint release surgery and remove the osteosynthesis in the left shoulder.\nIn his last check-up two years after the trauma, the patient showed a favorable evolution, consistent with the functional scales evaluated.\n",
    "summary": "52-year-old male patient, transferred to a high-complexity center for a tonic-clonic convulsion and a right LFGHP. In the initial study with radiographs, a right shoulder injury was confirmed and a simple posterior glenohumeral dislocation of the left shoulder was diagnosed, which had not been previously detected. The study was complemented with a computed tomography (CT) of both shoulders, showing a bilateral LFGHP, which demonstrated intrahospital aggravation of the injury of the left shoulder. An open reduction and osteosynthesis with a bilateral blocked plate was performed in one time. The left shoulder required two reinterventions, one for osteosynthesis failure and another for joint release. Two years after the procedure, the patient was satisfactorily progressing with a 5% on the Quick DASH scale and a score of 72 and 76 on the Constant scale in the left and right shoulder, respectively.\n"
  },
  {
    "id": "multiclinsum_gs_en_439.txt",
    "fulltext": "A 70-year-old white man was treated for severe symptomatic aortic regurgitation due to healed endocarditis using TAVI from the apical approach. TAVI was performed at that time because he was considered a high-risk surgical patient due to secondary pulmonary hypertension, severely impaired left ventricular function with a left ventricular ejection fraction (LVEF) of 20%, chronic renal failure, and a logistic EuroSCORE I of 24.36%. At the time he was treated by diuretics (torasemide 20 mg once a day), an angiotensin-converting enzyme (ACE) inhibitor (ramipril 5 mg once a day), a ß-blocker (bisoprolol 2.5 mg twice a day), and an aldosterone antagonist (12.5 mg once a day). On admission he had cardiac decompensation and resulting dyspnea (temperature 36.7 °C, pulse 99/minute, blood pressure 109/48 mmHg) but his emotional status and neurological constitution were good. The laboratory results were unremarkable except for: a mild increase in liver enzymes, aspartate aminotransferase (AST) 59 U/l and alanine aminotransferase (ALT) 67 U/l; a known chronic renal insufficiency (creatinine 2.1 mg/dl); and a mild decrease in hemoglobin (Hb) 10.7 g/dl. No urine analysis was done. Due to normal C-reactive protein and normal count of leukocytes no microbiological examination was performed. After interdisciplinary discussion of the case (including a normal coronary angiography that was performed a few days before) and cardiac recompensation, he was initially treated with an implantation of a JenaValve 27 mm self-expandable valve. Despite a good result after implantation with the JenaValve and minimal transvalvular central insufficiency, he presented recurrent cardiac decompensation due to his severely impaired LVEF. His case was discussed again at an interdisciplinary meeting: 4 weeks after TAVI he underwent the implantation of a LVAD system (Thoratec® HeartMate II). His postoperative course was uneventful. He remained asymptomatic for 1 year until the LVAD system showed recurrent significant high flow alarms. Echocardiography examinations during this year showed a continuous increase in transvalvular central insufficiency to the level of a severe regurgitation without any sign for structural alteration of the leaflets of the JenaValve prosthesis. Treatment options were discussed and a new TAVI as valve-in-valve was decided.\n\nThe procedure was performed under general anesthesia using a CoreValve Evolut R 29 mm prosthesis. The prosthesis was implanted without prior valvuloplasty. The flow rate of LVAD was reduced to minimum and pacing with a frequency of 140 beats/minute was applied during placement of the valve prosthesis. Positioning was done with great care using fluoroscopic and transesophageal echocardiography (TEE) guidance with the aim of having the ventricular strut end of the CoreValve Evolut R prosthesis between the ventricular end and the “cusp feelers” of the JenaValve prosthesis. This position was obtained because of JenaValve structure and individual computed tomography analysis of our patient which had shown the ventricular edge of the JenaValve well positioned in left ventricular outflow tract (LVOT). The first positioning was successful with no need for repositioning. After the last fluoroscopic control the CoreValve Evolut R was released successfully in the planned position. Slow rapid pacing was stopped and the LVAD flow was increased and required good hemodynamic under normal LVAD flow. His postoperative course was uneventful and he has shown a very good recovery. A second TEE did not show any change regarding the performance of the valve-in-valve and only marginal residual insufficiency. At 12-month follow-up our patient had no complaints and had a satisfactory capacity in daily life. Echocardiography showed no relevant aortic regurgitation and an increase of LVEF to 33%. At that time the 6-minute walk test was significantly increased to 381 m (compared to 148 m on admission).",
    "summary": "We report the case of a 70-year-old white man who was treated for severe symptomatic aortic regurgitation using transcatheter aortic valve implantation from the apical approach. Because of recurrent cardiac decompensation 4 weeks after implantation he underwent the implantation of a left ventricular assist device system. A year later echocardiography showed a severe transvalvular central insufficiency. Our heart team decided to choose a valve-in-valve approach while reducing the flow rate of left ventricular assist device to minimum and pacing with a frequency of 140 beats/minute. There was an excellent result and our patient is doing well with no relevant insufficiency of the aortic valve at 12-month follow-up."
  },
  {
    "id": "multiclinsum_gs_en_458.txt",
    "fulltext": "A 12-year-old boy was brought to our department exhibiting sudden onset symptoms of headache and polyuria-polydipsia syndrome, which began one week prior to his initial visit. The child had no significant medical history. During the first clinical evaluation, he measured 146.5 cm in height (M) and weighed 30 kg (-1.4 SD). There were no observed signs of adrenal insufficiency or hypothyroidism. He was at the onset of puberty, with gonad sizes measuring 3.2 cm on each side and a penis length of 6.2 cm (M). Notably, the patient experienced polyuria-polydipsia syndrome, with fluid excretion reaching up to 113ml/kg/day, nocturnal enuresis, and an excessive liquid intake of 3.8 liters/m². Ophthalmologic examination yielded expected results, with no visual impairments detected and normal optical coherence tomography (OCT) findings.\n\nThe biological assessment revealed DI, with a serum sodium level of 140 mEq/l and plasma osmolality of 287 mosm/kg, while the urine osmolality was significantly low at 179 mosm/kg. Furthermore, his serum levels of insulin-like growth factor-1 (IGF1), prolactin (PRL), free T4, cortisol, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were all within the normal range.\n\nMRI scans with and without contrast highlighted apoplexy in an RCC, showing a spontaneous hyperintensity on T1 and T2 sequences measuring 15x6x11 mm. The anterior pituitary gland displayed homogeneous contrast uptake. However, we observed a loss of the typical hyperintensity of the posterior pituitary gland, with no radiological indications of a craniopharyngioma. Therefore, during the initial hormonal evaluation, the only hormone deficiency identified in our case was DI, which showed significant improvement under vasopressin treatment. The case was reviewed in a multidisciplinary meeting, including an endocrinologist, neurosurgeon, and radiologist. Given the absence of clinical or biological signs other than DI and the stability of the RCC apoplexy over nine months of MRI monitoring—with measurements of 12 × 11 × 10 mm—a conservative management approach with regular follow-ups was chosen.\n\nThe child was monitored for three years, during which he displayed normal puberty development and maintained a stable hormonal profile (Table 1). Visual evaluations revealed no abnormalities. However, a decrease in growth velocity was noted, dropping from -0.8 SD to -1.1 SD. This necessitated an investigation for acquired growth hormone (GH) deficiency. At the age of 14 years and nine months, the child was readmitted to undergo two GH stimulation tests: A propranolol-glucagon test and an Insulin Tolerance Test, which indicated a partial GH deficiency with peaks of 19.3 µUI/ml and 10.0 µUI/ml, respectively. After receiving GH treatment, the patient experienced a notable increase in growth velocity, improving from -1.1 SD to 0.2 SD over one year.\n\nSubsequently, MRI monitoring showed a stable appearance of the RCC apoplexy after two years (11 × 12 × 11 mm), with a slight decrease in size observed at the three-year follow-up, measuring 7 × 10 × 6 mm. It is important to note that the radiological follow-up was consistently conducted at the same MRI center, with the same radiologist interpreting both recent and previous MRI findings during multidisciplinary meetings that included an endocrinologist and a neurosurgeon.",
    "summary": "We present the case of a 12-year-old boy admitted due to the recent onset of headaches and diabetes insipidus. Magnetic resonance imaging revealed Rathke cleft cyst apoplexy. Given the absence of compressive symptoms in a child at the early stages of puberty and without abnormalities in basic endocrine tests, a conservative strategy was employed, involving regular clinical, biological, and radiological follow-ups. The child experienced normal puberty without any endocrine deficiencies except for a partial growth hormone deficiency."
  },
  {
    "id": "multiclinsum_gs_en_474.txt",
    "fulltext": "Patient and observation\nPatient information: This was a 67-year-old patient with no medical history who presented with dysphagia, dysphonia and altered general condition.\n\nClinical findings: initial clinical examination found a conscious patient with a Glasgow score of 15/15, apyrexia, blood pressure of 12/07 cmHg, oxygen saturation of 100%, heart rate of 80/min, conjunctivae of normal colour with a large mass in the cavum. There was no hepatomegaly or splenomegaly, the lymph node areas were free, the rest of the physical examination was normal.\n\nChronology: the patient had been experiencing difficulty swallowing with dysphonia for 6 months, the clinical picture worsened with the development of dysphagia for solids with a deterioration in general condition (weight loss of 15kg/6 months).\n\nDiagnostic approach: cervico-thoraco-abdomino-pelvic CT scan showed a 70 mm x 40 mm nasopharyngeal mass extending to 60 mm. The patient's blood work was normal (white blood cell count, renal and hepatic function, lactate dehydrogenase and HIV, HCV and HBV serologies). The histological and immunohistochemical study of the nasopharyngeal biopsy was in favour of a grade 1,2 CD20+; CD19+; CD79a+; CD10+ follicular B-cell NHL in 2 readings in 2 different laboratories. The bone marrow biopsy was normal as was the pre-therapeutic work-up.\n\nTherapeutic intervention: the patient received 4 RCHOP 21 cures (rituximab 375mg/m2 intravenous (iv), cyclophosphamide 750 mg/m2 iv, oncovin 2 mg iv, prednisolone 100 mg orally, and doxorubicin 50 mg/m2 (iv) with no response and then 3 RDHAOX cures (rituximab 375 mg/m2 intravenous (iv) on day 1, high dose aracytine 2 g/m2 x 2 iv on day 2, dexamethasone 40 mg from day 1 to day 4, and oxalipatine 100 mg/m2 on day 1) with no clinical response.\n\nFollow-up and results of therapeutic interventions: the persistence and increase of the nasopharyngeal mass led to the realization of the tracheotomy, the biopsy of the nasopharyngeal mass objectified the disappearance of the lymphoid B infiltration with presence of the amyloid deposits AL type kappa.\n\nImmune electrophoresis of plasma proteins showed the presence of immunoglobulin M kappa, the dosage of light chains was not performed due to lack of resources, the myelogram and a second bone marrow biopsy were normal, the TEP scan objectified a hypermetabolic nasopharyngeal process without other anomalies, the cardiac evaluation (ECG, natriuretic peptides, troponin, echocore) and renal were without particularities, the patient is currently under protocol bortezomib, prednisone and bendamustine with good clinical evolution after the first treatment.\n",
    "summary": "We report the case of a 67-year-old patient without pathological CDDs who presented with a deterioration of general condition with progressive dysphonia and dysphagia with a large mass in the neck that was biopsy-proven to be a grade 1 and 2 follicular non-Hodgkin lymphoma. A cervico-thoraco-abdomino-pelvic CT scan showed a 70 mm x 40 mm nasopharyngeal mass extending to 60 mm. Bone marrow biopsy was normal and the pre-therapeutic evaluation was normal. The patient received 4 courses of rituximab plus CHOP (cyclophosphamide, adriamycin, prednisone and oncovin) without response and then 3 courses of rituximab plus DHAOX (dexamethasone, high dose ara-cytin and oxalipatin) with persistence of the mass. The biopsy of the latter showed the disappearance of the B lymphocyte infiltration with presence of the AL amyloid deposits. The immunoelectrophoresis of plasma proteins showed the presence of immunoglobulin M. A positron emission tomography (PET) scan showed a hypermetabolic nasopharyngeal process. The patient is currently receiving a protocol of bortezomib, prednisone and bendamustine.\n"
  },
  {
    "id": "multiclinsum_gs_en_539.txt",
    "fulltext": "46-year-old Haitian male, residing in Chile for one year. In Haiti he was a livestock farmer. He presented a one-and-a-half-year history of a lesion that began as a papule on the anterior aspect of the right leg, which increased in size progressively. Initially asymptomatic, three months prior to the consultation he developed pruritus, pain, superficial ulceration and yellowish discharge. On physical examination, the patient was found to be of phototype V, with 1 x 1 cm, 2 x 2 cm and 3 x 2 cm warty plaques on the anterior aspect of the right leg. A dermatoscopy revealed a hyperkeratotic mass with ulcerated center, with reddish-black dots and congested hemorrhagic vessels. The general laboratory was normal; VDRL, HIV and PPD were non-reactive. Tissue samples were taken by a punch biopsy, including epidermis, dermis and subcutaneous tissue, and stained with Gram, routine bacteriological culture and anaerobic culture, which were negative. Bacilloscopy and Koch culture of the same tissue were also negative. The histopathological study was performed with hematoxylin and eosin stain, and showed a pseudoepitheliomatous epidermis with irregular hyperplasia, a dermis with abundant mixed inflammatory infiltrate with suppurative foci and giant cells of the foreign body type, some of which contained round cells with a thick brown wall, compatible with muriform cells; these cells were more evident when evaluated with PAS stain. Fungal culture was performed on Sabouraud dextrose agar at 25°C, which showed, after 15 days of incubation, the growth of black or dematiaceous, elevated, well-defined, velvety colonies. Direct microscopic examination with 20% KOH showed long, branched, sometimes tortuous, hyphae, and short chains of acropetal conidia, suggestive of Fonsecaea spp. Itraconazole was administered at 100 mg every 12 h for six months, in association with physical measures, which consisted of cryotherapy (liquid nitrogen) application to hypertrophic areas every six to eight weeks. Due to local complications, such as erosion or ulceration of the lesions, frequent healing was performed with application of mupirocin ointment topically for signs of bacterial superinfection.\n\nThe patient had a favorable evolution, with regression of the lesions and no evidence of relapses to date, remaining with a mild local hypopigmentation, expected in areas of treatment with cryotherapy.\n",
    "summary": "A 46-year-old Haitian man, residing in Chile, presented with warty plaques in the anterior tibial region that had been present for one year. The diagnosis of chromoblastomycosis was confirmed by the presence of muriform cells in the histopathology and dematiaceous colonies in the mycological culture. In addition, conidia compatible with Fonsecaea spp. were observed in direct microscopy. After six months of treatment with systemic antimycotics and cryotherapy, complete remission of the lesions was achieved.\n"
  },
  {
    "id": "multiclinsum_gs_en_285.txt",
    "fulltext": "Patient information: A 19-year-old male with no significant medical history was admitted to our department with a painful left scrotal mass that had been present for 8 months and had not improved with antibiotics for pyogenic organisms. The patient reported intermittent low grade fever, night sweats, anorexia and unexplained weight loss since the onset of symptoms. He did not have a cough, sputum or haemoptysis. There was no history of tuberculosis in his personal or family medical history. He was vaccinated against tuberculosis at birth.\n\nClinical findings: Physical examination revealed a large, painful, slightly hot left bursa and two elongated, poorly defined, firm, painful subcutaneous formations in the anterior thoracic wall, 3 to 4 cm long. There were no rales on auscultation. The remainder of the examination was normal. Laboratory studies revealed a high c-reactive protein of 90 mg/dl. The blood count, creatinine, blood glucose and liver function tests were within normal limits. The standard chest X-ray showed reticulonodular infiltrates in both lung fields.\n\nDiagnostic approach: In the presence of an ultrasound finding in favour of an epididymal tumour, the patient underwent a left orchidectomy. However, the pathological examination of the surgical specimen showed a granulomatous epitheloid necrosis of the epididymis, suggestive of active epididymal tuberculosis involving the body and tail of the epididymis and sparing the head and testicle. The intradermal tuberculin reaction was positive. The search for acid-fast bacilli (AFB) in sputum and urine for 3 consecutive days was negative on direct examination and culture. The serologies for human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and Wright's stain were also negative. In search of other tuberculous sites, a thoraco-abdomino-pelvic tomodensitometry was performed, which showed a miliary tuberculosis, coelo-mesenteric necrotic adenopathies, two thoracic parietal collections (at the expense of the external oblique muscles measuring 33 × 10 mm on the right and 45 × 10 mm on the left) and a focal osteolysis of D11 and L5, suggestive of a spondylodiscitis in the early stages. The magnetic resonance imaging (MRI) of the spinal cord confirmed the existence of a spondylodiscitis at the level of D7, D11, L4 and L5. The diagnosis of disseminated tuberculosis with epididymal, pulmonary, parietal, ganglionary and osteo-articular sites was retained.\n\nTherapeutic intervention: a poly-chemotherapy for tuberculosis with isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months, followed by the association of isoniazid and rifampicin, was initiated.\n\nFollow-up and results: however, at the 4th month of treatment, the patient had presented generalised tonic-clonic convulsive seizures. A brain MRI was performed, showing multiple nodular lesions above and below the tentorial membrane corresponding to tuberculomas. The patient was put on anticonvulsive treatment and anti-tuberculosis treatment was continued. The evolution was favourable with recovery of the general condition and weight gain from the first months of treatment as well as a disappearance of thoracic parietal formations, adenopathies and tuberculous milia on the tomodensitometry with absence of recurrence of convulsive seizures. However, the slow decrease of the size of the tuberculomas obliged us to continue the anti-tuberculosis treatment for a long period. Finally, the patient was declared cured, without sequelae, at the end of the 234th month of treatment with a 2-year follow-up.\n",
    "summary": "A 19-year-old man with no significant history was admitted to hospital with a painful left scrotal mass that had been present for 8 months. He had undergone an orchidectomy and the pathological examination was in favour of epididymal tuberculosis. A radiological examination had shown other sites of infection: lymph nodes, lungs, parietal and osteoarticular. An anti-tuberculosis treatment was initiated. However, in the 4th month of treatment, the patient had convulsive seizures. A brain MRI was performed and concluded that there were brain tuberculomas. The anti-tuberculosis treatment was continued in association with an anticonvulsant with good clinical and radiological evolution.\n"
  },
  {
    "id": "multiclinsum_gs_en_508.txt",
    "fulltext": "We present the case of a 10-year-old male diagnosed with high-risk early T-cell acute lymphoblastic leukaemia, who was treated according to the LAL SEHOP-PETHEMA 2013 protocol. Two years after diagnosis, he developed an early CNS relapse, so he was treated according to the InteReALL HR 2010 protocol with bortezomib. During induction, after being neutropenic for four weeks (20 neutrophils/μL), he was receiving prophylaxis with cefepime, cotrimoxazole and fluconazole. In addition, he was being treated with acyclovir for a herpes simplex virus 1 skin infection. In this context, he developed a severe headache that did not respond to usual analgesia. A cranial computed tomographic scan was performed that showed a hypodens lesion in the right temporal lobe. When the possibility of an infectious origin was considered, a lumbar puncture was performed and cefepime was replaced with meropenem and vancomycin.\n\nDespite remaining afebrile, he developed signs of septic shock on the first day after admission to the clinic and was transferred to the paediatric intensive care unit for inotropic and vasoactive support. In addition, the antimicrobial spectrum was extended with gentamicin and caspofungin.\n\nThe blood analysis showed a progressive increase in C-reactive protein and procalcitonin (up to 312 mg/L and 47.58 ng/mL, respectively, on the third day of evolution), with no other relevant biochemical alterations. The blood count showed pancytopenia due to chemotherapy. The blood cultures ruled out bacteremia and fungemia, and herpes virus serologies were negative. The urine culture and the fecal culture were also negative. The biochemical analysis of the cerebrospinal fluid was completely normal (glucose, 63 mg/dL; proteins, 16 mg/dL; leukocytes 1/µL), but the presence of B. cereus was detected in the microbiological study (sensitive to meropenem, vancomycin, linezolid and ciprofloxacin). The presence of herpes simplex 1 and 2, herpes virus 6, cytomegalovirus, varicella-zoster virus, enterovirus, parechovirus, toxoplasma, Neisseria meningitidis, Listeria monocytogenes, Streptococcus pneumoniae and Cryptococcus was ruled out in the cerebrospinal fluid.\n\nThe EEG showed diffuse slowing of brain activity with no clear epileptiform activity. On day 4, after the haemodynamic support was removed, a cranial MRI showed two hyperintense lesions in T2 and FLAIR that involved the subcortical region of the right temporal and parietal lobes. The parietal lesion had ring enhancement after administration of gadolinium and both lesions showed peripheral diffusion restriction. In addition, small haemorrhagic foci were observed scattered in the brain parenchyma. The image suggested a bacterial origin with an atypical germ, and these findings, together with those of the cerebrospinal fluid, led to the diagnosis of B. cereus abscess.\n\nAfter two weeks of treatment, the patient had a favorable outcome with resolution of the headache and no neurological findings. A follow-up MRI showed a decrease in the size of the lesions. Vancomycin and acyclovir were discontinued after three weeks and meropenem was continued for six weeks.\n",
    "summary": "We present the case of a 10-year-old boy undergoing chemotherapy for acute lymphoblastic leukaemia. During the induction period he developed a cerebral abscess caused by B. cereus that was diagnosed by imaging tests and direct detection in the cerebrospinal fluid. His evolution was favourable with antibiotic treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_222.txt",
    "fulltext": "Female patient, 16 years old, presenting a depressed gray plaque of 10.5 × 8.0 cm interspersed with hypochromic areas in the lower lateral part of the left thigh. Telangiectatic vessels overlap the lesion peripherally, with visible veins close to it. The plaque was present from birth, but was initially violaceous. It evolved with the passing of the years, with lightening and depression. There is no discrepancy in the length of the lower limbs.\n\nAngioresonance showed vascular malformations in the skin and subcutaneous tissue supplied by intermuscular branches of the popliteal artery. Early venous filling was found in both the region and the malformations, suggesting early venous shunting. Dilated draining veins were not documented, except for a superficial draining vein running along the subcutaneous cellular tissue of the anterior thigh. In addition, thinning of the subcutaneous tissue was noted in the topography of the vascular alteration, but without intramuscular or bone extension.\n",
    "summary": "16-year-old girl with a depressed gray plaque on the left thigh, with a vascular malformation affecting the skin and subcutaneous tissue evident by angioresonance.\n"
  },
  {
    "id": "multiclinsum_gs_en_590.txt",
    "fulltext": "A 57-year-old woman with a 14-year history of asthma and allergic rhinitis, on salmeterol/fluticasone, was hospitalized for recurrent abdominal pain that began two months earlier. The pain was intermittent and dull, accompanied by nausea, anorexia, malaise, and a weight loss of 5 kg. There was no fever, blood / mucus in the stool, or respiratory symptoms (rhinorrhea, wheezing, coughing). She had no history of alcohol/tobacco use or traditional herbal medicines. Six weeks before admission, she was diagnosed with an intestinal infection in a local clinic after a complete blood count (CBC) revealed leukocytosis and significant eosinophilia (25.61 G/L, 77.8% eosinophils). She received antibiotics and mebendazole without relief of symptoms. At presentation, the patient was alerted and oriented with stable vitals (BP 110/70 mmHg, T 37°C, HR 88 bpm, RR 18 bpm). She had a BMI of 16.6 kg/m² and sarcopenia, but no skin rash, lymphadenopathy, or edema. The abdominal exam showed tenderness in the epigastric and umbilical regions without guarding. CBC revealed leukocytosis and significant eosinophilia (20.8 G/L, with a total white blood cell count of 26.8 G/L, comprising 77.8% eosinophils). Peripheral blood film examination showed normal eosinophils. Bone marrow aspiration reveals 48% eosinophils without blasts, atypical cells. Fluorescence in situ hybridization (FISH) for CHIC2 deletion as a surrogate marker for FIP1L1-PDGFRA showed no rearrangements of the PDGFRA gene. Autoimmune and vasculitis screenings (ANA, anti-dsDNA, p-ANCA, c-ANCA) were negative. Elevated serum IgG (2760 mg/dL; normal range, 700–1600 mg/dL) and IgG4 (1260 mg/dL; normal range, 3.9–86.4 mg/dL), slightly elevated IgE (137.5 IU/mL; normal range, <100 IU/mL) and high RF (144.4 IU/mL; normal range, <20 IU/mL) were observed. Other parameters were normal, including aminotransferase, blood urea nitrogen, serum creatinine, complement C3, complement C4, vitamin B12, serum cortisol, and NT-proBNP. ECG and echocardiogram were normal. Chest CT scans showed mild fibrosis and bronchiectasis. Sputum AFB smears and bronchoscopy were negative. The cytology of the bronchoalveolar lavage fluid showed 35% neutrophils, no eosinophils. Spirometry indicated severe obstruction with bronchodilator response. The fractional exhaled nitric oxide (FeNO) level was 15 ppb. Stool samples were tested positive for leukocytes, with no signs of ova or parasites. Serology tests were positive for toxocariasis (positive IgG of Toxocara canis at 54.2 NovaTec-Units) but negative for Strongyloides stercoralis, Fasciola sp., Toxoplasma gondii, Trichinella spiralis, Ancylostoma sp., Angiostrongylus cantonensis, Ascaris lumbricoides, Clonorchis sinensis, Paragonimus sp., Gnathostoma sp., Entamoeba histolytica, cysticercosis, filariasis, and HIV. An abdominal contrast-enhanced computed tomography scan revealed gallbladder stones without acute cholecystitis and showed no gastrointestinal tract abnormalities. The upper gastrointestinal endoscopy showed unremarkable results with a normal appearance. Colonoscopy showed mucosal inflammation in the sigmoid, left, transverse, and right colon with systemic biopsy. A five-day course of albendazole (400 mg twice daily) for suspected toxocariasis was ineffective. Colonic biopsies revealed significant eosinophilic infiltration (>85 eosinophils/High-power field (HPF) in the left colon, >100 eosinophils/HPF in the transverse and right colon). Given the patient’s nonresponse to toxocariasis treatment and the significant eosinophilic infiltration observed in the colon mucosa biopsy, a diagnosis of eosinophilic colitis was confirmed. The patient was treated with oral methylprednisolone (16 mg) and montelukast (5 mg). Symptoms resolved in two weeks and eosinophil counts normalized (0.3 G/L). The corticosteroid was reduced and discontinued, and the patient was maintained on montelukast for three months without symptom recurrence.",
    "summary": "We present a unique case of a 57-year-old patient with a medical history of asthma and allergic rhinitis who presented recurrent abdominal pain, significant blood eosinophilia, and elevated levels of Immunoglobulin G4. After ruling out hematological and secondary causes of eosinophilia, a biopsy of the colon mucosa revealed an excess of tissue eosinophils, confirming the diagnosis of EoC. The patient responded well to corticosteroids and was subsequently maintained on montelukast, with no recurrence of symptoms over 3 months."
  },
  {
    "id": "multiclinsum_gs_en_569.txt",
    "fulltext": "A 38-year-old male presented to the hospital with chest tightness and shortness of breath. Three years prior, he had experienced similar symptoms post-activity and received treatment at our hospital. Outpatient echocardiography indicated a left heart echomass suggestive of a myxoma, which led to his admission for further evaluation. Physical examination revealed pigmentation of the patient’s ears characterized by multiple small brown and black spots. Abdominal computed tomography (CT) showed multiple livers and small cysts in the left kidney. Genetic testing identified mutations in the TTN and PRKAR1A genes. The diagnosis of CNC was confirmed through clinical examination, imaging, and genetic testing. Following symptomatic treatment, the patient’s condition improved; however, he refused surgical intervention. On September 20, 2023, the patient presented to our hospital with exacerbated chest tightness and dyspnea. He reported difficulty lying supine and needing to sit upright to breathe. Physical examination revealed jugular vein distension, leftward and downward displacement of the heart boundary, irregular heart rhythm on auscultation, and a mitral valve murmur of intensity 2/6–3/6 in the fourth intercostal space along the left sternal margin. Wet rales were audible in both middle and lower lung fields. Palpation revealed a firm liver extending three fingers below the xiphoid process and two fingers below the rib cage, along with mild pitting edema in both lower limbs. Echocardiographic images indicated global heart enlargement, dilation of the aortic sinus and pulmonary artery, small-to-moderate mitral valve regurgitation, and an irregular echoic mass measuring 54 mm ×43 mm in the left chamber attached to the atrial septum. The left ventricular (LV) ejection fraction (EF) was 23.1%, with fractional shortening (FS) of 10.9%. Electrocardiography demonstrated atrial fibrillation (average ventricular rate, 150 beats/min) and abnormal Q waves in leads V1-V3. Based on the patient’s history, the diagnosis included DCM and CNC with cardiac myxoma. Given the presence of end-stage heart failure and concurrent cardiac myxoma, the patient was hospitalized, and heart transplantation was considered a viable therapeutic option to address both conditions simultaneously. A suitable donor heart became available for immediate transplantation on October 1, 2024.\n\n\nSurgical procedure\n\nThe skin and subcutaneous tissues were carefully incised layer-by-layer through a median sternotomy. The sternum was sawed longitudinally open, and bleeding was controlled using electrocoagulation and bone wax. Extracardiac exploration uncovered global heart enlargement, most prominent in the LV. The heart showed diminished contractile strength. The aorta and the main pulmonary artery (PA) were dissected from the supravalvular region. Some tissues were preserved for posterior suturing, whereas most diseased right atrium, left atrium(LA), right ventricle, and LV were excised. Resection revealed a greyish-white mucoid mass. The donor and residual recipient LA tissues were sutured using double continuous 3/0 Prolene threads. The anastomosis was meticulously inspected multiple times, and no significant bleeding was observed. Similarly, end-to-end anastomosis of the donor ascending aorta and recipient PA was performed using continuous 5/0 Prolene sutures, and careful inspection revealed no bleeding.\n\nFurthermore, the donor’s LA and recipient’s PA were securely closed using double continuous 5/0 Prolene sutures. The inferior vena cava tissues of both the donor and recipient were similarly sutured with 5/0 Prolene sutures, and several inspections were performed to confirm no significant bleeding was present. The left side of the heart was then deflated, and as rewarming commenced, oxygenation was restored, the ascending aorta was unclamped, and the heart spontaneously returned to sinus rhythm. Continuous suturing with 5/0 Prolene was applied to both the donor and recipient’s superior vena cava and diligently inspected to ensure the absence of significant bleeding. After the successful discontinuation of assisted circulation, the venous cavity was decannulated. Tissue samples from the patient’s left heart and gray matter were collected for histopathological examination, and the diagnosis of DCM and cardiac myxoma were confirmed.\n\n\nPostoperative management\n\nOn the first day after heart transplantation, the patient produced 1200 ml of urine. Laboratory tests revealed a hypersensitive troponin T level of 796.70ng/L and an NT-proBNP level of 10798pg/ml. The complete blood count showed white blood cells at 17.15 × 109/L, with no significant abnormalities in other test results. The echocardiograph displayed an LVEF of 65%, FS of 35%, normal ventricular wall thickness and echogenicity, and no discernible abnormalities in valve morphology and structure. After heart transplantation, Methylprednisolone Sodium Succinate (0.25 g)intravenous hormone therapy was administered to enhance immunity, and Cefoperazone and Sulbactam Sodium (2 g) intravenous anti-infection treatment was provided. The patient was given a nutrient solution and liver and tiopronin on the first day post-surgery. On postoperative day three, Methylprednisolone Sodium Succinate was replaced with oral Prednisone Acetate (25 mg). Mycophenolate Mofetil capsules (0.5 g) were administered orally to minimize heart rejection, and (50 mg) of Carpofungin Acetate was administered intravenously to prevent fungal infections. The patient’s urine output was 2000 ml, with hypersensitive troponin T levels of 390ng/L, NT-proBNP levels of 7877pg/ml, and a leukocyte count of 12.15 × 109/L. On the 7th day post-surgery, tacrolimus capsules were introduced at an oral dose of (1 mg) to minimize the patient’s rejection of the donor heart, with careful monitoring of blood concentrations. Subsequently, the oral dosage of Prednisone Acetate was gradually decreased to (10 mg) while adjusting the tacrolimus blood concentration to 10.90ng/ml. The patient’s recovery improved. On October 20, 2023, follow-up echocardiography (Fig. 6) indicated no abnormalities, with troponin levels of 85 ng/L, NT-proBNP of 210pg/ml, and all other test results within normal ranges. The patient exhibited excellent postoperative recovery and was discharged. Regular follow-up visits to our department after discharge showed that the patient remains in good condition.",
    "summary": "Herein, we report a case of heart failure due to Carney syndrome that resulted in cardiac myxoma combined with dilated cardiomyopathy. A 35-year-old male was admitted to the hospital three years ago because of sudden chest tightness and shortness of breath. Echocardiography indicated myxoma, and a combination of genetic screening and physical examination confirmed Carney syndrome with cardiac myxoma. Following symptomatic management, he was discharged. Surgical interventions were not considered at the time. However, the patient’s chest tightness and shortness of breath symptoms worsened, and he returned to the hospital. A New York Heart Association grade IV heart function was confirmed, and echocardiography indicated the presence of dilated cardiomyopathy accompanied by cardiac myxoma. Ultimately, the patient’s heart failure was successfully treated with heart transplantation."
  },
  {
    "id": "multiclinsum_gs_en_324.txt",
    "fulltext": "2 years 6 months old female pre-schooler with a previous diagnosis of NF1. She consulted due to a 4 week diarrhea with blood streaks (5 to 10 episodes a day). A week after the onset of the diarrhea she consulted the emergency department, where rotavirus (+) was detected, with low inflammatory parameters, negative coproculture and normal abdominal ultrasound. She was hospitalized for 3 days to manage dehydration and was discharged without bleeding, with persistence of semi-liquid stools. 10 days after discharge she presented diarrhea with blood streaks, associated with low intake and weight loss of 1 kg reported by parents. They consulted a pediatric gastroenterologist who requested a polymerase chain reaction (PCR) panel of gastrointestinal pathogens and PCR of Clostridium difficile (which were negative) and indicated hospitalization for study.\n\nOn direct questioning, the parents reported no fever, abdominal pain, vomiting, respiratory or urinary symptoms, arthralgia, or new skin lesions. They did not own pets, and there was no history of travel or recent dietary changes.\n\nThe patient was diagnosed with confirmed NF1 at 8 months of age by genetic testing with the heterozygous pathogenic variant c.5606_5627del (p.Gly1869Valfs*28). She has skin involvement (café con leche spots) and bone involvement. At 18 months she required ankle arthrodesis for tibial curvature. She has no family history of NF1 or inflammatory bowel disease.\n\nOn physical examination, the abdomen was soft and indistinct, with increased air-bubble murmurs, without masses or visceral enlargement. The perianal examination was normal. There were multiple brown-coffee stains on the lower extremities and back. General examinations were performed, including a blood count with moderate microcytic-hypochromic anaemia (Hb 9.6 g/dL), leukocytosis with left shift (leukocytes 13,900), and discretely elevated inflammatory parameters (CRP 1.37 mg/dL, normal value up to 0.5 mg/dL).\n\nA colonoscopy was performed, the rectum, sigmoid and various segments of the colon were examined up to the cecum, visualizing the ileocecal valve and the appendicular orifice. The last few centimeters of the distal ileum were also inspected. The mucosa from the anal margin to the cecum was observed to be erythematous, with loss of vascular transparency, unlike the cecal mucosa, which appeared normal. No lesions were identified in the anal canal or cecum.\n\nBiopsies of the small intestine (ileon) and large intestine were taken. Microscopic examination showed mucosa of ileal type with preserved villous architecture and adequate epithelial differentiation, with a non-inflamed lamina propria. The mucosa of the large intestine had a mild distortion of architecture and adequate epithelial differentiation, a swollen lamina propria with a mild mixed inflammatory infiltrate and hyperplasia of lymphoid follicles. Isolated foci of microabscesses were recognized. The biopsy was consistent with mild colitis, with signs suggesting chronicity.\n\nIn addition, a PCR study for cytomegalovirus (CMV) was requested in a colon biopsy, which was positive.\n\nGiven a positive PCR for CMV, CMV IgG and IgM and CMV viral load in blood were requested, resulting in a positive IgG, negative IgM, and CMV viral load of 79.7 IU/ml. Further laboratory studies included PCR for gastrointestinal pathogens and PCR for Clostridium difficile in stool, both of which were negative. In the colon biopsy, Gram stain microbiological studies were requested, which showed +++ leukocytes without bacteria; biopsy culture showed S. gallolyticus/equinus complex in very low amount (interpreted as bacterial flora); acridine orange, Ziehl-Neelsen, Koch culture, and ADV PCR were negative.\n\nEndoscopy and histology suggestive of UC was reported in the context of a patient with moderate symptoms (PUCAI 50) who was started on Mesalazine (70 mg/kg/day three times daily) and a request for a faecal calprotectin was made which was greater than 600 ug/g.\n\nThe immunology team evaluated the patient for suspected immunodeficiency. The parents did not report a history of infections, they reported that they were vaccinated, that they had good weight gain, no family history of immunodeficiencies, auto-immunity or early deaths. A study with lymphocyte subpopulations (normal), immunoglobulins (normal), HIV (negative), memory T lymphocytes (with alterations expected in the context of CMV viremia) and lymphoproliferation test (normal) was requested. In addition, a genetic panel of primary immunodeficiencies (Invitae) was performed, which contains 429 genes, of which 68 make up the panel of monogenic inflammatory intestinal disease. 7 variants of uncertain significance were obtained, none included in the panel of monogenic IBD.\n\nGanciclovir was initiated intravenous for CMV infection and continued for 15 days. The last PCR CMV control prior to discharge reported undetectable load.\n\nThe patient improved during the hospital stay with decreased frequency of stools and increased consistency, no rectal bleeding, no nocturnal stools and no abdominal pain, with PUCAI 0 at discharge.\n\nTwo months later, he presented with a reactivation of IBD with bloody diarrhea (PUCAI 35). A blood count was performed (normal), a panel of gastrointestinal pathogens was performed (–), PCR for Clostridium difficile was performed (+), and CMV load was undetectable. He was treated with oral metronidazole. However, he persisted with diarrhea with blood streaks, so he was hospitalized again.\n\nA colonoscopy was performed, where erythematous mucous was observed in a diffuse form from the rectum to the cecum, with nodularity and loss of vascular transparency in the submucosa, greater in the left and transverse colon segments. No focal lesions were observed. The mucosa of the ileum and anal canal were observed without lesions.\n\nBiopsy of the terminal ileum, right colon and left colon was performed. Microscopic examination of the ileal-type mucosa showed preserved villous architecture and adequate epithelial differentiation. The lamina propria showed no signs of inflammation. There were no aphthous erosions or granulomas. The mucosa of the large intestine showed mild distortion of architecture and epithelial dedifferentiation. The lamina propria was expanded by mixed inflammatory infiltrate, transmucosal distribution. Foci of cryptitis and cryptitic microabscesses and hyperplasia of reactive lymphoid follicles were recognized. No granulomas, viral or parasitic cytopathic changes were observed. All fragments of the left colon sample presented a similar histopathological picture.\n\nShe was given oral treatment with Vancomycin and Prednisone (1 mg/kg/day) with a good response and a favorable evolution. She was discharged with a decrease in the frequency of bowel movements. She persists with mild symptoms (PUCAI 5) in outpatient control, so the dose of corticosteroids is progressively decreased and she remains on treatment with Mesalazina.\n",
    "summary": "2.5-year-old pre-schooler with a history of NF1 presenting with bloody diarrhea. On endoscopic examination, the mucosa from the anal margin to the cecum was erythematous with loss of vascular transparency. Colon mucosal biopsies showed signs of chronic inflammation consistent with a diagnosis of ulcerative colitis and CMV infection was diagnosed by PCR.\n"
  },
  {
    "id": "multiclinsum_gs_en_459.txt",
    "fulltext": "40-year-old HIV-positive man with regular adherence to treatment (viral load 4500/mm3 and CD4 70/mm3 from the previous year), consulted for intermittent fever of two years' evolution that did not respect the standard time and gave way to transient antinflammatory non-steroidal drugs. He added in the last two months diffuse abdominal pain with predominance in the upper right lobe where he acquired a configuration of a tree in bud and bilateral pleural effusion, and at the abdominal level, marked increase of hepato-splenomegaly associated with ascites. After 48 hours of his suspension, he presented fulminant hepatic failure and was transferred to the intensive care unit. Tracheal aspirate was performed and after transfusion support a liver biopsy was obtained by puncture.  The patient died a few hours later. The postmortem culture of the tracheal aspirate was positive for Mycobacterium tuberculosis and the liver biopsy was performed with non-necrotizing granulomas and the rest of the parenchyma preserved. This work was carried out in accordance with the principles laid out in the ethical code of the WHO (Helsinki Declaration).\n",
    "summary": "We present the case of a 40-year-old HIV-positive man with regular adherence to treatment, who consulted for intermittent febrile episodes of two years' evolution, adding in the last two months progressive diffuse abdominal pain and generalized adenomegaly. In the laboratory, he presented pancytopenia, coagulopathy, hypoalbuminemia and increased acute phase reactants. The computed tomography (CT) of the thorax, abdomen and pelvis only showed hepato-splenomegaly and generalized adenomegaly. Multiple microbiological examinations were performed, including cultures for Mycobacterium sp. of different samples, all with negative results, with the exception of RT-PCR for HHV-8. A left iliac ganglion biopsy was performed with findings consistent with Castleman's disease. Despite restarting antiretroviral therapy, the symptomatology progressed, initiating treatment with corticosteroids and ganciclovir. After a week, he developed multiple organ failure and anasarca, which contraindicated the drugs initiated. A new chest CT was performed that showed infiltrates with a tree-like pattern in the upper right lobe associated with bilateral pleural effusion, and at the abdominal level, progression of hepato-splenomegaly and ascites. He passed to the intensive care unit 48 hours later due to fulminant hepatic failure. The patient died within a few hours. A postmortem culture of the tracheal aspirate was received positive for Mycobacterium tuberculosis and a liver biopsy with non-necrotizing granulomas.\n"
  },
  {
    "id": "multiclinsum_gs_en_41.txt",
    "fulltext": "4-month-old indigenous lactating mother from the rural area of the interior of Panama, from the town of Urracá, 3 hours by canoe from the nearest health center. Her background included being the fourth daughter, born by vaginal delivery at home by a relative, without prenatal controls, her weight, height and Apgar score at birth are unknown. She did not breastfeed and was fed with powdered milk formula with iron for children under 6 months, receiving 3 ounces every 4 hours.\n\nThe nuclear family was composed of 6 people (parents and 4 children) who lived in a house with walls and floor of boards and palm roof, 2 rooms, without electricity, they were illuminated with kerosene lamps, water from a well, excreta in a river and they burned the garbage, their economic income came from subsistence agriculture.\n\nHe had no health care in his first 4 months of life and did not receive the vaccinations included in the national expanded programme of immunizations. According to his parents, his neurodevelopment was normal until his hospitalization.\n\nThe minor consulted in a health center with a history of 4 days of diarrhoea, without mucus or blood associated with vomiting of food content (the mother gave her tea because she could not tolerate milk), afebrile and without respiratory symptoms. Oral fluids and 4 doses of Enterogermina® (B. clausii: two billion spores/5 mL) were administered. Due to the lack of supplies (they did not have catheters, or intraosseous for the administration of intravenous fluids) she was transferred to a second-level hospital in the provincial capital and then to our institution in Panama City with a diagnosis of acute gastroenteritis and severe dehydration.\n\nHe presented to the emergency department with a consciousness compromise, dehydration characterised by a tearless cry, dry oral mucosa. He had oedema of +++ hands, feet, abdomen and face. He was afebrile and had signs of shock, capillary refill time > 2 seconds, cold extremities, filiform pulse and marble skin, heart rate 170 bpm, respiratory rate 55 bpm, blood pressure 91/37 mmHg, oxygen saturation 99%. He weighed 4.7 kg and was 56 cm tall at admission, Z-score height/age -2.52, weight/height and weight/age Z-scores were not quantifiable due to severe dehydration. On segmental examination, there were fine crepitus in both lung bases and erythematous-squamous lesions with desquamation of skin and others with hypopigmentation of trunk and upper limbs (interpreted as pellagroid dermatosis).\n\nLactate Ringer bolus was given at 10 ml/kg in the emergency department, followed by 5% Dextrose in 0.33% Saline 500 ml at an infusion rate of 29 ml/h over 6 hours without KCL until diuresis was obtained. She was started on Ceftriaxone 50 mg/kg/day for suspected sepsis, stabilised and sent to the ward where she continued to receive 500 ml of 5% Dextrose in 0.9% Saline at 20 ml/hr.\n\nAmong the examinations, a blood count revealed leukocytosis at 39.0 x 103/uL, severe anaemia 5.6 g/dL, thrombocytosis 502 x 103/uL, the rest of the results are detailed in. He was transfused with 50 ml of filtered and leuko-reduced red blood cells and 40 cc of fresh frozen plasma due to altered coagulation times. Enteral feeding was initiated by nasogastric tube and infusion was decreased to 15 ml/h of 5% Dextrose in 0.9% Saline 500 cc, and continued with negative water balance.\n\nOn day 2, initial peripheral blood culture was reported as Gram positive cocci in clusters, Oxacillin was added at 200 mg/kg/day, Ceftriaxone was increased to 75-100 mg/kg/day, total fluids to 120 ml/kg/day and calcium was corrected (value received 6.38 mg/dL).\n\nOn her 3rd day she lost venous access, so a central venous catheter (CVC) was placed. She was hypovolemic with subhydrated oral mucosa, increased respiratory work, cold extremities and capillary refill time of 3-4 seconds. Ringer's lactate was given at a load of 20 ml/kg in one hour. Arterial blood gas revealed uncompensated metabolic acidosis with pH 7.26, HCO3 13 mmol/L, PCO2 28.4 mmHg, PO2 39.2 mmHg, lactate 2.8 mmol/L. She was intubated and transferred to the paediatric intensive care unit (PICU) where she was placed on mechanical ventilation.\n\nTotal fluids of 100 cc/kg, infused epinephrine, low-salt albumin, and 10% calcium gluconate were administered, and fentanyl was changed to remifentanil due to elevated liver enzymes.\n\nThe blood culture of admission reported growth of methicillin-resistant Staphylococcus aureus (MRSA), Oxacillin was omitted and Clindamycin was added at 40 mg/kg/day; the blood culture of admission on the second day of admission to the ICU with Gram-negative bacillus smear was positive, and Ceftriaxone was changed to Ceftazidime at 150 mg/kg/day.\n\nOn his first day in the ICU, a substantial increase in serum biomarkers of cardiac damage was documented, the echocardiogram showed mild mitral and tricuspid regurgitation, left ventricular dilatation, left ventricular ejection fraction (LVEF) 58%, no evidence of thrombi, vegetations or pericardial effusion, and he was diagnosed with acute myocarditis. Milrinone was started at 0.4 mcg/kg/min, furosemide and IV immunoglobulin 1 g/kg single dose.\n\nThe second day blood culture the germ was identified as Bacillus clausii, identified by the system (VYTEK 2TM), the susceptibility profile was not performed because the team did not have cut points for this germ, for this reason the antibiotic coverage was adjusted, considering it was not a contaminant, Ceftazidime was changed to Ciprofloxacin at 30 mg/kg/day and Ceftaroline was added at 8 mg/kg every 8 hours along with Clindamycin for MRSA. The 3 subsequent blood cultures with intervals of 48 hours between each were positive in both peripheral blood and CVC for isolation of B. clausii.\n\nOn his 6th day in hospital, the gastrointestinal panel (Maripoc gastro test methodology) performed on the second day detected Clostridiodes difficile toxin A/B, the tests for Campylobacteryeyuni, Norovirus GI, Norovirus GII.4, Adenovirus and Rotavirus were negative. Following these findings, therapy was escalated to IV Vancomycin at a dose of 60 mg/kg/day and metronidazole was added orally. Ceftaroline, clindamycin and ciprofloxacin were omitted, covering both B. clausii and C. difficile and MRSA .\n\nHIV testing, serology for Chagas and SARS-CoV-2 antigen by immunofluorescence (FIA) were negative, immunoglobulins were within normal limits.\n\nOn the seventh day, arterial hypertension was reported and spirinolactone was added to the management.\n\nOn the 8th day, the laboratory tests showed altered coagulation times and increased azotaemia associated with anuria that had lasted for 12 hours. However, due to the patient's condition, a peritoneal catheter was not placed, the vancomycin dose was adjusted and vitamin K was administered. The patient continued to have anuria and anasarca, and she developed sustained hypotension. Noradrenaline was added, but her condition deteriorated with multisystem organ failure and she died twelve days after admission. No autopsy was performed because the mother refused permission for cultural reasons.\n",
    "summary": "4-month-old lactating infant, indigenous ethnicity, from the rural interior of Panama, 3 hours by canoe from the nearest health subcenter, with protein-caloric malnutrition, who presented with acute diarrhea and moderate-severe dehydration, receiving Enterogermina as part of the initial treatment. She was transferred to a third-level hospital, where she arrived with respiratory distress and signs of shock. The initial blood culture reported growth of methicillin-resistant Staphylococcus aureus (MRSA), the gastrointestinal panel was positive for Clostridiodes difficile, and later growth was confirmed in serial blood cultures of peripheral blood and central venous catheter, of Bacillus clausii. With a torpid evolution and resistance to multiple antibiotic regimens, she died of multisystem organ failure twelve days after admission.\n"
  },
  {
    "id": "multiclinsum_gs_en_59.txt",
    "fulltext": "A 2-year-old female presented with a 1-year history of painless left progressive proptosis with no reported systemic diseases or family history. Ophthalmologic examination revealed light sensation as the only vision in the left eye, along with proptosis, inward and upward eyeball displacement, and restricted extraocular muscle movements in downward and outward directions. An irregularly shaped, well-defined soft mass was palpable in the inferior aspect of the left orbit, accompanied by left lower eyelid ectropion. The pupil was enlarged (4 mm in diameter), and pupillary reaction was absent. The remaining anterior segment examination showed no apparent abnormalities. Fundus examination was challenging due to the child’s size. Hertel exophthalmometry readings measured 10.5 mm in the right eye and 18 mm in the left. Magnetic resonance imaging (MRI) revealed a well-circumscribed mass, displaying hypointense signals on T1-weighted images and hyperintense signals on T2-weighted images. Contrast-enhanced imaging demonstrated no significant improvement. A transconjunctival approach via the inferior fornix with canthotomy and cantholysis was performed, revealing a grayish-white cystic mass with a distinct boundary from surrounding tissues. During posterior separation to the eyeballs’ posterior part, tight adhesion to the optic nerve was observed. Due to the mass’s substantial size and the restricted surgical field, volume reduction was necessary. Approximately 12.5 mL of the fluid was aspirated, and the mass was completely excised. Histopathological examination disclosed a fibrous capsule wall covered with squamous and glandular epithelium, along with visible brain tissue and a cartilage-like matrix consistent with orbital teratoma. One month postsurgery, the patient exhibited enophthalmos, conjunctival hyperemia, and keratitis on ocular examination. This was attributed to the mass’s prior enlargement of the orbital cavity, resulting in postoperative enophthalmos. The cornea could not adhere to the eyelids, creating a space and causing corneal inflammation. After obtaining the consent of the patient’s guardian, a second operation involved the implantation of an allogeneic sclera into the orbit to increase the orbital volume, alleviate fossa pitting and restore keratitis to normal. No recurrence of the teratomas was noted during the 1-year follow-up. The patient still had minor enophthalmos and outer canthus abnormality. The visual acuity remained consistent with pre-operation levels. Hertel exophthalmometry readings measured 10.5 mm in the right eye and 8 mm in the left. The remaining anterior segment examination showed no apparent abnormalities.",
    "summary": "Patient concerns: A 2-year-old female child was presented exhibiting proptosis and inward and upward eyeball displacement. Enhanced magnetic resonance imaging revealed a well-circumscribed mass, persisting with hypointense signals on T1-weighted images (T1WI) and hyperintense signals on T2-weighted images (T2WI).\n\nDiagnoses: The diagnosis of teratoma was confirmed finally through histological and immunohistochemical exams.\n\nInterventions: A transconjunctival approach via the inferior fornix, coupled with canthotomy and cantholysis, was performed. However, a month postsurgery, the patient developed enophthalmos, conjunctival hyperemia, and keratitis upon ocular examination. A second operation involved the implantation of allogeneic sclera into the orbit to increase orbital volume, improve the pitting of the fossa, and restore keratitis to normal.\n\nOutcomes: No recurrence and other complications were noted during the 1-year follow-up."
  },
  {
    "id": "multiclinsum_gs_en_490.txt",
    "fulltext": "A 78-year-old woman, who came to collect her blister pack with her medication reconstituted in a personalised dosage system (PDS) from the community pharmacy, informed us that for some months she had been suffering from tiredness, weakness, dizziness and confusion. These symptoms were preventing her from leaving her home to walk as often as she normally did. In view of this situation, she was invited to the personalised care area to review the degree of knowledge that the patient had of her medication and the use she made of it, to analyse whether any of her medication could be related to the health problem described.\n\nPharmacological treatment of the patient\n\nMedication  Dose  Dosage  Health issue  Start date\nDoxazosin  2 mg/24 h  0-0-1  Hypertension  2014\nLosartan  100 mg/24 h  1-0-0  Hypertension  2014\nManidipine  20 mg/24 h  0-1-0  Hypertension  2014\nSimvastatin  40 mg/24 h  0-0-1  Hypercholesterolemia  2014\nAcetylsalicylic acid  100 mg/24 h  1-0-0  Secondary prophylaxis  2014\nOmeprazole  20 mg/24 h  1-0-0  Prevention of peptic ulcer  2014\nPregabalin  100 mg/12 h  1-0-1  Neuralgia  2019\nTorasemide  10 mg/24 h  1-0-0  Edema  2023\nDulaglutide  1.5 mg/week  1 time/week  Diabetes  2014\nInsulin glargine  74 IU/24 h  1-0-0  Diabetes  2014\nInsulin lispro  20 IU/24 h  0-1-0  Diabetes  2014\nBrimonidine  1 drop/12 h  1-0-1  Ocular hypertension  2018\n\nStudy and evaluation\nThe interview revealed that there was no new medication and that it did not appear in the SPD service register. Given the suspicion of a possible hypotension, her blood pressure was measured with an Omron Complete device, with the following values: Systolic Blood Pressure (SBP) 96 mmHg, Diastolic Blood Pressure (DBP) 52 mmHg and Heart Rate (HR) 69 beats per minute. Given these values, it was suggested that her blood pressure be monitored and the influence of her medication on these values and the symptoms described by the patient be analysed.\n\nThe patient's medication doses, starting with antihypertensive medications, are reviewed to adjust to the patient's estimated glomerular filtration rate (eGFR) and to see if hypotension is related to the dosage of these medications. The patient's eGFR value, calculated using the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) formula, is 30 ml/min/1.73 m2.\n\nThe guidelines for the revision of the dose according to the value of the eGFR are the product information for the medicinal products and the consensus guidelines for the use of medicinal products in renal impairment of the teaching and research group in the field of practical pharmacy of the Faculty of Pharmacy of the University of Barcelona, which is available on the Internet. This guide has been prepared from the analysis of the most dispensed medicinal products in community pharmacies. They have been organised by therapeutic groups according to the ATC (Anatomical-Therapeutic-Chemical) classification, information on the symptoms of overdose has been included and it has been agreed to categorise the risk to the patient of taking these medicinal products according to their eGFR as low, moderate or high.\n\nAfter the medication review was performed according to the eGFR value of 30 ml/min/1.73 m2, the results were obtained.\n\nFollowing the study of the medication, our intervention focuses on the dosage of the following medicines: losartan, manidipine, torasemide and pregabalin. The antihypertensive medicines, losartan and manidipine, and pregabalin require a dose adjustment depending on the patient's eGFR value, while the diuretic torasemide can influence blood pressure values.\n\nInitially, it was decided to intervene in the dosage of losartan and manidipine. There is the possibility of reducing the dose of pregabalin, but the pharmaceutical team agreed with the patient to assess the influence of this medication after the possible adjustment of the dose of antihypertensive during the evolution and follow-up of the patient.\n\nIntervention\nThe information is used to prepare a report for the doctor (see annex), recommending a reduction in the dose of losartan and manidipine, as the available information recommends a reduction in the dose to 50-75% of losartan for eGFR of 30-59 ml/min/1.73 m2 and adjusting the dose of manidipine for eGFR of 15-30 ml/min/1.73 m2.\n\nThe proposed intervention was explained to the patient and the report was given to the primary care doctor, explaining the possibility of adjusting the dose of losartan and manidipine to improve the patient's condition (table 4). When this information reached the doctor, he opted to reduce the dose of losartan to 50 mg/24 hours and manidipine to 10 mg/24 hours. Pregabalin 100 mg/12 hours was also replaced with gabapentin 300 mg/12 hours.\n\nFollow-up\nFollowing this change in the patient's treatment and after a follow-up of two months, the patient showed an improvement in blood pressure values (table 5) and a remission of the symptoms described. It was reviewed whether the gabapentin dose of 300 mg/12 hours was adequate for the eGFR value of 30 ml/min/1.73 m2, and it was correct (eGFR between 30 and 60, recommended total daily dose 300-900 mg).\n\n",
    "summary": "78-year-old patient, taking many medicines and included in the Personalised Medication Dosage System (SPD). When she came to collect her medication, she informed us that for some months she had been suffering from tiredness, weakness, dizziness and confusion. A review of the medication was carried out, focusing on the dosage of the medicines metabolised or eliminated by the kidneys, depending on the patient's estimated glomerular filtration rate (EGFR). A referral was made to the Primary Care Physician (PCP) by means of a report, in which the reduction of the dose of losartan and manidipine was recommended, depending on the patient's estimated glomerular filtration rate (EGFR). The PCP reduced the dose of the antihypertensive medicines. The case was monitored, which allowed us to observe that the patient no longer presented the symptoms described initially.\n"
  },
  {
    "id": "multiclinsum_gs_en_483.txt",
    "fulltext": "It is a case study, approved by the Research Ethics Committee (CEP) under number 1.012.635. The prior authorization of the relatives and the participant was requested from the signature of the Free and Informed Consent (TCLE) and the Free and Informed Consent (TALE).\n\nThe participant in this study is a female student in the 3rd year of elementary school. In the first evaluation, in 2018, the child was 8 years and 2 months old, while in the second evaluation, in 2019, she was 9 years and 6 months old. The interval between the evaluations occurred due to the fact that it is a public service. Thus, the laboratory was absent from activities during the holidays. In addition, it is important to consider that the appointments were only made once a week and, during that period, the participant was absent, which also prolonged the process. As for her history, she was born at term and presented adequate neuropsychomotor and linguistic development. The child was born and lived in a French-speaking country until the age of 2 years, but had exposure to another language at home, since her parents are Brazilian Portuguese speakers. However, her first words were in French. When she returned to Brazil, she went through two private schools. In the first school, she was unable to communicate, as she only expressed herself in French. After that experience, at the age of 3, she began studying in a French school, still in Brazil. Over the years, she presented difficulty in acquiring reading and writing; for that reason, she repeated the 1st year of elementary school, at the request of her mother. At the age of 6, she began studying in a bilingual Portuguese-English school. At the age of 8 years old, she underwent evaluation by an interdisciplinary team in the areas of speech therapy and neuropsychology, finding the diagnosis of developmental dyslexia (DD) and high abilities/giftedness (AH/S). Soon after, she was referred to the evaluation of reading and writing in the Laboratory of Written Language, Interdisciplinarity and Learning - LEIA/UFRN.\n\nPhases of the study: four assessment sessions for each moment - pre and post intervention (T1 and T2, respectively) - and 20 sessions of phonological remediation, once a week for 60 minutes. The intervention took place in the second semester of 2018, where parents were not very engaged due to work demands.\n\nAssessments were conducted individually over a one-hour period. They included tasks to assess performance in phonological processing - phonological working memory, phonological awareness and mental lexical access - reading and writing.\n\nThe following protocols were used to evaluate the child:\n\nPhonological awareness: to evaluate this ability, the Consciência Fonológica Instrumento de Avaliação Sequencial - CONFIAS (11) was used. This protocol proposes tasks of synthesis, segmentation, rhyme, alliteration, initial and final syllable identification, exclusion and transposition. First, syllabic awareness, formed by nine items, is analyzed, followed by phonemic awareness, formed by seven items. Each hit is equivalent to one point, with 40 for syllabic awareness and 30 for phonemic awareness, totaling 70 points. Its results should be compared with the expected writing hypotheses based on Ferreiro and Teberosky (12). In this way, the following normal values were used: for the syllabic-alphabetic writing hypothesis, 27, 12 and 39 for the syllabic, phonemic and total score, respectively; for the alphabetic writing hypothesis, 31, 15 and 46.\n\nPhonological working memory: The Phonological Working Memory Test was used (13). In the application of this protocol, the assessor should begin with the non-word test, which consists of 40 invented words. The assessor should then say each word in the list, asking the child to repeat it immediately. The child has two attempts to repeat the words correctly. In the first attempt, each correct answer is worth two points, in the second attempt, the child is awarded one point, and in the third attempt, the child is awarded zero points. After this, the assessor should move on to the test of digits in direct and reverse order, which is scored in the same way as the pseudo-words. Depending on the age of the participant at the time of the assessments, the normal values of 69, 13 and 6 were used for pseudo-words, direct and reverse digits, respectively.\n\nAccess to the mental lexicon: the Rapid Automatic Naming Test (RAN)(14) was used in the evaluation and the Automatic Naming Test (TENA)(15) in the re-evaluation. Both tests aim to estimate the individual's ability to name a sequence of stimuli, that is, to measure the speed at which the child can verbalize a visual stimulus quickly. Two protocols were used, since the TENA had not yet been published at the time of the first evaluation. In addition, the TENA is a current and more complete protocol for the verification of normality, as it allows analysis according to age and months. The two tests used have similar application and are divided into four boards, where the child must name colors, objects, letters and digits. The naming must be done with the same movement that is used for reading - from left to right and from top to bottom. For T1, which used the RAN, the normality values correspond to children aged between 8 years and 8 years and 11 months, due to the age of the participant in that period, thus, it should have a score of 28, 29, 52 and 46 seconds for the subtests of digits, letters, objects and colors, respectively. For T2, the normality values of the age of 9 years and 6 months of the protocol (TENA) were used, with an expected score of 35, 32, 50, 53 seconds for the subtests of digits, letters, objects and colors, respectively.\n\nReading: First, the Protocol for the Assessment of Reading of Words/Pseudowords Isolated – LPI(16) was used, in which the child is asked to read aloud words and pseudowords, which are scored. 19 regular words, 20 irregular words and 20 pseudowords are arranged in black Arial font, size 24 and white background. The child may obtain a total of 59 points, since each correct reading is worth one point. After this, the Protocol for the Assessment of Reading of Expository Texts was used(17). This instrument aims to assess reading comprehension through directed questions about texts compatible with the subject's school year. It assesses and times patterns of silent and oral reading. This allows the reading level to be verified and compared. In addition, the number of words read per minute is averaged, allowing the reading speed to be verified and compared.\n\nWriting: To evaluate the writing, the child was asked to produce a text on a topic of their interest. After finishing the story, the professional asked the child to read out loud what was written. Furthermore, the child was asked to write the target words of the LPI(16) on a separate sheet, in order to carry out a dictation of words and pseudo-words. With this, a qualitative investigation of the writing was carried out, based on the orthographic analysis of Zorzi and Ciasca(18).\n\nThe remediation was based on a program used for children with dyslexia(19) and included activities that aimed to improve phonological abilities, such as: identification of graphemes and phonemes, phoneme pairs, syllable pairs, word pairs, addition and subtraction of phonemes, syllabic and phonemic manipulation, rhymes, alliteration, access to mental lexicon, visual working memory, auditory working memory and reading training. In all sessions, these activities were explored in a playful way, mainly directed to the metalinguistic aspects of phonological awareness. In reading training, the child was exposed to children's books from the Mico Maneco collection. This collection has various stories that increase the level of complexity of words, so it is possible to follow the child's progress. The activities performed and the child's evolution were described in his/her medical record at the end of each session.\n\nAnalysing the results found, with regard to performance in phonological awareness, in both assessments the child presented performance consistent with the hypotheses of writing presented in each period. In the first assessment, he received the syllabic-alphabetic writing hypothesis and in the second, the alphabetic one, demonstrating progress. The performance score progressed in both categories of the skill, syllabic (T1 = 35; T2 = 37) and phonemic (T1 = 14; T2 = 20) (Table 1). The progress of 4 successes in the phonemic level is highlighted, which can be explained due to the phonological remediation having been performed with focus on the phonemic level.\n\nThe results of phonological working memory at the time prior to phonological remediation expressed below-expected performance for the pseudo-word category, with 66 points in T1, with expected performance for T1 (ET1) of 69, and for the reverse-order digits category (T1 = 04; ET1 = 06) (Table 1). Despite this, it presented results within the expected range for the reverse-order digits category (T1 = 20; ET1 = 13). In the post-intervention evaluation (T2), the results are adequate for the age. It is also possible to notice advances in this skill in all categories, pseudo-word (T1 = 66; T2 = 69), reverse-order digits (T1 = 04; T2 = 12) (Table 1), which requires aspects of executive functions that assist in the rapid storage of the response, a differential aspect in high abilities.\n\nAs for the automatic rapid naming, it is noted that in T1, the performance is inadequate for the standards of normality in all subtests. It is also possible to say that, in T2, the performance was below the expected for the categories of digits (T2 = 41; ET2 = 35), objects (T2 = 59; ET2 = 50) and colors (T2 = 56; ET2 = 53). Only the category of letters presented results within the expected (T2 = 29; ET2 = 32). On the other hand, the advance in the speed of naming is visible for the subtests of letters (T1 = 37; T2 = 29), objects (T1 = 62; T2 = 59) and colors (T1 = 60; T2 = 56), with the exception of digits (T1 = 37; T2 = 41) (Table 1). With the decrease of the time of naming of the stimuli, it is possible to say that the child becomes more effective to access the mental lexicon at the level of the phonological and visual representation, which is also not usual in isolated dyslexia.\n\nAs for reading, in T1 she presented an alphabetic level and in T2 an orthographic level. In the first test, it was noted that there was difficulty mainly with visually similar letters and phonologically close. In addition, the student used sub-vocal support to decode and had an average reading of 20 words per minute, which demonstrates extremely slow decoding and is far below what is expected for her schooling. In the reassessment, she had an average of 94.4 words per minute in oral reading, which is considered adequate for her schooling. She demonstrated presence of prosody, rhythm, global reading, interest and adequate understanding. Qualitatively, it is observed that the child, even with adequate performance, read with a low intensity of speech, still demonstrating insecurity in carrying out the task.\n\nIn writing, it can be observed that in T1 the child had inadequate pencil grip, imprecise writing, with letter changes, omissions, hyper and hyposegments, repetition of words and low use of cohesive elements. In this period, it was shown with writing in the transition from the syllabic-alphabetic phase to the alphabetic phase. In T2 no significant change was observed, since his writing continued to be imprecise, with little intelligibility of the content, visual similarities between letters (such as “d” and “b”) and lack of punctuation. According to the sample collected, it was shown in the alphabetic phase of writing, although difficulties not expected for his age persisted. Despite this, it is noted that he used a greater repertoire in the use of vocabulary for the lexicon of visual input.\n\nAfter the analysis of the results in their entirety, it can be observed that the written language skills advanced during the interval between the evaluations, despite the persistence of consonant characteristics with dyslexia, as it still presents performance below the expected in the access to the mental lexicon and in writing - with the presence of exchanges between phonemes that are audibly and visually similar in a persistent way, omission of letters and hypersegmentation.\n",
    "summary": "This study is a case report of the evaluation and intervention process of a 9-year-old child with the paradoxical combination of high abilities associated with dyslexia. The objective was to compare the performance in the tasks of phonological processing, reading and writing before and after phonological remediation. In the first evaluation, the child presented an alphabetic level in reading, a transition phase between the syllabic-alphabetic and alphabetic levels in writing and a performance below the expected level in phonological processing abilities. After the intervention, there was an improvement in phonological processing abilities, consolidation of alphabetic writing and of the orthographic level of reading.\n"
  },
  {
    "id": "multiclinsum_gs_en_443.txt",
    "fulltext": "65-year-old woman with no relevant personal or family history. In August 2022, a posterior mediastinal tumour was found in the preoperative assessment for a knee surgery, which was why she was referred for evaluation and treatment. On admission, the physical examination was not relevant and the laboratory studies were within normal parameters. A chest CT scan was performed that showed a tumour located in the posterior right mediastinum measuring 6.5 × 4.2 cm, with well-defined borders, with a fat and solid density, with no evidence of bone erosion or infiltration of surrounding tissue. A biopsy of the lesion was performed using a 18G × 250 mm semiautomatic cutting needle, with image guidance, through a posterior approach. In the histopathological study, a benign neoplasm consisting of mature adipose tissue with areas of haemorrhage alternating with haematopoietic elements, predominantly precursors of the red series, was observed, as well as elements of the myeloid series in different stages of maturation and megakaryocytes, which established the diagnosis of MPM.  Finally, with the diagnosis established and the characteristics of the lesion, conservative management was decided. The patient evolved satisfactorily and was discharged without complications.\n",
    "summary": "We present the case of a 65-year-old woman with a primary mediastinal myelolipoma. Computed tomography of the chest showed an ovoid, well-defined bordered tumor of 6.5 × 4.2 cm, located in the posterior mediastinum. A trans-thoracic biopsy of the lesion was performed and microscopic examination revealed haemopoietic elements and mature adipose tissue.\n"
  },
  {
    "id": "multiclinsum_gs_en_180.txt",
    "fulltext": "The 52-year-old man tested positive for SARS-CoV-2 using a self-test kit after having a cold. He returned to work without fever after resting for two days, but lost consciousness while working outdoors in an ambient temperature of 35°C for five hours. Upon admission to the local hospital’s emergency department, his core temperature (Tc) was recorded as 40°C. The patient presented with persistent coma, dyspnea and gastrointestinal hemorrhage. No underlying diseases and relative family history was noted. Based on the characteristic presentation of hyperpyrexia, coma and multiple organ damage, a diagnosis of HS was established. He was admitted to emergency intensive care unit (ICU) of the local hospital and then received mechanical ventilation. The test results indicated the presence of pulmonary infection, hepatic and renal dysfunction, myocardial ischemia and coagulation disorders. The patient received initial management including rehydration (intravenously infused Lactated Ringer’s solution and normal saline at a rate of 2.5mL/kg∙h), intravenous administration of Piperacillin Sodium and Tazobactam Sodium, vasoactive medications for blood pressure support, continuous mechanical ventilation, and continuous renal replacement therapy (CRRT) to manage subsequent anuria. The patient received plasma transfusion and was administered Tranexamic acid on day 5. The worsening of his condition led to his admission to the medical ICU of our hospital 7 days after HS.\n\nFollowing admission, Reverse-transcription polymerase chain reaction (RT-PCR) testing of a nasopharyngeal swab yielded positive results for SARS-CoV-2. The patient was diagnosed with HS and severe COVID-19 based on China’s COVID-19 Diagnosis and Treatment Program (trial version 10): 1. real-time fluorescent RT-PCR detection of SARS-CoV-2 nucleic acid is positive; 2. respiratory failure and requires mechanical ventilation; 3. shock; 4. combined with multiple organ failure requiring intensive care. The patient had no contact with COVID-19 diagnosed patients or healthcare workers in the hospital, indicating community-acquired infection. The physical examination showed a Glasgow Coma Scale (GCS) score of 3/15, with scores of 1 for eye-opening, verbal response, and motor response. Additionally, the pupils were symmetrical and non-reactive. The heart rate was recorded at 106 bpm and blood pressure was maintained at 126/77 mmHg by continuously infusing norepinephrine at a rate of 0.4 ug/kg·min. The laboratory test results indicated a severe infection, along with anemia, thrombocytopenia, disseminated intravascular coagulation (DIC), as well as acute liver and kidney injury. The white blood cell count (WBC) decreased from 3.55×109/L to 3.13×109/L, lymphocytes significantly decreased from 0.25×109/L to 0.1×109/L, and neutrophil percentage (N%) increased to 85.3%. The Procalcitonin level measured 2.81 ng/mL and C-reactive protein (CRP) level was 32.6 mg/L. Sputum culture testing yielded Stenotrophomonas Maltophilia and Candida lipolytica. The central venous catheter culture test detected Staphylococcus epidermidis, but the continuous blood culture test yielded no positive results. The Computed Tomography (CT) scan revealed bilateral frontal subdural effusion, consolidation and atelectasis in the lower lungs, inflammation in the right upper lobe, bilateral pleural effusion, and a small amount of abdominal fluid.\n\nThe patient received synchronized intermittent mandatory ventilation with a positive end expiratory pressure of 5 mmH2O and an oxygen concentration of 80% and continuous administration of norepinephrine and pituitrin to sustain normal blood pressure. Polyene phosphatidylcholine, adenosylmethionine budisulfonate, ulinastatin, and hemofiltration have been employed for the management of hepatic and renal dysfunction. The antibiotic was substituted with Meropenem and Thymalfasin was administered for 20 days to augment immune function. Mannitol was used to alleviate intracranial pressure for 3 days. To improve coagulation dysfunction, the patient received plasma and cryoprecipitate transfusions, continuous intravenous infusion of heparin sodium at 6000u/day and CRRT with sodium citrate for anticoagulant (8g/day) on day 7. Platelet transfusion was administered after 9 days of HS. His Tc fluctuated between 36 °C and 38.5 °C. CRRT was administered without anticoagulant on day 8. The patient had gastrointestinal hemorrhage and fever after 9 days of HS, but electronic gastroenteroscopy showed no signs of active bleeding. He underwent red blood cell suspension transfusion, hemostasis treatment and gastric acid suppression. Teicoplanin was added due to the presence of Methicillin-resistant Staphylococcus aureus isolated from sputum culture. The patient regained consciousness on day 13 with a GCS score of 14/15 and presented with a moderate fever. Gastrointestinal hemorrhage was not observed. Mechanical ventilation was discontinued and the tracheal tube was removed. But the creatinine levels increased following the suspension of CRRT on day 12.\n\nOn day 17, he developed sudden dyspnea with desaturation (oxygen saturation <85%) followed by a high fever (Tc: 39.3°C), necessitating reintubation and mechanical ventilation. Bronchoscopy revealed less sputum in both lungs and subbranches. He experienced a recurrence of coma, with a GCS score of 3/15. WBC increased to 14.94×109/L and NEU increased to 13.77×109/L. The levels of serum total bilirubin rose to 235.2 µmol/L, while creatinine increased to 441µmol/L. The brain CT scan revealed an ischemic stroke in the right frontal lobe and a hemorrhagic infarction in the right occipital lobe. The patient underwent cooling therapy using CRRT with ice-cold replacement fluid, along with persistent administration of Meropenem and Teicoplanin for anti-infection treatment. Carpofungin was added on day 18 due to the observed elevation in serum levels of Aspergillus galactomannan, Aspergillus IgG antibody, and Candida mannan. The RT-PCR testing for SARS-CoV-2 returned negative results.\n\nThe patient’s fever and infection improved on day 20, but he subsequently developed cerebral hemorrhage and hernia with bilateral dilated pupils. The dehydration therapy was used to reduce intracranial pressure, as surgery was refused by his family. On day 22, indicators of infection, levels of aspartate aminotransferase and creatinine increased again. Carbapenem-resistant Acinetobacter baumannii and A. fumigatus were cultured in the bronchoalveolar lavage fluid. The combination of Meropenem, Teicoplanin, and Carpofungine was administered for anti-infective therapy. The patient’s condition progressively worsened over the next 7 days, ultimately resulting in his demise on day 29. The patients’ inflammatory indicators, cytokines, and coagulation indicators are presented in Table 1.",
    "summary": "We report the first case of heatstroke comorbid with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in a 52-year-old male. After receiving intravenous antibiotics, organ protection measures, and treatment for coagulation disorders, his fever and coma resolved. However, he developed dyspnea and cerebral hemorrhage after several days. This patient experienced a multi-pathogen pulmonary infection and an intractable coagulopathy that ultimately resulted in MODS and death."
  },
  {
    "id": "multiclinsum_gs_en_583.txt",
    "fulltext": "A 19-year-old female presented to our hospital’s emergency room with a chief complaint of a two-day history of headache, accompanied by recurrent nausea, vomiting, and a one-day fever. On admission, her physical examination revealed a high fever of 39.1°C, elevated blood pressure at 189/120 mmHg, and a pulse rate of 148 beats per minute. Laboratory results indicated an elevated white blood cell count of 14.77×10^9/L and a neutrophil count of 13.55×10^9/L, suggesting a possible infection or inflammatory response. Initial empirical treatment with antibiotics was administered due to suspected infection, but her symptoms persisted. Given her abnormal vital signs, elevated inflammatory markers, and lack of symptom improvement, the patient was admitted for further diagnostic evaluation and transferred to the intensive care unit for close monitoring. A year prior, the patient had presented with similar symptoms and was diagnosed with myocarditis at a local hospital based on clinical findings at that time. During that hospitalization, she was also diagnosed with hypertension and prescribed antihypertensive medications. However, after discharge, the patient did not adhere to the prescribed antihypertensive therapy and did not regularly monitor her blood pressure. Additionally, it is notable that her father had a history of sudden, unexplained death.\n\nTo investigate the underlying etiology of the patient’s symptoms, a chest computed tomography (CT) scan was performed. Incidentally, this scan revealed a left adrenal mass with soft tissue density, measuring 43 mm × 36 mm. No pathological findings were observed in the head and chest CT scans. The electrocardiogram demonstrated sinus tachycardia with a shortened PR interval and tall, peaked P-waves in leads II, III, and aVF. Transthoracic echocardiography did not reveal any significant abnormalities.\n\nOn the second day of admission, the patient exhibited rising levels of brain natriuretic peptide (BNP) and Troponin I (TnI). The cardiologist provisionally diagnosed the patient with myocarditis of uncertain etiology, based on clinical presentation, elevated cardiac biomarkers (BNP and TnI), and supportive electrocardiogram findings. Treatment was initiated with methylprednisolone (0.25 g daily) to address potential myocardial inflammation due to suspected myocarditis. Furosemide (20 mg every 12 hours) and spironolactone (20 mg every 12 hours) were administered as diuretics to manage fluid retention and reduce cardiac workload. Perindopril amlodipine (10 mg: 5 mg daily) was prescribed as an angiotensin-converting enzyme inhibitor and calcium channel blocker combination to control blood pressure and reduce afterload. Metoprolol tartrate (25 mg every 12 hours) was used to manage heart rate and decrease myocardial oxygen demand, while esmolol (0.2 g/hour intravenous infusion), a short-acting beta-blocker, was administered for additional acute heart rate control due to sinus tachycardia. Due to concerns about a potential infection, moxifloxacin was added as empiric antibiotic therapy.\n\nGiven the patient’s presentation with an adrenal mass and hypertension, the endocrinologist recommended an evaluation of the aldosterone-to-renin ratio, plasma cortisol, plasma catecholamines, and 24-hour urinary catecholamines along with their metabolites. In the recumbent position, plasma and urinary catecholamine levels were markedly elevated (Table 1), including plasma dopamine at 524.5 pmol/L, norepinephrine at 83975 pmol/L, and epinephrine at 10579.3 pmol/L. Additionally, the 24-hour urinary levels showed free adrenaline at 4368.89 nmol/24 hours, free norepinephrine exceeding 12697.60 nmol/24 hours, normetanephrine at 8312 nmol/24 hours, metanephrines at 4078 nmol/24 hours, and vanillylmandelic acid at 58.1 mg/24 hours. These findings supported a clinical diagnosis of pheochromocytoma. On the fifth day post-admission, glucocorticoid therapy was discontinued, and perindopril amlodipine was substituted with terazosin for more targeted blood pressure management.\n\nAn enhanced abdominal CT scan further confirmed a left adrenal mass, highly suggestive of pheochromocytoma. Additionally, after obtaining informed consent, whole-exome sequencing was performed, revealing a heterozygous missense mutation, c.1900T > C: p. Cys634Arg, in the RET gene, leading to a substitution of cysteine with arginine at codon 634. This mutation raised suspicion for multiple endocrine neoplasia syndrome, prompting further evaluation of the thyroid and parathyroid glands. Thyroid color Doppler ultrasound identified a hypoechoic mass measuring 6 mm × 4 mm in the left thyroid lobe, and a mild elevation in calcitonin levels was noted. No additional significant abnormalities were detected.\n\nAs the patient’s condition gradually improved, plasma cortisol and ACTH levels returned to normal. The patient was subsequently discharged with a prescription for metoprolol tartrate (100 mg every 12 hours) and ivabradine hydrochloride (5 mg every 12 hours) for home management. Three months later, after achieving stable clinical status, the patient underwent resection of the left adrenal tumor, which measured 50 mm × 40 mm × 30 mm. Immunohistochemical analysis confirmed positive staining for Vim, CD56, Syn, CgA, and NSE, with S-100 positive in Sertoli cells, while CKpan, CD10, MART-1/Melan-A, and Melan-A were negative. The Ki67 index was 1%, leading to a definitive diagnosis of adrenal pheochromocytoma. The patient was discharged without further medications and has since been regularly followed up postoperatively without recurrence of symptoms. Over a 15-month postoperative follow-up, the patient exhibited persistently mild hypercalcitoninemia with stable thyroid nodule size, while PTH and serum calcium levels showed a progressive increase (Table 2). Further parathyroid scintigraphy using 99mTc-MIBI was performed, and the conclusion was a negative result for parathyroid adenoma.",
    "summary": "We report the case of a 19-year-old female who presented with pheochromocytoma without experiencing a crisis, despite having a significant adrenal mass and undergoing high-dose glucocorticoid treatment. Genetic testing revealed a heterozygous missense mutation in the RET gene (c.1900T > C: p. Cys634Arg), associated with MEN2A. Further endocrine evaluation identified a thyroid nodule with mildly elevated calcitonin levels, but normal electrolyte and parathyroid hormone levels. Over a 15-month postoperative follow-up, the patient exhibited persistently mild hypercalcitoninemia with stable thyroid nodule size, while PTH and serum calcium levels showed a progressive increase. Further parathyroid scintigraphy using 99mTc-MIBI was performed, yielding a negative result for parathyroid adenoma."
  },
  {
    "id": "multiclinsum_gs_en_515.txt",
    "fulltext": "February 2020, a 36-year-old with no significant past medical history presented with 5 years history of left sided penoscrotal mass. He has no lower urinary tract symptoms. No History of trauma or infections and he denied any history of weight loss, anorexia or fever. On examination, there is a smooth surface, tender cystic lesion around 20 mm ∗ 20 mm attached to the left side of the bulbar urethra at the penoscrotal junction, it was deep without any skin tethering and not related to the left spermatic cord and it was partially mobile.\n\nDoppler ultrasonography showed a well-defined hypoechoic mass measuring 2.7 ∗ 3.1 ∗ 2.0 cm with significantly increased vascularity at the left of penoscrotal junction. Pelvis Magnetic resonance imaging revealed a mass in the left inferolateral side of the base of the penis with a clear fat plane, which is isointense to the testes in the T2 weighted imaging, T1 weighted imaging and Diffusion-weighted imaging and it was connected to the vas deferens, no lymphadenopathy was noted. Alpha fetoprotein and beta-human chronic gonadotrophin levels were all in the normal range. Given the results of workup and the pain experienced by the patient, a decision was made to proceed with surgical removal of the mass for both diagnostic and therapeutic purposes. During surgery, a mass was seen in the left posterolateral of the scrotum and it was resected completely and sent for histopathology.\n\nHistopathology of the mass showed cellular spindle cell tumour arranged into interlacing fascicle, the cells have spindle to oval vesicular nuclei with evenly dispersed chromatin and inconspicuous nucleoli. The tumour showed high mitotic activity reaching up to 3/High-power field. Immunohistochemistry analysis was consistent with synovial sarcoma, revealing a positive TLE-1, CD99, B-cell lymphoma 2 (BLC2), Focal cytokeratin and focal epithelial membrane antigen (EMA). The material was sent for Fluorescence in situ hybridization (FISH) and reported a rearrangement of the SS18 gene at 18q11.2 which has been observed in synovial sarcomas. The mass margins were difficult to be assessed by histopathology as the sample had fragmented margins.\n\nThe patient presented to the clinic after 2 weeks and given the histopathology report, a re-resection with wider margin was discussed with the patient and he agreed. Positron emission tomography – Computed tomography (PET/CT) was done for Head and Neck, Chest, Abdomen, Pelvis and musculoskeletal structures. Only a 29 ∗ 27 mm thyroid nodule in the lower pole of the left thyroid lobe with moderate hypermetabolism at standardized uptake values (SUVs) of 4.9. Thyroid US showed a solid isoechoic well-defined nodule in the lower pole of the left thyroid lobe with no echogenic foci, Thyroid Imaging Reporting and Data System (TIRADS) was TR3.\n\nA second resection was made 3 weeks from the first one. The whole specimen was resected from both cords bilaterally which was deepened until reaching the corpus spongiosum which was shaved superiorly up to the urethra. The specimen was sent for histopathology. The resected mass was 6.0 ∗ 6.0 ∗ 3.0 cm in size, and it was negative for any pathology. The patient then went into active surveillance and after 16 months of active surveillance he was found to have metastatic lesions in the sixth liver segment and L1 vertebral body. Oncology team started chemotherapy regimen of Ifosfamide and Doxorubicin for 6 cycles with no improvement in the liver lesion. Surgical resection was made for the Fifth and Sixth liver sections with cholecystectomy. Patient then developed a new lung lesion and was started on Pazopanib and Stereotactic Body Radiation Therapy SBRT. The patient then underwent surveillance for 6 months then developed new liver and lung lesions then chemotherapy regimen of Gemcitabine and Docetaxel combination for 3 cycles and progressed then he was started 2 cycles of Dacarbazine and progressed then 2 cycles of Pembrolizumab and progressed. The patient then was shifted to palliative care, and he stopped following up.",
    "summary": "A 36-year-old man presented with a tender penoscrotal mass for 5 years. The patient underwent surgical resection of the mass. Histopathology revealed cellular spindle cell tumour arranged into interlacing fascicle, Immunohistochemistry analysis revealed a positive TLE-1, CD99, B-cell lymphoma 2 (BLC2), Focal cytokeratin and focal epithelial membrane antigen (EMA). In our case, the patient was aggressively treated with two surgical resections and still progressed and metastasized and continued progressing even after different chemotherapy regimens."
  },
  {
    "id": "multiclinsum_gs_en_91.txt",
    "fulltext": "A 13-year-old adolescent male, with no significant previous medical history, presented to the emergency department with a 3-day history of acute bilateral pleuritic chest pain associated with mild non-productive cough and no dyspnea. Associated with this, he had mild rhinorrhea and a single febrile episode that day (temperature of 38ºC). Chest pain was localized to the costal margin region and worsened with cough, without diurnal variation. The patient-reported relief with paracetamol. There were no complaints of joint pain, weight loss, anorexia, fatigue, episodes of syncope or exercise restriction. In fact, he practiced sports regularly—canoeing 2 times a week. No evidence of an infectious exposure or contact with household or environmental fumes, dust, or mineral oils was described. There was no known family history of cardiopulmonary conditions. He had a chest radiograph taken 4 years earlier during an acute illness, which showed a marked interstitial infiltrate that was presumptively treated with azithromycin with no further clinical symptoms and no further follow-up.\n\nOn admission, the patient’s temperature was 37.8°C with normal peripheral oxygen saturation (99%) in room air. His heart (93 beats per minute) and respiratory rate (15 breaths per minute) were normal and blood pressure was on the 85th percentile (115/66 mmHg). Physical examination revealed diminished breath sounds in the lower two thirds of the chest with no adventitious sounds. No respiratory distress, finger clubbing, cyanosis, abnormal heart sounds, or other findings were present. Chest radiograph revealed a marked interstitial infiltrate, comparable with his previous examination. A thoracic computed tomography (CT) revealed multiple bilateral areas of ground-glass opacities involving > 65% of lung parenchyma, suggestive of PAP. Respiratory viral testing was negative, and he remained stable throughout his monitoring in the emergency department. He was discharged with empiric antibiotics (amoxicillin-clavulanic acid and azithromycin) to cover a potential respiratory infection, with clinical resolution of symptoms and was sent for follow-up at the pediatric respiratory clinic.\n\nUpon further investigation in the outpatient setting, positive antinuclear antibodies (ANAs) at a titer of 1/89 with a fine speckled pattern were detected, while other autoantibodies tested negative and immunoglobulin levels remained within normal limits. Bronchoalveolar lavage revealed fluid with a milky appearance and positive periodic acid-Schiff staining; microbiological examination, including for mycobacteria, returned negative results. Spirometry indicated a mild restrictive pattern with reduced forced vital capacity (FVC) at 2.92 L (77%) and forced expiratory volume in 1 second (FEV1) at 3.21 L (69.9%), alongside a normal FEV1/FVC ratio (109%). In addition, the DLCO single breath (SB) showed a moderate decrease at 13.8 ml/min/mmHg (48.6%). Suspecting PAP, a genetic panel was conducted, which showed no mutations associated with surfactant dysfunction. Subsequently, GM-CSF antibody testing was performed with a positive result, raising suspicion for AI-PAP. At 20 months of follow-up, the patient remains asymptomatic and continues to exercise regularly. He repeated spirometry testing with normal FVC at 4.03 L (81.3%); FEV1 at 3.71 L (87.5%); FEV1/FVC ratio at 91.96% and DLCO SB at 25.54 ml/min/mmHg (83.7%). As the patient remains stable with no respiratory symptoms, we decided to defer treatment and continue monitoring with regular clinic visits.",
    "summary": "We describe the case of a 13-year-old adolescent male who presented to the emergency department with acute pleuritic chest pain not associated with systemic complaints. On examination, he had diminished breath sounds in the lower two thirds of the chest with no other abnormal findings; SpO2 (oxygen saturation) was 98% on room air. Chest radiograph revealed a marked interstitial infiltrate, comparable with the one taken 4 years earlier during an acute illness that was presumptively treated with azithromycin. A computed tomography (CT) scan revealed multiple bilateral areas of ground-glass opacities with areas of crazy paving, involving > 65% of lung parenchyma, suggestive of pulmonary alveolar proteinosis (PAP). Respiratory viral testing, including for coronavirus (SARS-CoV2), was negative. Bronchoalveolar lavage performed in the outpatient setting revealed a milky fluid and positive periodic acid-Schiff staining. Spirometry indicated a mild restrictive pattern (forced vital capacity [FVC] = 77%) and diffusing capacity of the lungs for carbon monoxide (DLCO) showed a moderate decrease at 48.6%. No mutations associated with surfactant dysfunction were found on the genetic panel. Anti-granulocyte macrophage colony-stimulating factor (GM-CSF) antibody testing was strongly positive, raising suspicion for autoimmune PAP. At 20 months of follow-up, the patient remains asymptomatic with a normal spirometry."
  },
  {
    "id": "multiclinsum_gs_en_212.txt",
    "fulltext": "27-year-old woman with a history of uncontrolled asthma, mild SARS-CoV-2 infection. In March 2021, she consulted a doctor for pain in the left hemicara and trismus. She reported having completed 48 hours before the antibiotic treatment with phenoxymethyl penicillin 1,000,000 IU daily orally for five days for a peritonsillar abscess. She was hemodynamically stable at the physical examination, without the need for supplemental oxygen, and without relevant findings in respiratory symptoms. The head and neck examination showed a soft, painful, cervical adenopathy, palpable and painful, predominantly homolateral and trismus. Complementary studies were performed. The admission laboratory reported leukocytosis, platelopenia, increased acute phase reactants and the rest of the parameters within normal values. An angiotomy of the craniofacial mass was performed, where a large thrombus was found in the internal and external carotid arteries. Studies were completed with a chest tomography and arterial Doppler ultrasound of neck vessels with no relevant findings. Early intravenous antibiotic treatment was initiated with ceftriaxone 1 g every 12 hours, clindamycin 300 mg every 6 hours and anticoagulation with enoxaparin adjusted to body weight and renal function, 60 mg subcutaneously every 12 hours. The patient evolved 72 hours after initiating the directed treatment with a fever of 38.5 °C and increased leukocytosis, so new complementary studies were performed, including a Doppler ultrasound of the heart without finding cardiac vegetations and a chest tomography where bilateral pulmonary septic emboli were found. With the admission hemocultures negative, a new admission of 3 units, culture of pharyngeal exudate and rotation of ceftriaxone to piperacillin tazobactam 4.5 g every 6 hours intravenous was decided. The patient evolved favorably, without rescue of germs in cultures. After 14 days of initiating the new therapeutic scheme, and with a control chest tomography without pulmonary lesions, it was decided to continue antibiotic treatment with oral clindamycin 300 mg every 6 hours, anticoagulation with acenocumarol adjusted to body weight and hospital discharge.\n",
    "summary": "A 27-year-old woman presented with facial oedema and trismus 48 hours after completing treatment with phenoxymethylpenicillin for an odontogenic infection. A head and neck CT scan showed a large thrombus in the internal jugular vein and a chest CT scan showed pulmonary septic embolism. Treatment consisted of early intravenous broad spectrum antibiotics and anticoagulation.\n"
  },
  {
    "id": "multiclinsum_gs_en_205.txt",
    "fulltext": "A 5-year-old presented to the paediatric emergency department (ED) having ingested chlorpyriphos 13 hours prior to presentation, followed by abnormal jerks, fast breathing and difficulty with breathing. The history was also comprised of excessive sweating and urination, mouth secretions and involuntary movement of the limbs. Vomiting followed the ingestion of crushed charcoal and palm oil. The patient had lapsed into coma prior to presentation. The temperature at presentation was 38.3°C, Glasgow coma score was 3, pupils were pinpoint pupils and there was hypotonia in all limbs. In addition, the patient was severely dyspneic, tachypneic (respiratory rate of 48/minute with intermittent sighing breaths), a saturation of 88% and widespread crackles. The pulse rate was 180/minute, blood pressure 120/80 mmHg, and random blood glucose 14 mg/dl. Serum lactate and cholinesterase tests were not done due to lack of facilities.\n\nThe patient was diagnosed with severe organophosphate poisoning (OPP) and aspiration pneumonitis. As ICU care was beyond the affordability of the parents, non-invasive ventilation (NIV) was administered using bubble continuous positive airway pressure (b-CPAP) causing his saturation to increase to 99%–100%. Hypoglycemia was corrected with a bolus of dextrose solution and tachycardia was treated with 20 ml/kg of normal saline. Intravenous Dexamethasone, Mannitol and IV Atropine at 0.02 mg/kg/dose were also administered. Empirical intravenous antibiotics were administered for aspiration pneumonitis. Pralidoxime was not given due to unavailability. Within 3 hours of presentation, the patient had fresh-whole-blood exchange-blood-transfusion (FWB-EBT) with 500mls of blood.\n\nThe patient’s GCS appreciated to 9/15 but IV Atropine was discontinued after the first dose due to a rapid increase in the heart rate. The blood glucose fluctuated between 41 to 259 mg/dl in the first 15 hours of admission and subsequently normalized with treatment. By the second day on admission, the patient developed thready pulses and hypotension for which another bolus of normal saline was administered. Dopamine infusion was commenced at 5mcg/kg/min using a peripheral vein and IV Mannitol discontinued. A second aliquot of FWB-EBT was administered with 500mls of blood.\n\nOver the first 30 hours of admission, the consciousness level improved and respiratory distress slowly declined. However, the patient developed rhonchi which was treated with nebulized Salbutamol and Budesonide and was subsequently transited to Oxygen therapy with nasal prongs with clinical improvement. The saturation remained stable at 97%. On Day 2 of admission, a chest radiograph was done which showed bilateral infiltrates in keeping with pneumonia.\n\nThe patient regained full consciousness by the 39th hour of admission. Intravenous Vitamin C and B, as well as oral Vitamin E and Zinc were commenced for their antioxidant effects, and regular diet was recommenced in a graded manner over the subsequent 48 hours. The patient’s clinical condition progressively improved and was discharged home after 10 days but was subsequently lost to follow-up.",
    "summary": "We present the case of a 5-year-old with severe organophosphate poisoning from ingestion of chlorpyrifos, further worsened by aspiration of a charcoal-palm oil mixture. The clinical illness was marked by respiratory failure, shock, coma and type I paralysis. The patient was treated in the emergency department with noninvasive ventilation, multiple episodes of exchange transfusion, intravenous atropine, inotrope infusion, antibiotics and steroids. The patient responded rapidly to treatment, did not develop intermediate syndrome and was discharged after 10 days of admission."
  },
  {
    "id": "multiclinsum_gs_en_76.txt",
    "fulltext": "A 19-year-old woman presented to the emergency department of our institution for acute onset of palpitations. An electrocardiogram (ECG) showed ventricular tachycardia, with right branch bundle block associated to left posterior hemiblock, and T waves inversion in the inferior and precordial leads. Blood test showed elevated troponin (27 ng/L, normal values <14 ng/L) and NT-pro BNP (aminoterminal pro B-Type Natriuretic Peptide) levels (2225 pg/mL, normal values <130 pg/mL). Hence, she was admitted to the coronary care unit.\n\nAbout 5 years before, she had already presented to the emergency department with cardiogenic shock due to fascicular ventricular tachycardia; she was subsequently hospitalized and underwent cardiac magnetic resonance (CMR) and a transoesophageal electrophysiological study, both with inconclusive results. She was discharged with a diagnosis of tachycardiomiopathy, with the prescription of a standard medical therapy (angiotensin-converting enzyme inhibitors, mineralocorticoid receptor antagonist, and beta blockers), and a follow-up was planned. Her subsequent clinical history was uneventful.\n\nDuring the present hospitalization, no further episodes of hyperkinetic arrhythmias were detected. Basal 12-lead ECG. Echocardiography showed diffuse hypokinesia of both the left and the right ventricles, and CMR was once again inconclusive. Then, the patient was advised to undergo cardiac computed tomography angiography (CCTA) to evaluate the anatomy of the coronary tree, under the suspicion of an undiagnosed congenital cardiac anomaly. CCTA was performed with a GE Lightspeed unit (GE HealthCare, Chicago, United States), with retrospective gating, at 100 kVp and 696 mAs, with a gantry rotation time of 0.35 s, and 0.625 mm slice thickness, with intravenous injection of 70 mL of Iomeron 400 mgI/mL (Bracco Imaging, Milan, Italy).\n\nDifferential diagnosis\nCardiogenic shock, namely a shock caused by inadequate blood flow, may be caused by different pathologies such as myocardial infarction, arrhythmias, or other cardiomyopathies. Undiagnosed congenital heart disease is a non-negligible cause of cardiogenic shock in otherwise healthy adult patients. Once myocardial infarction is ruled out by a 12-lead ECG, and an underlying cardiomyopathy has been excluded by an inconclusive CMR examination, CCTA is the technique of choice for the differential diagnosis among diverse causes of cardiogenic shock.\n\nInvestigations/imaging findings\nThe CCTA examination showed regular origin of the left main coronary artery, the left anterior descending artery, which presented a wide ramus intermedium, 2 diagonal branches, and the left circumflex artery, which appeared thin and non-dominant. Among all these vessels, there was no evidence of obstructive coronary artery disease. However, the ostium and the proximal portion of the right coronary artery (RCA) were absent, whereas its mid and distal portions were supplied by a wide collateral branch originating from the distal left anterior descending artery, which then surrounded the lateral wall of the right ventricle, ran through the distal part of the atrioventricular groove, finally giving rise to thin posterior interventricular and posterolateral arteries. Furthermore, a thin branch going from the mid left anterior descending artery to the sinoatrial node was observed.\n\nTreatment, outcome, and follow-up\nIn view of the CCTA findings, the patient underwent an echo-stress test, which confirmed the presence of inducible myocardial ischaemia in the inferior wall, in line with the positioning of the arrhythmic focus. After being transferred to a specialized centre for the diagnosis and treatment of congenital heart disease, the patient underwent transcatheter radiofrequency ablation of sustained ventricular tachycardia originating by the posteromedial papillary muscle. Then, she was discharged with medical therapy (Acetylsalicylic acid and Verapamil). At her 6-month follow-up, she has always been asymptomatic, with no further signs of arrhythmias.",
    "summary": "A 19-year-old woman presented to the emergency department with arrhythmia and signs of cardiogenic shock. After a 12-lead electrocardiogram ruled out acute myocardial infarction, and cardiac magnetic resonance showed no sign of cardiomyopathy, cardiac computed tomography angiography (CCTA) was performed, displaying ostial atresia of the right coronary artery. She was thus referred to a specialist centre for congenital cardiovascular disease, where an electrophysiological study observed an arrhythmogenic focus on the posteromedial papillary muscle, which was ablated, and she has been asymptomatic since."
  },
  {
    "id": "multiclinsum_gs_en_72.txt",
    "fulltext": "A 17-year-old male with no significant past medical or family history was referred to our clinic from the dental department following an incidental finding of a NFB during preoperative orthodontic planning, including dental x-rays and cone beam computed tomography (CBCT) without contrast. The patient was entirely asymptomatic and denied any history of nasal obstruction, rhinorrhea, epistaxis, foul odor, hyposmia, halitosis, facial pain, discomfort, or sleep disturbances. The patient's parents recalled an event when their son was seven, where he inserted an object into his nose. They sought medical advice, where no imaging was performed and an anterior rhinoscopy was utilized for diagnoses but due to the child's non-cooperation during the examination, the physician recommended the removal of the foreign body under sedation. However, the family did not follow up, and since the child remained asymptomatic, they assumed the foreign body had fallen out on its own. On endoscopic examination of the right nasal cavity, a deviated nasal septum with inferior turbinate hypertrophy was noted. The mucosa appeared erythematous and slightly edematous. A foreign body was visualized, lodged, and adhered to the floor of the nasal cavity beneath the inferior turbinate. The object was partially covered with mucus and possibly some crusted material and had a shiny appearance, indicating a metallic nature. Radiographic evaluation, including lateral and frontal X-rays, revealed a circular radiopaque object consistent with a metallic snap button located along the floor of the nasal cavity. The surrounding bony structures appeared normal. A CBCT confirmed the presence of the foreign body with associated mild inflammation, but no significant bony damage or sinus involvement was observed. With informed consent from the patient's parent, the foreign body was removed under local anesthesia in a semi-sitting position to reduce the risk of dislodgment to the airway. After decongesting the nasal cavity with Xylometazoline 0.1 % and administering Lidocaine spray (10 mg/spray) in the right nostril, a hook was utilized to disengage the foreign body, which was then retrieved using bayonet forceps. The procedure was uncomplicated, with minimal bleeding, easily controlled with saline irrigation. Post-removal examination showed no significant tissue damage. The retrieved object, a metallic snap button measuring 1 cm in diameter, exhibited signs of long-term exposure, including substantial corrosion and biological deposits. The patient was discharged in stable condition and prescribed nasal rinses with a sodium chloride irrigation solution (0.9 %). The patient was doing well at his two-week follow-up with an unremarkable examination.",
    "summary": "We present the case of a 17-year-old male with an asymptomatic NFB discovered incidentally during routine dental radiography. The patient denied any history of nasal obstruction, epistaxis, or discomfort. Imaging revealed a radiopaque object in the right nasal cavity, later identified as a metallic snap button embedded in the floor of the nasal cavity. The foreign body had likely been retained for over a decade."
  },
  {
    "id": "multiclinsum_gs_en_293.txt",
    "fulltext": "An 18-year-old hispanic male patient with no significant medical history presents to the emergency department (ED) complaining of substernal, non-radiated chest pain, orthopnoea, dry and non-productive cough, and subjective fevers at home, for the last 3–4 days. Family history remarkable for paternal grandfather diagnosed with non-ischaemic cardiomyopathy and a pacemaker at age 86 years old. Patient lives with both parents and denies any smoking, ethanol consumption, recreational drug use, abuse or neglect at home. He worked at auto-part shop and planned to start college soon.\n\n\nInvestigations\n\n\nIn the ED, serum troponin I levels were found to be elevated and ECG showed diffuse ST-segment elevation. He was admitted to the local hospital and initial workup was remarkable for an enlarged cardiac silhouette and mild pulmonary oedema observed on chest X-ray, a transthoracic echocardiogram (TTE) demonstrating left ventricular ejection fraction (LVEF) of 40%, with severe left ventricular (LV) concentric hypertrophy and mild posterior pericardial effusion. Additionally, the patient was found to have elevated titres for Coxsackie virus A and B. His symptoms initially improved with the initiation of ibuprofen and colchicine. Cardiac catheterisation was performed, which revealed no evidence of coronary artery disease. Repeat TTE showed an LVEF of 40%–45%, hypokinesis of anteroapical and inferolateral wall, with an elevated LV end-diastolic pressure, consistent with diastolic dysfunction. Chest CT angiogram showed evidence of pneumonitis and a pericardial effusion. And at this point, the constellation of symptoms was thought to be secondary to Coxsackie myopericarditis, for which he continued to receive medical treatment as previously mentioned.\n\nOn the fourth day of admission, the patient became diaphoretic, tachycardic and hypotensive with an undetectable blood pressure. Emergent TTE showed large pericardial effusion with impending cardiac tamponade features, and pericardiocentesis was performed. During the procedure, the patient developed pulseless electrical activity (PEA) cardiac arrest and received advanced cardiovascular support for 30 min. Ultimately patient was intubated, placed on venous-arterial extracorporeal membrane oxygenation (VA ECMO) and started on vasopressor support (norepinephrine 5 mcg/min and vasopressin 0.05 units/min), with numerous transfusions (9 packed red bloodcells, 10 units of platelets, 10 units of cryoprecipitate and 4 units of fresh frozen plasma) due to significant oozing of blood from the ECMO cannula. He was transferred to our hospital where endomyocardial biopsy (EMB) was then obtained due to concern of fulminant myocarditis and to test for other infiltrative cardiomyopathies. Pathology reports showed no signs suggestive of inflammatory or infiltrative process in the endomyocardium. Coxsackie Abs were repeated and were positive for Cox A type 9, Coxsackie B2 and Coxsackie B6, and an elevated Epstein-Barr virus (EBV) DNA quantitative PCR at 133 000 IU/mL. At this point, another TTE was done, which showed a severely decreased ejection fraction (EF) of 10%–15% with previously noted severe LV concentric hypertrophy (1.9 cm septum and 2.2 cm in the inferolateral wall).\n\nThe patient was started on intravenous immunoglobulin (IVIG) for treatment of Coxsackie myocarditis, and broad-spectrum antibiotics due to worsening leucocytosis, but with no identified infectious focus. Colchicine was discontinued due to concern for rhabdomyolysis, with elevation of serum creatine kinase level to 2874 unit/L. Vasopressors were then discontinued and the patient was extubated. He also developed episode of flushing, fever, dyspnoea and decreasing oxygen saturation, with chest X-ray showing congested lung parenchyma with concerns for ARDS, therefore, IVIG was stopped.\n\nGiven improvement of cardiac function in another TTE with LVEF of 25%–30%, it was decided to attempt to remove the ECMO, which was unsuccessful. The patient remained on ECMO support and emergent discussion with heart failure team took place to determine best approach. The patient was evaluated for possible left ventricle assist device, however, deemed not a candidate due to significant global concentric LV hypertrophy, and the multidisciplinary team agreed to facilitate emergency listing for heart transplantation, with consideration to transition to another cardiovascular support such as intra-aortic balloon pump, with potential inotrope support.\n\nDuring further evaluation for possible heart transplant, an incisional biopsy of a 1×1 inch palpable, painless, rubbery, mobile mass in the right arm was done and sent for pathology. The patient mentioned he first noticed this lesion approximately 2–3 months before presenting to the ED. Pathology report of the right upper extremity mass showed aggressive EBV (+) NK/T-cell lymphoma with a cytotoxic immunophenotype (positive for CD 2, CD3, CD56, BCL2, granzyme B, TIA1, MUM1 and diffuse coexpression of Epstein-Barr virus-encoded small RNAs by in situ hybridisation), and a modified SMILE (Steroids, Methotrexate with leucovorin, Ifosfamide with mesna, L-asparaginase and Etoposide) chemotherapy regimen was started. In situ hybridisation of the EMB previously obtained were negative for EBV-RNA.\n\nCardiac MRI was obtained, which revealed hypokinesis of the inferolateral and anterolateral wall, as previously described by TTE, delayed enhancement in the subendocardial and transmural distribution in these regions, with relative sparing of the septum. Additionally, avid enhancement and thickening of the pericardium, without a mass identified, and a pocket of pericardial fluid with septations, concerning for loculations, were also noted.\n\n\nDifferential diagnosis\n\nThe constellation of symptoms (shortness of breath, orthopnoea, hypotension and subjective fevers), with findings such as diffuse ST-segment elevation on ECG, leakages of cardiac markers (troponin), elevated Coxsackie virus titres (both of serotype A and B), as well as echocardiographic findings of pericardial effusion; all seemed to correlate with a classic presentation of viral pericarditis clinical due to Coxackie virus. However, despite medical treatment with colchicine, the patient continued to decompensate and eventually required pericardiocentesis due to cardiac tamponade, then developed cardiac arrest and ultimately requires ECMO support, for what seems acute onset heart failure. In this setting, fulminant myocarditis secondary to Coxsackie virus was considered. Cardiotropic RNA virus, such as Coxackie viruses, induce receptor-mediated endocytosis, with viral replication contributing to cellular dysfunction and ultimately apoptosis of the cell.1 When susceptible individuals are infected with highly virulent viral strains, maladaptive immunologic activity can occur, leading to persistent activation of T cells and continued antibody-mediated myocyte destruction, which can ultimately lead to fulminant myocarditis. EBV myocarditis could also explain the rapid deterioration in the setting of a positive EBV PCR, which is a more sensitivity test than traditional serologies for detection of acute infection.2 However, in situ hybridisation was negative for EBV-RNA.\n\nNevertheless, the significant concentric hypertrophy observed on the initial TTEs and the atypical delayed enhancement observed on the cardiac MRI are not explained by this diagnosis. Additionally, the EMB did not show an inflammatory process.\n\nFortuitous finding of EBV (+) NK/T-cell lymphoma by incisional biopsy of the right upper extremity allowed for a more fitting diagnosis for this case. The pericardial effusion, unresponsive to initial medical treatment and new acute heart failure with concentric hypertrophic cardiomyopathy, in the setting of newly diagnosed NK/T-cell lymphoma, raises the possibility of NK/T-cell lymphoma with involvement of the myocardium and pericardium as the most adequate diagnosis in this scenario, which englobes all the features previously mentioned in this case.\n\nOther differentials taken into consideration include infiltrative cardiomyopathy such as amyloidosis. However, Congo red staining of the EMB samples failed to demonstrate deposition of amyloid.\n\n\nTreatment\n\nGiven the diagnosis of extranodal NK/T-cell lymphoma (ENKTCL) with suspected pericardial involvement and no bone marrow involvement, modified SMILE regimen was desired as the first-line chemotherapy regimen. This regimen includes dexamethasone, ifosfamide, mesna and etoposide, and excluded methotrexate, due to evidence of third-spacing and effusions, which could lead to delayed excretion and increased risk of toxicity.\n\nHowever, due to his compromised cardiac function, it was believed that the patient would not tolerate cytotoxic chemotherapy which requires aggressive intravenous, and alternatively, emergent chemotherapy regimen was instituted: carboplatin (day 1–day 3), etoposide (day 1–day 5) and dexamethasone. Peg-asparaginase was later introduced in the regimen (day 7–day 21). This regimen proved effective, as evidenced by rapid recovery of the LV function and overall haemodynamic stability, and decision was made to incorporate a modified SMILE chemotherapy regimen, of which he received two cycles. Then chemotherapy regimen was changed to dexamethasone, gemcitabine, carboplatin and peg-asparaginase (DDGP). The patient received two cycles of DDGP. A full body positron emission tomography (PET) scan was negative for lymphoma. The plan is to continue two more cycles of chemotherapy (to complete six total cycles of chemotherapy). Currently, the patient is considering radiation therapy and possible stem cell transplant, after completion of the chemotherapy regimen. Additionally, the patient is currently on guideline-directed medical therapy for heart failure and has completed cardiac rehabilitation.\n\n\nOutcome and follow-up\n\nThe patient has completed five out of six chemotherapy sessions with the previously mentioned regimens. After initiation of chemotherapy and optimal medical treatment for heart failure, the patient has recovered much of his cardiac function, as evidenced by an LVEF of 55%, no wall motion abnormalities and normal myocardial wall thickness on his most recent TTE. He continues to be followed by heart failure/cardiology team and oncology team in clinic.",
    "summary": "An 18-year-old male patient presented to the emergency department complaining of new onset chest pain, fever and orthopnoea. Initial workup was remarkable for elevated troponin, diffuse ST-segment elevation on ECG and chest X-ray with enlarged cardiac silhouette. Transthoracic echocardiogram (TTE) demonstrates severe biventricular concentric hypertrophy and pericardial effusion. Also, Coxsackie virus A and B titres were positive, concerning for a classic viral pericarditis. However, despite medical management, the patient became dyspnoeic and hypotensive. Impending cardiac tamponade was observed on repeat TTE, and pericardiocentesis was performed, complicated by pulseless electrical activity cardiac arrest, and ultimately patient requiring venoarterial extracorporeal membrane oxygenation support. Emergent endomyocardial biopsy showed no inflammatory process, and a skin biopsy of a small lesion in the right arm showed unexpected diagnosis of Epstein-Barr virus (+) natural killer/T-cell lymphoma. On initiation of chemotherapy, clinical improvement was observed as evidenced by improving ejection fraction, resolution of pericardial effusion and gradual decrease in myocardial hypertrophy."
  },
  {
    "id": "multiclinsum_gs_en_405.txt",
    "fulltext": "We report a rare case of euthyroid unilateral GO with early massive mono-muscular fibrosis in a 50-year-old male patient. The patient had a family history of cardiovascular disease, type 2 diabetes mellitus, and myasthenia gravis but no family or personal history of thyroid autoimmune disease. The patient was a smoker of 20 cigarettes a day from the age of 30 and presented dyslipidemia for several years. Since June 2020, he experienced rapid and progressive swelling of the soft tissues in the right orbit, moderate pain during ocular globe movements, redness of eyelids and diplopia. Visual acuity was normal in both eyes. In October 2020, the patient was evaluated in our outpatient clinic. Moderate right orbit active inflammation was confirmed by Clinical Activity Score 3/7 (CAS),3 and eyelid edema was moderate. The eyelid aperture was 14 mm in the right orbit and 10 mm in the left orbit, and the Hertel measurements were 24 mm and 18 mm in the right and left orbits, respectively. In addition, the patient presented a severe reduction in elevation, persistent depression in the primary position of the right ocular globe and constant diplopia, as scored according to the Gorman score.4 The quality of life evaluated by Graves’ Ophthalmopathy quality of life questionnaire (GO-QOL)5 was reduced in both appearance and functional subscales. However, the functional subscale was reduced with respect to the appearance subscale, as the values were 12.5 and 50, respectively (considering 0 = worse condition and 100 = the best health state). Visual acuity was normal, and color vision by Ishihara tables was 16/17 and 17/17 in the right and left eyes, respectively. Evaluation of extraocular muscles by computer tomography (CT) scan (contiguous 1.25 mm thick slices, 200 mA, 120 kV, pitch 0.5) showed severe enlargement of the lower rectal body to the edge of the insertion tendon in the right orbit. Remarkably, the morphology of the other extraocular muscles in both orbits was normal. The muscle orbit area ratio measured in the right eyes was 0.25 Autocad units (in-house method; vn ≤ 0.20±0.03).6 Thyroid function was normal with a slight increase in TSH-R-Ab: 1.75 mU/l (n.v. < 1.5 mU/l). The amplitude of the p100 wave was slightly reduced by electrophysiology evaluation in the right eye. A thyroid ultrasound scan of the thyroid gland showed a thyroiditis pattern. Biochemical and clinical evaluations were negative for hematological or other systemic diseases. Routine clinical tests were normal, but the total cholesterol levels that were 220 mg/dl, triglyceride levels were 297 mg/dl, and high-density lipoprotein cholesterol (HDL) levels were 38 mg/dl.\n\nThe patient was treated by intravenous corticosteroid pulse therapy (Solumedrol; Pfizer, Karlsruhe, Germany) with a cumulative dose of 4500 mg over 12 weeks, leading to the resolution of inflammatory signs and symptoms. However, GO-QOL, Hertel measurements and diplopia remained unchanged; in contrast, electrophysiology evaluation and visual acuity worsened. Two-wall orbital surgical decompression plus parenteral glucocorticoids was chosen as the second-line treatment for GO. In that context, a biopsy of the right inferior rectus muscle revealed massive fibrosis with adipose tissue infiltration of this extraocular muscle.",
    "summary": "Here, we present a rare case of euthyroid single muscular GO in a 50-year-old patient who was a smoker and had dyslipidemia for several years. The patient experienced a very rapid and severe depression of ocular motility of the right eye that caused uncorrectable and constant diplopia, severely affecting his quality of life. He was euthyroid, and TSH-R-Ab plasmatic levels were only slightly elevated. Intravenous corticosteroid pulse therapy was partially effective, and two rounds of wall orbital surgical decompression were necessary. Massive mono-muscular fibrosis was evidenced by biopsy of the right inferior rectus muscle."
  },
  {
    "id": "multiclinsum_gs_en_345.txt",
    "fulltext": "We present the clinical case of a 15-year-old male with no medical history or previous interventions, who presented to the paediatric emergency department with a history of vomiting and epigastric abdominal pain of four days' duration, remaining afebrile during the course of the illness.\n\nInitially treated as gastroenteritis, but with no improvement, and with persistence of epigastric abdominal pain and biliary vomiting, he was admitted to the emergency department for further evaluation.\n\nOn physical examination, the patient was in acceptable general condition, afebrile, with mild signs of dehydration. The abdomen was distended, without signs of peritonism and with decreased hydroaerolic sounds. The laboratory tests did not present significant findings, and an abdominal radiograph was performed with findings suggestive of intestinal obstruction.\n\nGiven the evolution, an urgent computed tomography was performed, which showed the presence of ascites and significant dilation of small intestine loops, suggesting the interposition of a small intestine loop at the beginning of the transcavity of the epiplons, with a change in caliber at the level of the hiatus of Winslow.\n\nUrgent surgical intervention was performed, initially by exploratory laparoscopy. Dilated loops of small intestine and terminal ileum, cecum and ascending colon of normal calibre but located in the right hypochondrium, with the cecum very mobile and without presenting adhesions to the right parietocolic space, were observed. Following the terminal ileum proximally, loops of small intestine of different calibre were observed from the depth of the theoretical location of the hiatus of Winslow. It was possible to pull the cecum and terminal ileum until they were displaced to the right iliac fossa, but without correctly identifying the point of change of calibre, since the interposition of the lower edge of the liver and the distension of loops of small intestine hampered the technique. An attempt was made to improve visualization by percutaneous puncture of a dilated loop to empty the gas, without improvement. To ensure the resolution of the obstructive picture, a supraumbilical mid-laparotomy was decided. When accessing the cavity, the change of calibre in the ileum was evident, about 40 centimetres from the ileocecal valve, with signs compatible with hernia of a section of about five centimetres of the ileum through the hiatus of Winslow. In both ends of the herniated loop, we observed the congestive imprint of the hiatus on the loop (Fig. 3). The normal calibre of the hiatus of Winslow was identified, so no preventive technique was performed to reduce the risk of recurrence.\n\nDuring the first days of the postoperative period, the patient presented a paralytic ileus, and the nasogastric tube could be removed five days after surgery and oral tolerance was initiated with a good response. Simultaneously, he developed a pelvic collection that was managed conservatively with antibiotics, with a good evolution. Finally, the patient was discharged ten days after the intervention, with preserved transit, remaining afebrile and with a good general state.\n\nThe patient is currently being followed up in the outpatient department of paediatric surgery.\n",
    "summary": "We present the clinical case of a 15-year-old adolescent male with no previous surgical history, who presented with abdominal pain and vomiting, and whose computed tomography suggested a picture of intestinal obstruction due to internal hernia at the level of the Winslow hiatus. He required surgical intervention by exploratory laparoscopy, converted to a supraumbilical midline laparotomy due to poor visualization, for reduction of the herniated ileal loop. This presented a good appearance and intestinal resection was not necessary. No preventive technique was performed to reduce the risk of recurrence. Postoperatively, the patient presented a pelvic collection managed conservatively with antibiotics. He is currently being monitored in outpatient paediatric surgery.\n"
  },
  {
    "id": "multiclinsum_gs_en_325.txt",
    "fulltext": "This is a 75-year-old para 6 patient from Western Ethiopia who saw her last menses 25 years back. Her age at giving birth to her 1st child and menopause were 18 and 50 years, respectively. She had occasional pelvic pain for the last 3 years for which she was visiting different health facilities. Currently, she presented to Nekemte Specialized Hospital with exacerbation of lower abdominal pain for 3 weeks. She feels discomfort in her vagina but no protrusion of mass through her vagina. She has no history of fever, abdominal swelling, vaginal discharge, or bleeding. All her previous deliveries were normal vaginal deliveries. Upon enquiring about the history of family planning utilization, she reported that the intrauterine device was inserted 40 years back at a public hospital. Since then, she had no history of gynecologic evaluation for a checkup. She had no history of gynecologic procedures, pelvic or abdominal surgery. The patient has no history of medical problems like diabetes mellitus, hypertension, cardiac or renal problems.\n\nOn examination, she was acutely sick-looking. Her vital signs were blood pressure (BP) = 120/80mmHg, pulse rate (PR) = 82 beats per minute, respiratory rate (RR) = 18 breaths per minute, and temperature of 37.1°C. She had pink conjunctivae. Lymph glandular system, chest, and cardiovascular system were normal. On abdominal examination, there was no mass, organomegaly, area of tenderness, or signs of fluid collection. Inspection of external genitalia showed no vulvar mass or lesion. On speculum examination, there is a foreign body at the external cervical os. However, there is no other cervical mass or lesion. On bimanual examination, the uterus was not enlarged and there was no adnexal mass or tenderness. On the integumentary system, she had no palmar pallor. On neurologic examination, she was oriented to time, person, and place. She had normal reflexes and no neurologic deficits.\n\nOn laboratory investigation, an ultrasound examination was done by a radiologist and showed unremarkable pelvic findings. Urinalysis, complete blood count, and serum blood glucose level were normal. With the final diagnosis of postmenopausal pelvic pain secondary to the retained intrauterine device, the patient was prepared and taken to the gynecology procedure room. In the lithotomy position, the speculum was inserted and the intrauterine device was easily removed with spongy forceps. The mother was observed for 4 hours and discharged with analgesia and doxycycline 100 mg PO twice a day for three days. Upon follow-up, the pelvic pain was resolved.",
    "summary": "We present the case of retained Lippes loop IUD for 40 years in a 75-year-old postmenopausal patient from Western Ethiopia. The patient presented to the hospital with postmenopausal pelvic pain. Speculum exam showed part of loop at external cervical os. The loop was easily removed with spongy forceps. The patient was discharged with analgesia and doxycycline twice a day for 3 days."
  },
  {
    "id": "multiclinsum_gs_en_418.txt",
    "fulltext": "A 71-year-old patient with a history of untreated vitiligo presented with visual loss in the right eye 6 months prior to admission accompanied by bilateral hearing loss with a predominance in the right ear. Chronic headaches and intermittent fever were also reported, although the patient denied a history of drug use or prior infections. He was evaluated by our department due to the presence of significant and unintentional weight loss, generalized weakness and thickening of the skin. On initial ophthalmologic examination, visual acuity in the right eye (RO) was reduced to light perception and color discrimination, and visual acuity in the left eye (LO) was 20/200 with afferent pupillary defect in both eyes with hyperemic margins of the eyelid. On examination of the RO, it was found to have a hyperemic bulbar conjunctiva, ciliary injection, cornea with peripheral, nummular, subepithelial infiltrates, aqueous anterior chamber (AAC) without cellularity, normal iris and lens with nuclear opacities. On examination of the left eye, it was found to have a hyperemic bulbar conjunctiva, ciliary injection, cornea with peripheral, nummular, subepithelial infiltrates, AAC, aqueous without cellularity, normal iris and lens with nuclear opacities. On examination of the right fundus, a round, pale ++ papilla was found with a 50% excavation, slightly blunt nasal border, with a raised and thinned vascular pattern, with macular area and scattered pigment. On the left fundus, a vitreous haze 2+ was found with edematous papilla, blurred borders, hyperemic, peripapillary, streaked hemorrhages, and an unevaluable excavation with a thinned vascular pattern and macular area with scattered pigment, with right optic atrophy and left anterior optic neuritis.\n\nDue to ocular involvement, weight loss and neurological symptoms, additional testing was performed to rule out causes such as tuberculosis, herpes, ANCA and non-ANCA vasculitis, and sarcoidosis. As for the management of the neurological condition, a lumbar puncture was performed and an opening pressure within normal limits and a proteinocracy of 54 mg/dL was found. Due to distal symmetric polyneuropathy, nerve conduction velocities (NCV) were performed, which showed a pattern of polyradiculoneuropathy with moderate to severe axonal degeneration, involving all 4 extremities with a predominance of the lower extremities; the contrasted magnetic resonance imaging (MRI) of the skull and orbit did not show enhancement of the optic nerve or brain tumors; however, it did show sinusitis and meningeal enhancement. Within the management, sarcoidosis was ruled out, with angiotensin converting enzyme (ACE) within normal parameters, as well as a whole body gamma scan, without enhancement or boosting. After all the study and clinical evaluation of the patient, a second ophthalmological assessment was performed in which persistence and progression of the ocular condition was found, with optic atrophy in the right eye and anterior optic neuritis in the left eye. Because of this, high dose pulse steroid treatment was initiated, followed by a gradual reduction of the dose and the patient was referred for follow-up in the Outpatient Department. A clinical and functional improvement was observed, mainly at the neurological and ophthalmological level.\n",
    "summary": "A 71-year-old man with a history of long-standing vitiligo who had experienced visual loss in his right eye six months prior to admission, along with bilateral hearing loss, predominantly in the right ear. During his hospital stay, he presented with chronic headaches, fever, and significant involuntary weight loss. On ophthalmologic examination, the right eye was light sensitive with hyperemic bulbar conjunctiva, while the left eye had a visual acuity of 20/200. The fundus of the right eye had scattered pigmentation, while the left eye had a swollen optic disc and right optic atrophy.\n"
  },
  {
    "id": "multiclinsum_gs_en_406.txt",
    "fulltext": "A 39-year-old woman with a diagnosis of peripartum cardiomyopathy who received a heart transplant in October 2014. She received induction with Basiliximab and methylprednisolone. She also received maintenance treatment with tacrolimus XL prolonged release 7 mg daily, everolimus 1 mg twice daily, and prednisolone 5 mg/day. She had two episodes of acute rejection during the first year post-transplant, and was controlled with methylprednisolone pulse therapy with good results. There was no history of renal disease and her renal function was stable with creatinine of 0.88 mg/dL and a glomerular filtration rate (GFR) of 102 mL/min/1.73m2 during the first year post-transplant. Follow-up was done exclusively by the heart transplant group and routine polyomavirus viral load BK or urinary cytology was not performed. In 2016, she presented a creatinine serum elevation of up to 1.9 mg/dL, with a GFR of 32.6 mL/min/1.73m2. At that time, the minimum tacrolimus level was 7.2 ng/mL and everolimus, 5.2 ng/mL. Anticalcineurin toxicity was suspected; therefore, tacrolimus was reduced to 4 mg daily and creatinine returned to near baseline (creatinine 1.25 mg/dL, GFR 54.1 mL/min/1.73m2); no renal biopsy was performed. In March 2017, creatinine increased to 2.69 mg/dL, with a GFR of 21.4 mL/min/1.73m2, for which she was hospitalized. The patient stated that she did not have any symptoms. During physical examination, she was in good general condition, heart rate of 80 beats per minute, blood pressure of 130/90 mmHg, respiratory rate of 15 per minute, afebrile. Further studies were performed: renal tract ultrasound showed normal renal size but increased echogenicity; urinalysis and urine cultures were negative, without haematuria, pyuria or casts; echocardiogram with adequate cardiac function; HIV, syphilis, hepatitis B and C serologic tests were negative; minimum tacrolimus level of 5.2 ng/mL, and everolimus of 5.98 ng/mL. Control was initiated with intravenous hydration, and tacrolimus XL dose was reduced to 2 mg daily, but there was no improvement in renal function; a renal biopsy was planned.\n\nRenal biopsy revealed active chronic interstitial nephritis associated with advanced poliomyelitis virus nephritis. BK virus PCR was performed and was positive at 33,800 copies/mL in blood (log 4.5). Tacrolimus was discontinued; creatinine levels stabilized between 2.2 and 2.4 mg/dL, with no further elevation in post-discharge controls. Her viral load began to decline to undetectable levels. The patient did not have episodes of cardiac rejection in 3 years of follow-up; the last creatinine measurement was 2.5 mg/dL, corresponding to a GFR of 23.4 mL/min/1.73m2.\n",
    "summary": "We report a case of BK virus nephropathy in a patient who underwent heart transplantation due to peripartum cardiomyopathy. The renal biopsy reported active chronic tubulointerstitial nephritis associated with late-stage BK virus nephritis and the blood viral load for BK virus was positive (log 4.5). The immunosuppressive treatment was reduced, and after two years of follow-up, the patient had stable renal function with serum creatinine of 2.5 mg/dL (GFR of 23.4 mL/min/1.73m2).\n"
  },
  {
    "id": "multiclinsum_gs_en_504.txt",
    "fulltext": "14-year-old previously healthy adolescent who presented to the Primary Emergency Care Service (PEC) of Osorno with a 11-day history of a predominantly nocturnal irritative cough. Symptomatic treatment was indicated, evolving with dyspnoea and orthopnoea. He presented to the Emergency Department of the Osorno Base Hospital (OBH), with severe respiratory distress, intolerance to supine position, and abdominal pain. He was admitted to the Paediatric Intensive Care Unit (PICU), tachycardic, hypertensive, polypneic, oxygen saturation 96% with FiO2 35%, rosy, hydrated and well perfused, with flat jugular veins, small bilateral supraclavicular lymphadenopathies. The thorax was without retraction of soft tissue, maintained in a genupectoral position, with decreased pulmonary murmurs in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The soft abdomen was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and the cardiac auscultation had muffled tones, without breath sounds. The abdominal soft tissue was not easily depressible and sensitive in both hypochondria, with doubtful visceral enlargements and no injuries. The chest radiograph showed a superior mediastinal mass and atelectasis of the right middle lobe associated with ipsilateral pleural effusion. Contrast-enhanced chest X-ray was not performed due to contraindication of anaesthesia, as stated in the summary of transfer from OBH. He was transferred in a serious condition to the PICU HBV, with a Mediastinal Compression Syndrome, with clinical suspicion of non-Hodgkin lymphoma. He was evaluated by the paediatric haemato-oncology, paediatric surgery, paediatric intensive care, imaging, radiotherapy and paediatric oncology teams, with a normal pulmonary murmur in both bases, and\n\nA nephrological evaluation was performed, which confirmed renal failure secondary to tumor lysis syndrome, without dialysis urgency and tendency to hypertension, with creatinine 1.54 mg/dL, phosphemia 11 mg/dL, without hypernatremia. It continued with hyperhydration, diuretic (furosemide) and antihypertensive (amlodipine). From the respiratory point of view, it presented oxygen requirement, with FIO2 35% by mask of Venturi, suspending this supply on the third day of admission. It evolved with episodes of psychomotor agitation, associated to the diagnosis in process, which was treated according to the institutional protocol of psychomotor agitation, with psychological and psychiatric support, with satisfactory evolution. On the third day of admission and treatment a CT scan of the thorax, abdomen and pelvis was performed with contrast, observing an increase in the size of the thymus, of homogeneous aspect, probably in the context of a lymphoproliferative process and findings suggestive of pulmonary thromboembolism. The angioCT of the thorax showed thrombosis of the jugular vein, extensive bilateral pleural effusion associated to atelectatic phenomena in both bases, with signs of medical bilateral nephrosis. Anticoagulation with enoxaparin (1 mg/kg dose, every 12 hours) was indicated for twenty days. Then the angioCT of control showed resolution of the thrombosis.On the fourth day of admission and treatment, a diagnostic and extension study was performed, which included, among others, a complete biochemical profile including lipid profile, granulopoietic hyperplasia of the bone marrow (myelogram), flow cytometry (bone marrow) in which no cells with a predominant clonal or neoplastic immunophenotype of haemological lineage were observed, flow cytometry in peripheral blood negative for neoplastic cells, cytological of pleural fluid negative for neoplastic cells, flow cytometry of pleural fluid without evidence of haemological neoplasia. It was presented to the paediatric oncological committee, highlighting that it was not possible to take a biopsy of the tumour given that the mediastinal mass disappeared with the cytoreductive treatment, assuming the diagnosis of lymphoblastic lymphoma by the clinical picture and the response to treatment, according to the PINDA 0516 protocol. This protocol contemplates in Induction IA eight doses of Lasp E. coli of 10,000 IU/m2. Having received seven doses of L-asp and with a cumulative dose of ninety thousand international units plus glucocorticoid (prednisone), presented a picture of decline, vomiting, abdominal pain and mild dehydration. There was suspicion of pancreatitis, which was ruled out by normal amylase/lipase values and normal hepatic tests. At that time it had plasma electrolyte profile with hyponatraemia of 126 mOsm/kg and urinary osmolality of 510 mOsm/kg, both normal values. With hyponatraemia and hypertriglyceridaemia, there was suspicion of RAM of pseudohyponatraemia secondary to hypertriglyceridaemia associated to L-asp. It was evaluated by Gastroenterology and Endocrinology, indicating a diet low in refined sugars and rich in fiber, fibrates (ciprofibrato 100 mg oral daily) and omega 3 (4 g oral daily), until triglyceride values of 300 mg/dL were achieved. Two weeks later the triglycerides had a value of 79 mg/dL. Ciprofibrato and omega3 were suspended, indicating prophylactic use associated to corticoid and L-asp treatment. A total of twelve doses of L-asp were completed with a cumulative dose of one hundred and eighty four thousand international units corresponding to the induction protocol. The suspicion of RAM was subjected to causality evaluation, with the modified Karch and Lasagna algorithm by WHO5, which resulted in “Definitive” RAM for the association of L-asp and Prednisone\n",
    "summary": "A teenager who developed pseudohyponatraemia and hypertriglyceridaemia during treatment for non-Hodgkin lymphoma (NHL) was suspected to have a drug reaction (ADR). This suspicion of ADR was evaluated according to the modified causality algorithm (Karch and Lasagna), resulting in a \"definitive\" ADR for the association of L-asp and corticosteroids. He received treatment with a low-fat diet and lipid-modifying medicines. L-asp and prednisone were not discontinued due to the end of the indication, according to the protocol. The hypertriglyceridaemia recovered without complications after 14 days of treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_54.txt",
    "fulltext": "A 56-year-old Italian female patient with β-thalassemia major presented to the radiology department to undergo MRI to quantify myocardial, hepatic, and pancreatic iron deposition. The clinical history of the patient included a transfusion-dependent β-thalassemia condition (genotype HBB:c.118C > T/ HBB:c.93-21G > A), diagnosed at the age of 7 years, despite the fact that the first transfusion was carried out at 2 years. As a consequence of β-thalassemia, the patient underwent splenectomy and cholecystectomy.\n\nAt the moment of MRI, she had a negative HCV-RNA (Hepatitis C virus-Ribonucleic acid) test, no osteoporosis or other endocrine, cardiac, or hepatic complications, and good iron levels. The patient’s therapy included iron chelation with deferasirox, vitamin D, and luspatercept, an erythropoiesis modulator started 2 years before the MRI examination (good response, with an increase of about 35% of transfusion interval duration). Transfusion therapy included two units of concentrated and filtered red blood cells every 25 days with pre-transfusion hemoglobin values of 10–10.5 g/dl.\n\nOn MRI, a solid mass with lobulated and regular contours was incidentally identified within the prevascular compartment of the mediastinum.\n\nThe lesion was mildly hyperintense on T2-weighted images (T2-wi) and isointense on T1-wi. The mediastinal mass in question was discernible in a prior MRI examination conducted for the same purpose in 2020 before starting luspatercept therapy, albeit with a marginal enlargement.\n\nThere were no other apparent abnormalities observed in the remaining mediastinal compartments. No pleural or pericardial effusions were present.\n\nThe neurological examination was unremarkable, and in the preceding months, the patient exhibited no symptoms of mediastinal syndrome associated with compression of the adjacent neurovascular structures. Moreover, she did not exhibit any fever or experience any weight loss.\n\nFor further evaluation, the patient underwent 18F-deoxyglucose (18FDG) positron emission tomography (PET)-computed tomography (CT) and chest CT with contrast media. On PET-CT, the mediastinal mass showed only mild FDG uptake (SUVmax = 4.3); no other sites of abnormal radiotracer uptake were reported in the neck, chest, abdomen, and skeleton. On CT images, the lesion presented regular margins, solid density, and mild contrast enhancement. The adjacent structures did not exhibit any signs of invasion, and lymphadenopathies or extra-thoracic disease were not present. Such radiological features, the indolent behaviour over time, the absence of systemic symptoms, and the lack of avid FDG uptake on PET-CT scan made the diagnosis of thymoma probable.\n\nHowever, on lung window visualization, multiple rounded areas of parenchymal lucency, consistent with thin-walled cysts distributed symmetrically throughout both lungs, with normal intervening parenchyma, were evident.\n\nNo nodules or other interstitial abnormalities were associated with the cysts. No pneumothorax was detected. Coherently with thalassemic bone disease, the ribs appeared widened, and the spine displayed mild platyspondyly. The remaining portion of the chest and visible upper abdomen were unremarkable. The radiological findings were consistent with cystic lung disease, most likely LAM.\n\nThe patient was then referred to the pulmonary clinic for further evaluation. She was a never-smoker and did not report any respiratory symptoms. In particular, she denied a history of chronic cough, recurrent respiratory infections, or pneumothorax. No cutaneous lesions, notably facial fibrofolliculomas, were evident. On chest examination, the lung fields were clear. Peripheral capillary oxygen saturation was normal (98%), with a heart rate of 75 beats per minute. Pulmonary function tests revealed a substantial reduction in diffusing capacity of the lungs for carbon monoxide (DLCO; 42% of the predicted value), partly imputable to the condition of anemia, with a carbon monoxide transfer coefficient (KCO) of 73% of the predicted value. After discussion in a multidisciplinary tumor board setting, including a pulmonologist, the patient underwent left thoracoscopic thymectomy and concomitant lingual segment wedge resection. The histopathological report revealed a morphological finding and immunohistochemical pattern referable to type B2 thymoma with focal infiltration of the capsule. Extracapsular extension was not evident. However, the lesion was present at the resection margin (stage IIa according to Masaoka–Koga; stage 1a according to the tumor, node, metastasis [TNM] classification).\n\nRegarding the lung parenchyma, histopathologic analysis described lung parenchyma with cysts of variable size lined by spindle cells in myoid habit with immunohistochemical reactivity for actin, estrogen, progesterone receptors, and HMB45 (focal positivity). Modest chronic interstitial inflammation, vascular congestion, and recent blood extravasation were evident. These morphological findings were compatible with pulmonary LAM.\n\nA final histological diagnosis of thymoma and pulmonary LAM was made. For the neoplastic condition, the patient was a candidate for adjuvant radiation therapy due to the microscopically incomplete resection (R1). For LAM with concomitant β-thalassemia, treatment with sirolimus was recommended.",
    "summary": "A 56-year-old Italian female patient with β-thalassemia major underwent magnetic resonance imaging to quantify myocardial, hepatic, and pancreatic iron deposition. Her medical history included transfusion-dependent β-thalassemia, splenectomy, and cholecystectomy. At the time of magnetic resonance imaging, she had no significant endocrine, cardiac, or hepatic complications and was on deferasirox, vitamin D, and luspatercept. Magnetic resonance imaging revealed a lobulated mass in the prevascular mediastinum, which showed mild radiotracer uptake on positron emission tomography. Chest computed tomography revealed multiple thin-walled cysts in the lungs, indicating lymphangioleiomyomatosis. Following multidisciplinary evaluation, the patient underwent thoracoscopic thymectomy and lung wedge resection. Histopathology confirmed type B2 thymoma and pulmonary lymphangioleiomyomatosis. Post-surgery, the patient was recommended for adjuvant radiation therapy and sirolimus treatment."
  },
  {
    "id": "multiclinsum_gs_en_235.txt",
    "fulltext": "We present a case of a 49-year-old woman with renal and heart failure following a long-term (lasting from 13 years of age) SLE prepared for kidney transplantation. Due to LN (class III, then IV), starting at childhood, she was treated with steroids, together with cyclophosphamide, replaced later by methotrexate and then azathioprine. Hence, the partial remission of nephrotic syndrome was achieved and from 2002 the patient did not receive any immunosuppressive therapy. She was also HBV and HCV positive. SLE involvement of circulatory system presented with early coronary atherosclerosis, ischemic heart disease, and myocardial infarction at the age of 20. In 2007, because of deterioration of kidney function with a serum creatinine concentration of 2.2 mg/dL and proteinuria of 2 g/day, the kidney biopsy was performed. The biopsy showed active and sclerotic focal proliferative lupus nephritis nevertheless immunosuppressive therapy was not introduced for the reason of active replication of HCV. The kidney function was gradually deteriorating over time. Despite cardiac intervention (PCI RCA), the patient developed severe post-infarction and dilated cardiomyopathy and required ICD implantation in primary prevention in 2009. Later, on lupus and secondary cardiomyopathic background, the patient developed severe MV and TV regurgitation. For this reason, the patient underwent mitral and tricuspid valve repair and left ventricle volume reduction surgery complicated by low cardiac output syndrome with a need for intra-aortic balloon pump use (2014). In the postoperative period, the kidney function deteriorated, requiring the initiation of renal replacement therapy. The patient has been on dialysis for 4 years. While being on active waiting list for kidney transplantation presented remission of laboratory indices of lupus (complement splits within normal limits: C3–0,93 g/l, C4–0,4 g/l, ANA negative) and persisting circulatory insufficiency with markedly reduced stair-climbing capacity (to one flight of stairs) with elevated BNP 619 pg/ml (n. 0–100). In transthoracic echocardiography, performed before renal transplantation, the left ventricle and the left atrium were significantly enlarged and the left ventricular systolic function was significantly reduced with LVEF 26% and GLS -3. Due to the implantation of the mitral ring, it was not possible to assess the left ventricular diastolic function. The high tricuspid regurgitant flow gradient with widened and poorly respiratory mobile inferior vena cava indicated a high probability of pulmonary hypertension. Furthermore, while preparing the patient for the surgical procedure, it was decided to include cardioprotective therapy with Levosimendan. Due to the time frame associated with the transplantation procedure, the drug infusion was started as soon as possible after cross-match results were known, immediately after the dialysis session. The infusion at a dose of 0.1 μg/kg/min was continued after surgery for a total of 24 h. The patient’s anesthesia for kidney transplantation and perioperative care included the aspect of optimizing transplanted kidney perfusion, avoiding the use of renal toxic drugs and those excreted by properly functioning kidneys, as well as the use of nephroprotective agents. Because of the patient’s cardiological burden, including recurrent episodes of extrasystole proceeding with decompensation of the circulatory system, together with the need of ICD turning off for the transplantation period, the Swan-Ganz catheter for hemodynamic assessment was not used. Anesthesia monitoring was limited the to ECG, central catheter with CVP assessment, direct blood pressure measurement from the cannula inserted into the radial artery, and cardiac ultrasound. In the perioperative period the CVP parameter was used to assess the volatility, and in the postoperative period, a cardiac ultrasound was used along with the assessment of VCI respiratory fill and motility. The therapy was aimed at the standard of fluid therapy called Goal Directed Therapy (GDT). During general anesthesia, fentanyl, triacrium, propofol, desflurane, antibiotic therapy, and standard immunosuppressive treatment were used as well as 25 g of mannitol infusion was administered as a nephroprotective treatment and 0.9% NaCl as a fluid therapy. In the course of postoperative immunosuppression, she received steroids, tacrolimus with mycophenolate mofetil which was stopped due to persistent leukopenia and cytomegalovirus infection. Furthermore delayed graft function was observed with a need for hemodialysis for almost 6 weeks (mostly due to fluid retention). BNP levels raised to 2996 pg/ml and then slowly decreased. The kidney biopsy performed 2 weeks after transplantation revealed acute rejection (AR II B Banff 2015) with ATN. Finally, the patient was discharged from the hospital on the 67th POD with the serum creatinine concentration of 1.4 mg/dL and BNP level of 1794 pg/ml. One month after kidney transplantation, there was a reduction in left ventricular dimensions, improved systolic function in the EF (increase to 30%) and GLS (decrease to − 6) assessment. In addition, there was a decrease in the tricuspid regurgitant flow gradient with normal width and respiratory motility of the IVC, which indicates a low probability of pulmonary hypertension. The improvement of echocardiographic parameters also reflected the simultaneous improvement of exercise capacity in the recipient from NYHA III/IV to NYHA II. In the 5-month observation, further improvement of heart function with a drop of BNP to 1066 pg/ml and normal kidney function were noted.",
    "summary": "We present a case of a 49-year-old woman with renal and heart failure following a long-term SLE prepared for kidney transplantation. During the SLE course, the function of the heart and kidneys gradually deteriorated. The patient required the initiation of renal replacement therapy and was dialyzed until a kidney transplantation for 4 years. In the preparation of the patient for the surgical procedure, due to the extremely low ejection fraction, it was decided to include cardioprotective treatment with Levosimendan. The postoperative period was not straightforward but successful. In the monthly and five-month follow-up, a continuous improvement of heart function with normal renal function was noted."
  },
  {
    "id": "multiclinsum_gs_en_88.txt",
    "fulltext": "The patient was a 42-year-old woman with a history of menstrual migraine, Hashimoto Thyroiditis, Familial Mediterian Fever (FMF), and dyspepsia. She was taking 75 mg of levothyroxine, 30 mg of lansoprazole, and 1.5 mg of colchicine daily. In February of 2023, she was diagnosed with acute bronchitis, which was treated with antibiotics and bronchodilators. She developed a daily headache after two weeks, manifesting as more than ten short-lasting attacks per day provoked by coughing, straining, and lifting. The duration of each attack was 30 minutes, and the pain was bilaterally distributed from the neck to the top of the head. The headache was sharp and severe. She described the attack as a sensation of storm-like fluid movement in the head. She did not suffer any of the symptoms associated with previous migraine attacks, such as phonophobia, photophobia, vomiting, or throbbing. The severity of the attack was determined using a numeric rating scale (NRS) with a score of 9 out of 10. These attacks typically necessitated a visit to the emergency room. The results of her physical and neurological exams were unremarkable. The laboratory tests, including those for thyroid hormones, electrolytes, liver and kidney function, and serology, were negative. Brain and cervical spinal magnetic resonance imaging (MRI) with and without contrast, magnetic resonance venography (MRV), and angiography (MRA) were all normal. She did not give consent for a lumbar puncture. When we first encountered her in the clinic, she was taking 25 mg of indomethacin per day. Her attacks stopped after putting her on 60 mg of lansoprazole and increasing her daily dose of indomethacin to 150 mg. However, she encountered gastrointestinal side effects, so the indomethacin was discontinued on day three. Due to the adverse effects, she was unable to take topiramate and propranolol.\n\nShe came to the clinic 15 days after her initial visit with an NRS score of 9/10. She was taken to the local operating room. We used a GE Healthcare, Voluson™ E6, ultrasonography system with a linear 13–5 MHz probe for unilateral PGONB. The patient’s neck was prone to flexion. The linear probe was initially transversely positioned on the occipital protuberance and then advanced caudally, demonstrating that the C2 spinous process resembled the two horns. Through lateral probe movement, the inferior muscles of the obliquus capitis and semispinalis capitis were located. Here, the superior to the inferior oblique capitis muscle and beneath the semispinalis capitis muscle were identified to be the greater occipital neuron (GON). From this location, a 22-gauge spinal needle and 3 ccs of bupivacaine at a concentration of 0.5% were used to perform GON blocking. The intensity of her attack decreased from 9/10 to 2/10 after the first 20 minutes of the block. Throughout a month, the blocks were repeated once a week. In the second month, the frequency of her attacks decreased to two per month, with an intensity of 4/10. She did not encounter any attacks in the sixth month.\n\n",
    "summary": "Herein, we report that a 42-year-old female patient with PCH who could not use the oral medication because of side effects. When she came to the pain clinic with an attack with intensity of 9/10 , we took her to the local operating room. The ultrasound (US) guided proximal greater occipital nerve block with bupivacaine was performed and the intensity of the attack was reduced to 2/10. The blockage was repeated once a week for a month. After two months, both the intensity of headache and number of attacks decreased and no adverse effect was observed."
  },
  {
    "id": "multiclinsum_gs_en_172.txt",
    "fulltext": "Patient information\nA 20-year-old male Arabic martial artist (weight 91.5 kg, height 180 cm, and body mas index (BMI) 28.24) presented with pain in the back of the left thigh for the past 5 weeks and underwent pharmacological and physiotherapeutic intervention; however, he did not responded well to symptomatic treatment. He reported that the symptoms first appeared during a short sprint while playing soccer and heard a pop in the back of his thigh. The pain was so bad that he withdrew from the game soon after his injury and noted no bruising on the back of his thigh or significant swelling in that area. However, he reported progressive loss of flexibility in the left knee and inability to flex and extend the knee joint while the knee remained flexed at a 15° angle, whether standing or having the leg in the air. He denied any previous history of lower back pain but could barely support the weight of the affected limb. There was no history of alcohol, smoking, diabetes, high blood pressure, or other serious genetic diseases.\n\nClinical findings and diagnostic assessment\nThe patient reported having received icing and elevation of the affected leg while lying down following the injury as therapeutic interventions. He had a crepe bandage applied to his affected thigh to support him while standing and walking. He used crutches for ambulation and to go for a little longer distance. To climb the stairs, he had to use one step at a time, relying on his right lower extremity. He also reported adopting a sitting position at the edge of the chair as direct pressure on the thigh from the chair caused him discomfort. He denied ever hurting his legs or back in sports. As a result, the patient withdrew from all activities, such as playing sports, owing to the pain, and his knee was mildly bent most of the time. Despite taking medication (nonsteroidal antiinflammatory drugs (NSAIDs)), the pain worsened over time. Since the patient did not respond well to cryotherapy, compression bandages, and medications, he decided to see a doctor for further diagnosis and treatment before meeting with us.\n\nOn further evaluation, he presented with limited knee extension and flexion and exhibited an analgesic gait with a reduced heel strike phase. Active range of motion (AROM) of the left knee was 10–15° compared with 0–130°degrees in the right knee. Palpation revealed tenderness and firmness in the middle third of the semimembranosus and semitendinosus muscles.\n\nManual muscle testing and isometrics could not be performed owing to persistent discomfort. The patient reported pain at rest, rated 5/10, and during activity it was rated 7/10. Further, clinical evaluation rule out lumbar disc involvement or gluteal and ischial tunnel syndrome [4, 6].\n\nThe best way to screen nerve tension for peripheral pain in the lower extremities is with a slump test [17]. However, the result of the slump test in this patient was negative.\n\nTherapeutic interventions\nDespite the patient’s current clinical presentation, which was suggestive of HSI, the authors decided to treat him with neural glide technique on the basis of the structural and functional proximity of nerve to the lower limb flexibility through a novel neurodynamic tension technique [18, 19]. The scientific rationale for this neural approach was detailed to the patient and consent was obtained.\n\nThe patient was directed to sit with arms folded behind his back and knees and ankles held in extension and dorsiflexion, respectively, while a therapist guided the patient to flex his thoracic and cervical spine and extend his knee joint to the maximum tolerable limit. Next, the patient was instructed to move his neck forward and backward as much as possible while also moving his ankle up and down 15 times to help with nerve glide.\n\nThis was done in three sets each day. The therapist then helped the patient bend their middle and upper back as much as possible until the patient felt pain in the knee area. Then, the process was repeated. By the 3rd day, the patient’s active knee extension improved from 5° to 10° and then to a 15° degree bent position. In addition, the standing posture also got better.\n\nSubsequently, the patient was instructed in executing a set of posture re-education workouts, which involved doing active chin flexion, engaging in passive stretching of the cervical extensors while lying down in prone, and building up the shoulder retractors, arm from positions T to Y, then from Y to W with the limb’s weight while lying down.\n\nTo address the kyphotic posture, active chest stretches were taught at wall corners. The patient was instructed to increase the duration of the exercises from 5 to 10 seconds, doing 10 reps and 3 sets daily.\n\nOutcomes and follow-up\nThe results were assessed using a numeric pain rating scale (NPRS) and Knee Society score (KSS). Substantial enhancement in clinical outcome measures such as pain and function were achieved within 3 successive days of therapy. The use of pain medication was discontinued.\n\nThe patient continued his self-neural glides and postural reduction exercises at home and was advised for a follow-up after 4 weeks or to contact us if symptoms worsened. On the 3rd follow-up day, the patient’s NPRS from 5 at rest and 7 with activity to 2 at rest and 4 with activity. The KSS increased from 22 to 61 and from 30 to 80 in the functional domain. At the end of the 2-week home program, the patient reported to have full active straight leg raise (SLR). The patient had fully recovered from his knee dysfunction and pain at the 2-month follow-up.",
    "summary": "A 20-year-old male Arabic martial artist had a history of left hamstring strain for the past 5 weeks. He had undergone pharmacological and physiotherapeutic interventions for his clinical conditions but had not responded favorably. Further clinical assessment had ruled out hamstring syndrome. The patient refrained from all sports activities.\n\nIntervention: The patient was treated using a modified slump mobilization technique with four repetitions for 3 consecutive days, together with postural retraining. Results of the numeric pain rating scale and Knee Society score before and after the interventions were obtained.\n\nResults and discussion: Pre-intervention score of the numeric pain rating scale was 5/10 and 7/10 at rest and with activity, respectively. Assessment on the 3rd consecutive day of intervention, the numeric pain rating scale decreased to 2/10 and 4/10 at rest and with activity, respectively. Similarly, the pre- and post-intervention Knee Society score improved from 22 to 61 in pain and from 30 to 80 in function. At the 2-month follow-up, the patient reported a complete recovery from symptoms and resumed his sports activities without any disruption."
  },
  {
    "id": "multiclinsum_gs_en_313.txt",
    "fulltext": "A male was born via an emergency cesarean section due to fetal distress at 40 weeks of gestational age. The mother's age was 33 years, with gravida 1 and para 1 parity. Both the parents and brother had no family history of congenital anomalies, aortic-related diseases, or sudden death. Based on the results of the prenatal ultrasonography at the end of the second trimester, the femur length of the fetus was found to be 1 to 3 weeks longer than the supposed length of the actual gestational age. Fetal echocardiography showed cardiomegaly with a fetal cardiothoracic circumference ratio of 0.5 or higher based on the baby's term. Moreover, the size of the foramen ovale was larger than normal, and left aortic constriction was seen next to the subclavian artery basin. Furthermore, no other abnormalities were found on prenatal ultrasound.\n\nAt birth, the weight was 3560 g (75 percentile), the length was 56.5 cm (over 90 percentile), and the head circumference was 36 cm (over 90 percentile). Apgar scores at 1 and 5 minutes were 4 and 6 points, respectively. In the delivery room, the patient had no spontaneous breathing and had bradycardia and cyanosis. After being admitted to the neonatal intensive care unit, various musculoskeletal malformations were confirmed via physical examination. Severe arachnodactyly and camptodactyly were observed in both hands and feet, and the soles of the feet were flat. The elbow and knee joints were not fully extended. The face had malar hypoplasia with senile facial appearance. The eye was deeply settled with a down-slanting palpebral fissure, and the ear with hypoplastic cartilage was poorly settled and crumpled. The patient presented with a sagging mouth, prominent coronal suture, and brachycephaly. A grade V/VI systolic murmur was heard at both the upper sternal border and left lower sternal border with grade III parasternal heave. Echocardiography showed poor cardiac contractility, severe pulmonary hypertension, dilated aortic sinus (20.2 mm) (Z-score; 8.08 by Boston, 6.37 by Detroit, or 5.97 by Halifax), and multiple intracardiac valvular dysfunction with valve prolapses (moderate aortic regurgitation, severe mitral regurgitation, moderate tricuspid regurgitation, and moderate pulmonary valve regurgitation). And the ophthalmologic examination results showed ectopia lentis in both eyes as well as lens subluxation. Liver herniation was confirmed using abdominal X-ray and ultrasound. The systemic score of the musculoskeletal manifestation was 11 points, according to the Ghent criteria (international diagnostic criteria for MFS).\n\nFor genetic diagnosis, Sanger sequencing and polymerase chain reaction were performed on the nucleotide sequence as reference for the FBN1 gene. As a result, a mutation in which G, the first base of the 32nd intron in the form of a heterogeneous mutation, was substituted with T (c.3964 + 1G > T). This was confirmed as the likely pathogen variant based on the 2015 ACMG/AMP guideline. The location of the mutation was included in the site previously known as the neonatal region of MFS (exons 24–32). The patient could be diagnosed with neonatal MFS with a novel FBN1 gene mutation within 2 weeks of life.\n\nOn the first day of life, differential cyanosis was found to show refractory hypoxemia despite more than 60% oxygen supply and signs of low cardiac output. The patient was managed medically for improving the low cardiac output according to severe mitral regurgitation and aortic regurgitation. Afterload reduction including milrinone continuous infusion, full sedation using fentanyl continuous infusion, and use of diuretic were attempt to improve the oliguria and heart failure. Despite the medical management, the patient presented with respiratory failure, heart failure, and severe pulmonary hypertension requiring continuous invasive mechanical ventilation. Aortic regurgitation, mitral regurgitation, pulmonary hypertension, and cardiac contractility got worse. After several consultations with the patient's family and medical staff about the treatment plan, palliative care was continued instead of surgical treatment. As a result, hepatic and pulmonary congestion accompanied by pulmonary hemorrhage had progressed as well. Eventually, it had progressed to multiple organ dysfunction syndrome, and the patient died 32 days after the birth.",
    "summary": "Patient concerns:\nA newborn with neonatal MFS and severe cardiac involvement. He presented various severe clinical features such as arachnodactyly, camptodactyly, elbow and knee joint contracture, senile facial appearance, and deep settling with down-slanting palpebral fissure, hypoplastic ear cartilage, sagging mouth, brachycephaly, and ectopia lentis.\n\nDiagnosis:\nGenetic analysis revealed a novel mutation at nucleotide 3964 (c.3964 + 1 G > T) in intron 32 of the fibrillin-1 gene. This mutation is identified to be in the so-called neonatal region of fibrillin-1 exon 24 to 32, as reported previously.\n\nInterventions:\nThe patient was managed medically for improving the low cardiac output according to severe mitral regurgitation and aortic regurgitation. Afterload reduction, full sedation, and use of diuretic were attempted to improve the oliguria and heart failure.\n\nOutcomes:\nDespite the medical management, aortic regurgitation, mitral regurgitation, pulmonary hypertension, and cardiac contractility got worse. Surgical treatment is essential to prolong the patient's life, however, considerations for the grave progression of the disease make families decide to continue palliative care instead of surgical treatment. A few months after birth, he presented with rapidly progressive aortic regurgitation, mitral regurgitation, and congestive heart failure leading to death."
  },
  {
    "id": "multiclinsum_gs_en_86.txt",
    "fulltext": "A 27-year-old woman with beta-thalassemia major since 24 years and 16 weeks of pregnancy was referred from the Internal Medicine Department to the Oral Medicine Department with complaints of swelling, bleeding gums since early pregnancy, and bad breath. The patient was hospitalized with complaints of pain in her knee so he could not move. She was admitted to hospital with complaints of pain in her knees so she could not move and was diagnosed with Arthritis ar Genue Sinistra related to Thalassemia by an internal medicine specialist, sub division of rheumatology. General condition patient was weak, sick, and difficult to move during the approximately two weeks, when she was hospitalized. Patient has never visited a dentist, either before or now, with complaints about her oral cavity. The patient had a splenectomy in 2009. Her beta-thalassemia major was treated with routine blood transfusions once a month and iron anti- chelation drugs (deferoxamine); however, it was stopped due to pregnancy. There was no history of other systemic disease in this patient. A family history of the same disease was ruled out. History of recurrent stomatitis and drug or food allergies was ruled out.\n\nThe patient’s general condition weak, with normal vital signs; however, the patient had fever. Intraoral examination revealed gingival hyperplasia; erythema; soft consistency; a dark red, rounded gingival margin; tendencies to bleed on the labial, buccal, palatal, and lingual areas; and pain. Oral hygiene index-simplified (OHIS) score was poor (5.7) and there were true pockets in all regions. Peripheral blood morphology result: (1) erythrocytes: polychromacy in anisochrome populations (hypochrome, normochrome), anisopoikilocytosis (ovalocytes, target); (2) leukocytes: sufficient quantity, hypersegmentation (+); (3) platelet count: numbers increase, spread out; Interpretation: moderate anemia et causa thalassemia major accompanied by signs of increased erythropoiesis activity with suspected infection. The diagnosis was made based on the history, clinical features, and examination, as well as additional examinations, namely gingival enlargement accompanied by chronic periodontitis associated to pregnancy with β-thalassemia major and exfoliative cheilitis of the lips. The classification of periodontal disease in this patient is chronic periodontitis with gingival enlargement associated with pregnancy and beta-thalassemia major. The prognosis in this case was good because the patient was cooperative and followed the directions of the Oral Medicine Department. In this case, multidisciplinary therapy was a collaboration between an oral medicine specialist, a periodontist, and an internist. Dental therapy consisted of spooling with 3% hydrogen peroxide (H2O2) solution, chlorine dioxide spray mouthwash (Oxyfresh®, USA), antibiotics (amoxicillin 500 mg tablet, and metronidazole 300 mg tablet), and scaling/root planning. Spooling of H2O2 3% solution was performed at every visit; chlorine dioxide spray mouthwash was used three times a day after meals, and antibiotics were administered for seven days at third visit. Scaling and root planning were performed by the periodontist after the general condition was controlled and after the gingival hyperplasia and spontaneous bleeding improved. Blood transfusions to remove packed red cell buffy coat (PRC BCR) are also carried out routinely once a month. Non-pharmacological therapy, including oral hygiene instructions, was still given to patients. Oral complaints in this case occurred due to the poor oral hygiene, β-thalassemia major, and pregnancy, were also informed to the patient as education.\n\nThis patient had eight follow-up visits, consisting of two inpatient and six outpatient visits, with the following details:\n\nFirst Visit\nThe first visit was carried out one day after the initial inpatient visit (day +1). Intraoral bleeding still exists in the lingual-anterior part of the mandible, but bleeding in the anterior part of the maxilla has stopped. The patient still had a fever. Medications previously provided were used accordingly. Pharmacological were continued, including spooling 3% H2O2 on all parts of the gingiva, using chlorine dioxide as a mouthwash, and applying a thin layer of petroleum jelly to the lips. A blood transfusion was carried out last night. Oral hygiene instructions are still given to patients.\n\nSecond Visit\nThe second visit was performed two days after the initial visit (day +2). Intraoral bleeding Follow-up visits should be conducted in outpatient settings. Pharmacological therapy including spooling 3% H2O2 on all parts of the gingiva, using chlorine dioxide as a mouthwash, and applying a thin layer of petroleum jelly to the lips. A blood transfusion was carried out last night. Oral hygiene instructions are still given to patients.\n\nThird Visit\nNine days after the initial visit (Day+9). First outpatient treatment. Oral symptoms appeared to improve; bad breath was greatly reduced, but the gums were still swollen. The chlorine dioxide spray mouthwash was still being used and had run out. The patient could brush her teeth with a soft toothbrush but still experienced bleeding. Spooling was performed with 3% H2O2. The previous therapy was continued, antibiotics were prescribed 3x/day for seven days, and a blood transfusion was planned as a preparation for scaling the dental calculus. Oral hygiene instructions are still given to patients.\n\nFourth Visit\nOne month after the first visit (Day+30). Oral complaints improved significantly, bad breath was absent, gingiva enlargement decreased, and spontaneous bleeding ceased. The patient did not experience bleeding when brushing her teeth. Transfusions were performed between visits H+9 and H+30. During this visit, laboratory hematology tests and subsequent blood transfusions were performed. Antibiotics were no longer administered, 3% H2O2, chlorine dioxide, petroleum jelly and oral hygiene instructions were continued.\n\nFifth Visit\nOne week after the 4th visit (day +37), the oral complaints improved, but pharmacological and non-pharmacological therapy continued, including spooling 3% H2O2 on all parts of the gingiva, chlorine dioxide as a mouthwash, and applying a thin layer of petroleum jelly to the lips. Oral hygiene instructions are still given to patients. Supragingival scaling was planned two weeks later or after routine transfusions were administered.\n\nSixth Visit\nTwo months after the initial visit (day +60), the oral complaints improved. The gingival hyperplasia in some areas was no longer present, although in other areas still present, but they have undergone improvement. The transfusion had already been performed one week previously. Pharmacological therapy was continued, including 3% H2O2 spooling, chlorine dioxide spray mouthwash, and petroleum jelly. Non-pharmacological therapy namely oral hygiene instructions and an interdental toothbrush was suggested. Supra- and subgival scaling were performed.\n\nSeventh Visit\nTwo weeks after the 6th visit (Day+74), all the complaints improved. Gingival hyperplasia mostly resolved after scaling. Pharmacological includes 3% H2O2 spooling, chlorine dioxide spray mouthwash, and petroleum jelly as well as non-pharmacological therapy, consisting of oral hygiene instructions and the use of an interdental toothbrush.\n\nEighth Visit\nThree months after the initial visit (day +90), routine blood transfusions were performed one week before the visit. The patient is no longer presented with any oral complaints. All patients with gingival hyperplasia recovered optimally. The spooling process was stopped with 3% H2O2. Supra- and subgival scaling were performed again in all maxillary and mandibular regions. Instructions for the use of an interdental toothbrush, chlorine dioxide spray mouthwash, and petroleum jelly are still provided.",
    "summary": "A 27-year-old woman, suffering from beta thalassemia major who is undergoing therapy in the form of routine blood transfusions every month and taking anti-chelation drugs but is currently stopping this because she is pregnant, currently 16 weeks pregnant, complains complained of swollen gums, bleeding, and bad breath. Extraoral examination revealed dry, exfoliative lips. Intraoral examination revealed gingival hyperplasia with erythema, soft consistency, dark red rounded gingival margins, bleeding, true pockets and pain throughout the labial, buccal, palatal, and lingual. There was no history of systemic disease in this patient. Patient has never visited a dentist, either before or now, with complaints about her oral cavity. Hematological parameters showed abnormalities, and peripheral blood examination revealed an infection. The oral diagnoses included gingival enlargement and chronic periodontitis associated with pregnancy and β- thalassemia major.\n\nCase Management\nDental management consisted of spooling with 3% hydrogen peroxide (H2O2) spooling, chlorine dioxide spray mouthwash, antibiotics, calculus removal, and oral hygiene instructions. Blood transfusions were administered once a month, and anti-chelation therapy was stopped during pregnancy. After three months of multidisciplinary management, the results were satisfactory."
  },
  {
    "id": "multiclinsum_gs_en_373.txt",
    "fulltext": "A 91-year-old man presented to the emergency department with a high fever (maximum body temperature 39.0 °C).\n\nHe was elderly and in need of nursing care, almost bedridden.\n\nOver the last few years, he had long-term BIC due to urinary retention caused by BPH, which changed regularly at a community clinic every four weeks. The next exchange was scheduled for three days later. The patient had no relevant medical history.\n\nLaboratory findings showed renal dysfunction (serum creatinine was 1.18 mg/dL, and eGFR was 44.4 mL/min/1.73 m2) and inflammation (white blood cell count was 15120/μL). Blood culture yielded negative results. However, the urine culture indicated infections with Klebsiella oxytoca. The physical examination findings were unremarkable. Ultrasonography revealed a left-sided hydronephrosis. Computed tomography (CT) revealed extensive prostatic hypertrophy and urine retention in the bladder. The tip of the catheter was located in the left ureter. The bladder cuff was swollen in front of the ureteral orifice, causing obstruction and hydroureteronephrosis. CT showed no other cause of fever, and we diagnosed acute obstructive pyelonephritis; he was hospitalized. With little traction on the catheter, the pyuria drained.\n\nA new catheter was replaced, and CT showed improvement in the hydronephrosis on day 3. He was treated with antibiotic therapy with sulbactam/ampicillin. Consequently, his condition gradually improved, and he was discharged on day 10.\n\nSince discharged from the hospital, the BIC was changed regularly at the clinic, and there was no recurrence.",
    "summary": "A 91-year-old man with a long-term bladder indwelling catheter (BIC) for benign prostatic hyperplasia (BPH) presented to our emergency department with fever. Computed tomography (CT) showed the tip of the BIC was located within the left ureterovesical junction, which caused left hydronephrosis and a hydroureter. The catheter was replaced, and the hydronephrosis improved quickly. The patient was treated with antibiotic therapy and discharged on day 10."
  },
  {
    "id": "multiclinsum_gs_en_430.txt",
    "fulltext": "A 29-year-old primiparous Malagasy woman came for a consultation to the dermatological clinic of the Nord Franche-Comté Hospital in June 2020 for painful nodules on her legs typical of erythema nodosum. These lesions developed a month after a swelling of the right breast undergoing etiological investigation. She was not pregnant or lactating. She had last breastfed her child two years ago. She did not use oral contraceptives or any other medication. The patient had no history of tuberculosis infection or autoimmune disease or any family history of breast cancer. A contact with SARS-CoV-2 was noted in April 2020 for which she had not presented any symptoms.\n\nOn clinical examination, she was not febrile. Voluminous painful tender mass (10x6 cm diameter) was located in upper inner of the right breast with retraction of the nipple. The contralateral breast was unremarkable. The right axillary lymphadenopathy was palpable. The dermatological examination revealed a typical erythema nodosum lesions characterized by multiple erythematous, painful, infiltrated nodules of varying size on the lower limbs. The remaining examination was unremarkable.\n\nBiological investigations for an underlying cause such as inflammatory tests (full blood count, erythrocyte sedimentation rate, C-reactive protein), autoimmune markers (antinuclear antibody, anti-DNA, anti-neutrophil cytoplasm antibody) and infective serologies (HIV, hepatitis B and C) were negative or within normal range. Serology SARS-CoV-2 IgG testing as part of a systematic work-up came back positive at over 100.\n\nAn ultrasound examination, performed twice, showed a hypoechoic mass on the right side, frankly hyper vascularized in favor of mastitis. Mammography did not reveal any suspicious mass or microcalcification. A purulent nipple discharge occurred during the mammography.\n\nBreast biopsies showed a lobulocentric subacute mastitis with a non-caseating granulomatous inflammation and multinucleated giant cells. There was no evidence of malignancy. Immunohistochemistry was normal. No organisms were identified on Grocott methanamine silver (GMS), Gram, Periodic acid-Schiff (PAS) and Ziehl-Neelsen stainings. Bacterial, fungal and mycobacterium cultures of the aspiration specimen were all negative.\n\nTB quantiferon, polymerase chain reaction test and acid-fast bacilli staining were negative. On the other hand, blood calcium and angiotensin-converting enzyme level were within normal range. The chest X-ray did not show any hilar adenopathy or pulmonary parenchymal infiltrate. Either tuberculosis or sarcoidosis was excluded with these results.\n\nInitially, an infectious origin was suggested. She was empirically treated with antibiotics: pristinamycin (7 days), amoxicillin-clavulanic acid (10 days), and trimethoprim-sulfamethoxazole (2 months). Then, a treatment with colchicine 1mg/day was administered as the disease worsened with discharge and fistulation of the swelling at the biopsy sites. Spectrometry of a pus sample identified a germ called Corynebacterium kroppenstedtii. The other two bacteriological control samples were aseptic.\n\nThe diagnosis of IGM associated with erythema nodosum was evocated. Daily prednisone 60 mg was started with a gradual taper 5 months. The evolution was rapidly favorable with complete regression of the breast swelling and erythema nodosum. No recurrence was reported within two years of follow-up.",
    "summary": "A 29-year-old primiparous woman came to a dermatological consultation for typical erythema nodosum lesions that appeared one month after a breast swelling. She had no particular medical history. Examination revealed typical erythema nodosum lesions on the legs, voluminous tender mass in the right breast. Bacteriological samples and tuberculosis test were negative. Imaging showed mastitis on the right breast with no evidence of malignancy. Histology revealed a non-caseating granulomas on the lobule of the right breast. As part of an etiological work-up, COVID-19 serology was performed with a positive IgG antibody. The diagnosis of IGM associated with erythema nodosum was evocated. The evolution was favorable under systemic corticosteroid therapy."
  },
  {
    "id": "multiclinsum_gs_en_311.txt",
    "fulltext": "A 4-year-old male child, diagnosed prenatally with right pyelocalyceal dilation, was confirmed to have multiple hyperechoic microcysts in the upper right caliceal group after birth. Regular consultations showed no physical abnormalities, though follow-up ultrasounds indicated progressive enlargement of three upper polar cysts.\n\nAt birth, a renal ultrasound revealed moderate dilation of the superior calyceal system and multiple hyperechoic microcysts in the upper right kidney. The left kidney showed mild dilation of the pyelocalyceal cavities (7 mm anteroposterior diameter).\n\nAt 2 months, the child developed a febrile urinary tract infection (UTI). Ultrasound showed the right kidney measuring 58 mm, with a cystic lesion of 24 mm and a hyperechoic formation (18 × 8 mm), which was mobile. The left kidney measured 54 mm, with moderate global calyceal dilation (10 mm anteroposterior diameter). A voiding cystourethrography (VCUG) at 5 months confirmed bilateral vesicoureteral reflux (VUR), grade 2. DMSA renal scintigraphy showed symmetrical renal function with no scarring. Prophylactic urinary antiseptic treatment was started with regular clinical and radiological monitoring.\n\nBy 7 months, an uro-CT scan identified simple cortical cysts, the largest being 37 mm, and revealed finely delineated bilateral ureteropyelocaliceal cavities. At 11 months, the right kidney measured 75 mm, with three cysts (39 × 29 × 25 mm, 17 × 14 × 11 mm, and 10 × 6 × 5 mm). The left kidney remained normal, and no UTIs recurred, allowing discontinuation of prophylactic antibiotics at 1.5 years.\n\nAt 2 years, the right kidney measured 100 mm, with two upper polar cysts (60 × 50 × 53 mm and 15 × 12 × 2 mm). The left kidney remained normal. At 3.5 years, a follow-up ultrasound showed an exophytic upper polar cyst measuring 70 × 47 mm, with thin walls and incomplete septations. The left kidney continued to appear normal.\n\nA CT-guided percutaneous cyst aspiration yielded serous fluid. Cytological analysis confirmed a paucicellular fluid devoid of anaplastic features. However, post-aspiration ultrasound revealed a cyst in the right kidney's upper polar sinus (81 × 78 × 64 mm). In light of these findings, surgical intervention was recommended.\n\nA right upper pole nephrectomy was performed viaan open approach through an anterolateral lumbotomy incision. On anatomopathological examination, the hemi-nephrectomy specimen was occupied by a cyst with a whitish-colored, sclerotic-consistency wall. This cyst was capped by a crescent of renal tissue measuring 0.6 cm in thickness. Serial sectioning of the wall of this cyst revealed a second cyst with a lumen filled with a yellowish-white paste-like substance. The larger cyst had an internal surface lined with a multi-layered epithelium, often of the transitional type and focally keratinized squamous type. The rest of the cyst wall was composed of fibrous tissue rich in smooth muscle cells. The smaller cyst showed features of a dermoid cyst, with a lumen filled with keratin and desquamated squamous cells. Its wall was lined with an epidermis-like epithelium and contained hair follicles and sebaceous glands. Surrounding these cysts, connective and adipose tissue was observed, containing another cyst lined with squamous epithelium and tubules concentrically surrounded by cellular connective tissue resembling renal dysplasia. Additionally, the renal tissue identified macroscopically showed no lesions.\n\nPostoperative follow-up over three years revealed no urinary infections. Ultrasound monitoring demonstrated a right kidney reduced to 50 mm and a normal left kidney, with no cystic or solid lesions and no dilation of the excretory cavities.",
    "summary": "We report the case of a 4-year-old male diagnosed with right pyelocalyceal dilation in utero, confirmed postnatally as MCDK. Follow-up ultrasounds revealed rapid growth of three upper pole cysts, reaching 8 cm. A right upper pole nephrectomy was performed, and histopathology revealed a renal dermoid cyst within segmental multicystic renal dysplasia."
  },
  {
    "id": "multiclinsum_gs_en_278.txt",
    "fulltext": "A 51-year-old inpatient man was referred to the Oral Medicine Department of Hasan Sadikin Bandung Hospital with difficulty swallowing due to a sore throat and dry mouth last week. The patient could not taste the food. He also complained of fever, weakness accompanied by cold sweat, blurred vision, weak extremities, itchy skin, redness, and body swelling. He was diagnosed with chronic adrenal insufficiency, severe psoriasis vulgaris with psoriatic arthritis, acute circulatory collapse, anemia of inflammation (AI), acute kidney injury (AKI) stage III, dehydration, gastritis related to drugs (methotrexate and cyclosporine), urinary tract infections, and malnutrition by the Dermatovenereology Department and the Internal Medicine Department. He was given 0.9% NaCl, ceftriaxone, omeprazole, metoclopramide, methotrexate, cetirizine, loratadine, folic acid, calcium, albumin, 5% dextrose, chlorpheniramine maleate, cefadroxil, and paracetamol.\n\nAccording to his medical history, he has complained of reddish, scaly, itchy patches on his skin with a burning sensation on the scalp, nape, and knees since 15 years ago. He was diagnosed with psoriasis vulgaris by the Dermatovenereology Department and was treated with methylprednisolone. After the complaints of itching and redness on the skin subsided, he bought it himself and took the drug for 15 years without doctor monitoring. Four months before his hospitalization, he stopped taking medication on his own. He reported no history of other systemic diseases, such as hypertension or diabetes mellitus. He has no family history of having the same complaint. He denied a history of allergies to food, drugs, or other allergens.\n\nThe physical examination revealed a general state: looks moderately ill; consciousness: compos mentis; weight: 63 kg; height: 167 cm; blood pressure: 110/70 mmHg; pulse: 80 times/minute; respiration: 20 times/minute; body temperature: 36.5°C. Extra-oral examination revealed dry, scaly skin all over the body. He had joint stiffness. His face looked symmetrical, and the skin was scally, dry, and reddish. The conjunctiva was anemic, and the sclera was non-icteric. The lips were dry and peeling, and there were painful fissures at both corners of the lips. The nails appeared thickened with a ragged texture. The submandibular and submental lymph nodes showed no abnormalities.\n\nIntraoral examination revealed dryness and a glassy appearance of the oral mucosa, and the mouth mirror was adherent to the buccal mucosa. The palate had a glassy appearance and was free of debris. The tongue was erythematous, depapillated, and lobulated; two-thirds of the anterior dorsal tongue had shallow longitudinal fissures, and the mouth mirror stuck to the dorsal tongue. The ventral tongue appeared glassy. There was no saliva pooling on the floor of the mouth. Plaque and calculus were present in all regions. A serological examination may be seen in Table 1. Based on anamnesis and clinical examinations, he was diagnosed with severe xerostomia (a score of 8 according to the Challacombe scale and a score of 17 according to the Indonesian Summated Xerostomia Inventory (SXI-ID) questionnaire), a fissured tongue, exfoliative cheilitis, angular cheilitis, and generalized chronic marginal gingivitis.\n\nThe oral management of the patient was to apply a thin layer of petroleum jelly on the lips three times a day for exfoliative cheilitis, gargle with chlorine dioxide mouthwash three times a day for xerostomia, apply 2% miconazole cream two times a day for angular cheilitis, and suck benzydamine HCl lozenges three times a day for painful swallows. On the fifth day of his hospitalization, the patient developed respiratory distress and was diagnosed with hospital-acquired pneumonia (HAP). On the sixth day of his hospitalization, he had decreased consciousness, and his condition deteriorated. The patient’s family refused to have him intubated and transferred him to the Intensive Care Unit (ICU), and the patient passed away.",
    "summary": "A 51-year-old inpatient man with psoriasis vulgaris was referred to the Oral Medicine Department with complaints of difficulty swallowing due to a sore throat and dry tongue since last week. The patient had psoriasis vulgaris 15 years ago, chronic adrenal insufficiency, psoriatic arthritis, acute circulatory collapse, anemia of inflammation, acute kidney injury, dehydration, gastritis, urinary tract infections, and malnutrition. A complete anamnesis and oral examination were done. The patient was diagnosed with severe xerostomia, a fissured tongue, exfoliative cheilitis, angular cheilitis, and gingivitis by the Oral Medicine Department.\n\nCase Management\nThe patient was treated with petroleum jelly, chlorine dioxide mouthwash, miconazole cream, and benzydamine HCl lozenges."
  },
  {
    "id": "multiclinsum_gs_en_465.txt",
    "fulltext": "In February 2013, a 24-year-old black woman with anorexia nervosa, chronic anemia (baseline hemoglobin, 9.5–11 g/dL), and major depression was admitted to the cardiac care unit with congestive symptoms and low cardiac output that necessitated inotropic support. She had no notable family medical history. Three months earlier, she had been admitted for failure to thrive after several months of poor oral intake that had caused a 30-lb weight loss and metabolic abnormalities. Initial laboratory results included normal levels of thiamine, folate, and selenium; however, her zinc levels were low at 23 μg/dL (normal range, 70–120 μg/dL). She had a prolonged hospital stay while she underwent tube-feeding and received antidepressant therapy. A transthoracic echocardiogram (TTE), obtained to investigate subjective dyspnea, revealed a left ventricular ejection fraction (LVEF) of 0.60 and nothing unusual. She was discharged from the hospital with plans for outpatient mental health follow-up.\n\nTwo weeks before the current admission, the patient reported progressive dyspnea and cough, which were attributed to respiratory tract infection and were treated unsuccessfully with azithromycin. On the day of presentation, her mother noted that she had a disturbed gait, right-limb weakness, facial drooping, and slurred speech. The diagnosis was acute right-sided middle cerebral artery stroke. The patient was given intravenous tissue plasminogen activator, and she gradually recovered neurologic function. Hypercoagulability study results revealed nothing of note, and no dysrhythmias were detected. However, physical examination and auscultation revealed prominent jugular venous pulsations, a soft right ventricular heave, and a left ventricular (LV) S3. A TTE showed a dilated LV with globally reduced function, an LVEF of 0.10, an LV end-diastolic dimension of 4.6 cm, a left atrial dimension of 4 cm, and an estimated right ventricular systolic pressure of 60 mmHg.\n\nResults of right-sided heart catheterization included a right atrial pressure of 18 mmHg (normal, 2–6 mmHg), a pulmonary artery systolic pressure of 29 mmHg (normal, 15–30 mmHg), a pulmonary capillary wedge pressure of 16 mmHg (normal, 8–12 mmHg), a Fick cardiac output of 2.59 L/min (normal, 4–8 L/min), and a cardiac index of 1.71 L/min/m2 (normal, 2.5–4 L/min/m2). Cardiac magnetic resonance revealed normal chamber thicknesses and dimensions, severe biventricular failure, and a pericardial effusion of moderate size. No fresh or organized thrombi were seen in the cardiac chambers. Endomyocardial biopsy samples showed no acute inflammatory or infiltrative changes, viral inclusions, or adenovirus or herpes simplex virus after immunohistochemical staining. A reverse transcriptase polymerase chain reaction assay was negative for influenza A and B. Of note, no staining was obtained for changes associated with cardiomyopathy secondary to zinc deficiency, such as increased levels of superoxide dismutase or the protein LC3-II (a marker of autophagy).\n\nThe patient was started on conventional therapy for advanced HF. The cause of new-onset cardiomyopathy in this young woman was not obvious, so the treatment team searched the medical literature and consequently tested her zinc levels. These were consistently low at 34 μg/dL. She was started on an oral zinc supplement (220 mg/d) and was encouraged to increase her dietary intake. Four weeks later, she was discharged from the hospital on a therapeutic regimen of carvedilol (12.5 mg 2×/d), lisinopril (10 mg/d), spironolactone (50 mg/d), torsemide (10 mg/d), hydralazine (10 mg/d), isosorbide dinitrate (10 mg 3×/d), and zinc (220 mg/d).\n\nThe patient's LVEF improved to 0.25 after one month and to 0.35 after 3 months. Zinc supplementation was discontinued at 4 months by a practitioner who was unaware of earlier therapeutic decisions, and the remaining therapy continued. After 6 months on this regimen, the patient's zinc levels recovered only partially to 58 μg/dL, and her LVEF remained at 0.35. While not taking zinc, she had another period of poor food intake; her zinc level decreased to 44 μg/dL, and supplementation was resumed. One year later, during which time she had continued zinc therapy, the patient's HF symptoms had resolved, her LVEF had improved to 0.60, and her zinc level had increased to 62 μg/dL.",
    "summary": "We present the case of a 24-year-old woman with anorexia nervosa and new-onset heart failure whose depressed left ventricular systolic function improved after zinc supplementation. To our knowledge, this is the first report of low plasma zinc levels as the chief cause of cardiomyopathy that resolved after zinc supplementation.32603465"
  },
  {
    "id": "multiclinsum_gs_en_505.txt",
    "fulltext": "Patient information\nA 24-year-old man residing in Yopougon, a popular commune in the city of Abidjan, single, having stopped his studies in the final year, unemployed, suffering from undocumented psychiatric disorders was accompanied by his parents to the emergency department of our hospital for epigastric pain and swelling that had been developing for 15 days following the voluntary ingestion of a knife. No other signs (dysphagia, vomiting, intestinal disorders, cough, gastrointestinal haemorrhage) were found during the examination. The parents informed us of the presence of a mental disorder in the patient that had been diagnosed and was not being treated by psychiatrists or traditional therapists.\n\nClinical results\nThe physical examination revealed an ulcerated inflammatory mass measuring 3 x 4 cm, with the emergent tip of a blade in its center. The rest of the abdomen was soft and undistended, with no umbilical cry, and the rectal examination was normal. The patient had a body temperature of 37.5 °C.\n\nDiagnostic evaluation\nAn unprepared abdominal X-ray shows a linear, sharp-edged, knife-blade-shaped, radiopaque image.\n\nLaboratory tests revealed a haemoglobin level of 10 g/dl, a hyperleucocytosis of 16 600/mm3.\n\nTreatment and follow-up\nSurgical intervention under general anaesthesia was performed.\n\nThe intraoperative findings showed a healthy abdominal cavity, an adhesion of the anterior face of the gastric body with the abdominal wall, the release of which showed a gastric perforation, with a blade inside it, the tip of which passed through the entire anterior abdominal wall, the handle remaining in the gastric lumen.\n\nIntragastric foreign body extraction was performed: it was a whole knife of local craftsmanship with a sharp blade at one end, 6 cm long, 1.5 cm wide at its base, and a round carved wooden handle 2 cm in diameter and 7 cm long. The knife measured 13 cm. For gastric perforation, a superior wedge resection was performed. This sample did not show any histological abnormality. A gastric suture was then performed. The hospital stay lasted eight days, the consequences were simple. The one-year follow-up is excellent, the patient has a psychiatric follow-up.\n",
    "summary": "We report the successful management of the consequences of the voluntary ingestion of a knife in a 24-year-old man with undocumented psychiatric disorders. The patient was admitted to the emergency department for a fistulized epigastric cutaneous abscess with the tip of a knife emerging. This was the extraordinary migration of an ingested dagger that perforated the stomach and externalized itself as an epigastric abscess. Surgical extraction of the foreign body was performed.\n"
  },
  {
    "id": "multiclinsum_gs_en_318.txt",
    "fulltext": "A 10-month-old male infant was brought into the pediatrics unit with a 10-day history of high-grade fever and generalized body rashes without any prior vaccination history.\n\nAt the time of admission, the patient had a high fever of about 40.3°C and appeared conscious. Physical examination revealed several skin lesions that were in various stages of development and appeared as nodules with a central crust and round, ulcerated, necrotic papules.\n\nThe face, chest, and upper extremities were all affected by the lesions. After obtaining samples of the patient’s blood, cerebrospinal fluid, and skin lesion (pustule), an empiric course of intravenous Clindamycin (10 mg/kg per day) and Ceftriaxone (50 mg/kg per day) was started.\n\nLaboratory tests showed CRP 25 mg/l, LDH 579 U/L, WBC 15.06 × 1000/mm3, HGB 8.4 g/dl, and absolute neutrophils 1930/mm3 (12.8%), PLT 323 × 1000/mm3.\n\nCoagulase-negative Staphylococcus was found in the tissues that were taken from the lesion, supporting the diagnosis of ecthyma gangrenosum.\n\nCoagulase-negative Staphylococcus aureus, an isolated strain, was susceptible to vancomycin, quinupristin, daptomycin, and vancomycin. According to the drug susceptibility test results, intravenous Vancomycin (20 mg/kg per dose, 3 times daily) should be started. Coagulase-negative Staphylococcus aureus was eliminated as a result of this defervescence. The necrotic lesion was surgically removed from the patient. Twenty days after the treatment, the patient made a complete recovery. The lesions significantly improved. The necrotic lesion was surgically removed from the patient, and there was no sign of recurrence or new lesions. Lesions were seen on subsequent visits.",
    "summary": "Here, we report the case of a 10-month-old male infant who developed ecthyma gangrenosum after a measles infection. At the time of admission, the patient had a high fever of about 40.3°C and appeared conscious. Physical examination revealed several skin lesions that were in various stages of development and appeared as nodules with a central crust and round, ulcerated, necrotic papules in the face, chest, and upper extremities. Laboratory tests showed CRP of 25 mg/l, LDH of 579 U/L, WBC of 15.06 × 1000/mm3, and absolute neutrophils of 1930/mm3 (12.8%). The result of the culture showed coagulase-negative Staphylococcus. According to the drug susceptibility test results, intravenous Vancomycin (20 mg/kg per dose, 3 times daily) should be started. A coagulase-negative Staphylococcus was eliminated as a result of this defervescence. The necrotic lesion was surgically removed from the patient."
  },
  {
    "id": "multiclinsum_gs_en_567.txt",
    "fulltext": "24-year-old male with no personal or family risk factors or history of cardiovascular disease, with a history of autoimmune hepatitis with cirrhosis in Child Pugh A stage (diagnosed at 13 years of age and without specific treatment at the time of consultation), vitiligo and rapidly progressive alopecia areata. He consulted at the emergency department of another institution for dyspnoea of 15 days of evolution that progressed to functional class IV, associated with epigastralgia. In addition, he reported having had gastrointestinal symptoms one month before the consultation. During the directed questioning, he reported having a good previous functional class. On admission, he presented with a tendency to hypotension, with a heart rate of 115 beats per minute, saturating 98% to ambient air, good ventilatory mechanics and wet crepitations up to mid-pulmonary fields. He had no oedema in peripheral limbs and a 3/3 jugular engorgement was observed, without inspiratory collapse. The electrocardiogram showed a sinus rhythm at 115 beats per minute, with the electrical axis deviated to the left, narrow QRS with a striking poor progression of R waves in precordial leads. The ST-T segment did not show acute ischemic changes. The chest radiograph showed an increased cardiothoracic index with mild signs of redistribution of flow to the upper pulmonary fields. In the admission laboratory, he had hyponatraemia of 126 mg/dl (for a normal value of 135-145 mg/dl), altered hepaticogram with transaminases multiplied by 40 of the normal value, total bilirubin of 20 mg/dl (normal value between 0.10 to 1.4 mg/dl) with a predominant direct type, with mild increase of alkaline phosphatase and severe decrease of prothrombin time of 20% (normal value between 70-120%). The lactic acid was 4.15 mmol/L (for a normal value of up to 2.50 mmol/L). He also presented elevated cardiac biomarkers, with N-terminal brain natriuretic propeptide (NT-Pro BNP) of 8170 pg/ml (normal value up to 125 pg/ml according to age cut-off) and ultrasensitive troponin of 192 pg/ml (normal value up to 15 pg/ml). A transthoracic Doppler echocardiogram was performed that evidenced global severe biventricular dysfunction with marked thinning of the myocardial walls and dilation of the four cardiac chambers (left ventricular ejection fraction of 25% calculated by Simpson method).\n\nIn view of the clinical picture described, cardiogenic shock was diagnosed and various differential diagnoses were considered that could have led the patient to this state. One of them was cardiac compromise in the context of a worsening of his autoimmune disease and the other was acute myocarditis.  As part of the etiological study, a cardiac resonance was requested with intravenous contrast. In it, an increase in the volumes of both ventricles was observed with a severe biventricular deterioration, with a left ventricular ejection fraction of 10% and a right ventricular ejection fraction of 12%. In addition, a gadolinium enhancement was observed with an intramyocardial linear pattern in the basal and medial antero-septal segments and the basal infraseptal segments, and a subepicardial pattern in the inferior basal and medial segments and the infraseptal segments, suggestive of a diagnosis of myocarditis. In view of the clinical picture mentioned, treatment was initiated with pulses of methylprednisolone, high-dose intravenous diuretics and inotropic support with dobutamine. After the first day of admission, he developed a sustained ventricular arrhythmia and refractory cardiogenic shock to medical treatment. Subsequently, after a comprehensive multidisciplinary evaluation (in conjunction with rheumatology, infectious disease and hepatology teams) and the difficulty of the clinical condition mentioned, the possibility of a transplant was considered. At this time, the dilemma of a combined transplant (hepatic and cardiac) or a cardiac transplant alone was presented. After the decision to begin the pretransplant evaluation, the cannulation of an extracorporeal membrane oxygenation (ECMO) device was decided as a bridge to the same. The days following the placement of the ECMO, marked improvement of the hepatic and coagulation parameters was observed, which was interpreted in the context of the hemodynamic compromise resulting from the low volume minute, associated with the presence of a previously compromised hepatic parenchyma. For this reason, his admission to the emergency cardiac transplant list was rejected, ruling out the possibility of a combined transplant. On the seventh day of the placement of the ECMO, he received an orthotopic cardiac transplant. He had a good postoperative evolution and the successful removal of the ventricular assist device was achieved on the fourth day of the same. However, he died two months after the transplant due to an opportunistic infection by Aspergillus. The results of the biopsy of the explanted organ confirmed the diagnosis of lymphocytic myocarditis.\n",
    "summary": "A 24-year-old male with a history of autoimmune hepatitis in a cirrhotic compensated phase presented with dyspnea of 15 days' evolution. He had a gastrointestinal history one month prior to the consultation. Physical examination revealed signs of fluid overload. The laboratory reported elevation of cardiac biomarkers, acute versus chronic liver failure and severe coagulation disorders. A transthoracic echocardiogram was performed that showed global severe biventricular dysfunction with thinning of the walls. The diagnostic hypotheses were cardiac involvement by reactivation of autoimmune disease versus viral myocarditis. An MRI was performed that confirmed severe ventricular dysfunction in which late gadolinium enhancement suggestive of myocarditis was observed. Methylprednisolone pulse treatment was indicated. The first day of admission he developed signs of cardiogenic shock and ventricular arrhythmia refractory to treatment. After a thorough and difficult multidisciplinary evaluation of the clinical state, the possibility of a heart transplant was raised. Extracorporeal membrane oxygenation (ECMO) support was established as a bridge to transplantation. On the seventh day of ECMO, and after a great improvement of the hepatic parameters, he received a heart transplant. He had a good postoperative evolution, however, he died two months later due to an opportunistic infection. The biopsy results of the explanted organ confirmed the diagnosis of lymphocytic myocarditis.\n"
  },
  {
    "id": "multiclinsum_gs_en_538.txt",
    "fulltext": "A 56-year-old man with a history of hypertension diagnosed at 46 years of age was well-managed on telmisartan 40 mg and amlodipine 5 mg. The patient occasionally consumed alcohol and did not smoke.\n\nA 2011 TTE revealed mild AR directed towards the AML, with a vena contracta of 2.5 mm, jet width of 6.5 mm, and left ventricular outflow tract (LVOT) diameter of 29 mm. The ascending aorta diameter was 38 mm. Mild mitral regurgitation was also observed, without evidence of perforation or vegetation.\n\nSix months before admission, the patient experienced pain in the upper left eighth tooth and recurrent bleeding while brushing. For 3 months before admission, the patient had intermittent fevers over 40°C without shortness of breath. With no improvement, the patient presented to our hospital in April 2016, was admitted the same day for further evaluation and treatment, and was diagnosed with fever of unknown origin (FUO).\n\nOn admission, the patient’s height, weight, and body mass index were 179 cm, 79.2 kg, and 24.7 kg/m², respectively. He was conscious and had a temperature of 37.2°C, blood pressure of 124/77 mmHg, heart rate of 90 b.p.m., and oxygen saturation of 95% (room air). Auscultation revealed clear respiratory sounds and a systolic murmur at the fourth left sternal border, with no diastolic murmur. There were no skin rashes, oedema, pathological lymphadenopathy, or abnormal neurological or fundoscopic findings.\n\nA 12-lead electrocardiogram showed normal sinus rhythm with a heart rate of 82 b.p.m. and normal axis. Chest radiograph revealed a cardiothoracic ratio of 51% without pulmonary congestion or pleural effusion. Contrast-enhanced computed tomography scans from the chest to pelvis revealed no abnormalities, infection sources, neoplastic lesions, or embolic sources. Gallium scintigraphy performed to investigate the FUO did not reveal any abnormal accumulation.\n\nAlthough neoplastic lesions, collagen disease, and infectious diseases were considered as possible fever causes, these results excluded neoplastic and collagen diseases. Blood cultures from Days 1 to 4 of hospitalization (two sets each) were positive for S. oralis. Consultation with the dental and oral surgery department revealed caries in the upper left eighth tooth, which required treatment and was diagnosed as a possible bacteraemia source.\n\nThese findings suggested IE, prompting a cardiology consultation. The TTE revealed the following: left ventricular (LV) ejection fraction of 62%, LV diastolic diameter/systolic diameter of 58/42 mm, ascending aorta diameter of 38 mm, mild mitral regurgitation, trivial tricuspid regurgitation (TR), and TR pressure gradient of 20 mmHg. The AR, consistent with 2011 findings, had shifted posteriorly, colliding with the AML. Semi-quantitative evaluation showed an LVOT diameter of 29 mm, vena contracta of 4.2 mm, and jet width of 6.5 mm, indicating mild-to-moderate AR. A 7.7-mm vegetation was detected at the AR’s impact site on the AML, causing perforation and reflux.\n\nA TEE on hospitalization Day 5 confirmed findings similar to TTE findings, showing the migrating AR impinging on the AML with vegetation and perforation. The TEE also revealed partial bending of the right aortic cusp (RCC) and prolapse, but no aortic valve (AV) vegetation. Based on the Duke criteria, a definitive diagnosis of IE was made. No abnormalities were found in the fundus or dermatological examinations.\n\nTreatment included 8 g/day of AMPC (2 g q6) and 160 mg/day of GM (80 mg q12). The patient showed defervescence, had no haemodynamic problems, and was in a stable condition without cardiac failure or neurological symptoms.\n\nHowever, on Day 7, a head magnetic resonance imaging revealed multiple low signals in the bilateral cerebellar hemispheres, pons, bilateral basal ganglia, left thalamus, and left frontal lobe on the susceptibility weighted image, which were thought to be due to post-infarction haemorrhage caused by IE-related embolism.\n\nOwing to significant valvular dysfunction, antibiotic treatment was continued, and surgery was planned for Day 19. Approximately 7 mm of vegetation was removed from the AML at the AR jet site, followed by mitral valve repair (A2 vegetation resection, autologous pericardial patch, Physio II, 32 mm) and tricuspid annuloplasty (TAP) (De Vega procedure). Partial bending of the RCC was observed with no AV vegetation. To address residual AR and prevent recurrent IE, aortic valvuloplasty and ascending aorta replacement (CV-9 annuloplasty 22 mm, triples 24 mm) were performed simultaneously. The patient had no apparent postoperative complications. The AMPC and GM were administered for 42 and 17 days, respectively. The patient was discharged without any abnormal findings.\n\nThe TTE at 6 months postoperatively showed no IE recurrence and no mitral valve dysfunction. The patient remained stable for 3 years and 10 months postoperatively.",
    "summary": "In 2011, a 56-year-old man presented with mild AR towards the AML, revealed on a transthoracic echocardiogram. In 2016, 3 months before admission, the patient had been experiencing intermittent fevers of over 40°C, which did not improve, and was referred to our hospital. A detailed examination revealed a vegetation on the AML where the aortic valve was displaced, and the site was perforated. The AR was mild to moderate. Blood cultures were positive for Streptococcus oralis. From these results, a definitive diagnosis of infective endocarditis (IE) was made. The patient had cerebral infarction and underwent semi-emergency surgery."
  },
  {
    "id": "multiclinsum_gs_en_321.txt",
    "fulltext": "This case was developed following the guidelines of The CARE Guidelines: Consensus-based Clinical Case Reporting Guideline Development4. It presents the case of a 38-week-old male, born by caesarean section with Apgar 8/10, 2,950 g of weight and 50 cm of height, with prenatal diagnosis of gastroschisis. During the exploration, the exposure of loops of the large and small intestine with a violet and dilated appearance, and a clear abdominal-visceral disproportion were observed. A prognostic score (Gastroschisis Prognostic Score) of 1 was calculated. Defect of abdominal wall to the right of the umbilical cord. In the hospital of birth, the defect was enlarged on the first day of life and a surgical silo was placed with a plastic bag of physiological saline sutured to the aponeurosis. At 11 days of life, and without the intestine having been reduced, meconium was observed in the silo, so reintervention was indicated, during which a intestinal perforation was observed 70 cm from the ileocecal valve, with resection and end-to-end anastomosis. At 14 days of life, a new surgical exploration was required due to dehiscence of the anastomosis, observing an intestinal defect in the anastomosis of 1 cm in diameter, with friable loops; resection and anastomosis were performed again. Subsequently, at 22 days of life, new meconium was observed in the surgical silo, so it was decided to transfer the patient to our hospital due to lack of therapeutic options in his hospital of reference. The patient was admitted to our institution at 28 days of life, with severe malnutrition, with loss of 470 grams compared to birth and septic shock with multiple organ failure, so mechanical ventilation and vasopressor support were required. Physical examination presented a silo detached from the abdominal wall, liver included in the defect, frozen abdomen, severe peritonitis and five enteroatmospheric fistulas. Due to the severity of the patient, his respiratory and haemodynamic stabilisation was prioritised on admission, broad spectrum antibiotics and total parenteral nutrition were initiated.\n\nAt 29 days of life, the exposed intestinal loops were washed, Foley tube was used for fistulectomy and mild circumferential adhesive was used to place a preformed silo (Alexis XS®; Applied Medical, Rancho Santa Margarita, CA, USA), achieving stabilisation of the patient. At 36 days of life, 20 IU of botulinum toxin (Botox® AbbVie Spain, S.L.U. Madrid, Spain) was applied under ultrasound control in five different points of the oblique muscles of each lateral wall of the abdomen, as part of the preparation for the closure of the complex ventral hernia. At 38 days of life, the first surgical intervention was indicated in our institution, seeking a high shunt to avoid abdominal contamination, performing adhesive resection of the proximal jejunum, two-way jejunostomy 20 cm from the duodenum, resection of two enteroatmospheric fistulas and closure of a third in two planes. Due to the impossibility of closing the abdominal wall, an Alexis® surgical retractor was repositioned. At 43 days of life, a lesion was identified at the distal end of the jejunostomy, secondary to the Alexis® device ring, requiring reintervention. This surgical act was used to resect the remaining fistulas and perform a term-terminal anastomosis. After discarding the presence of intestinal atresia, a Ladd procedure was performed, remodelling the distal stoma of the jejunostomy and intubation using a Pezzer® 10 Fr. tube. For the closure of the abdominal wall, a surgical silo was made with polypropylene mesh, which was sutured circumferentially to the fascia with two lines of suture to ensure its fastening. Prior to the preparation of the polypropylene silo, the intestinal loops were protected with a plastic bag. At 44 days of life, serial reductions of the silo were initiated by continuous anchored surjete, achieving reduction of abdominal content at 52 days of life with subsequent removal of the mesh and closure of the abdominal wall without prosthetic material.\n\nThe hospital stay in our center lasted four months, requiring mechanical ventilation support for 48 days. Nutritional recovery was carried out in a mixed form, with parenteral nutrition for 88 days. Oral feeding was initiated seven days after the abdominal wall was closed, requiring 23 days to reach total enteral intake. Due to the high flow rate of the jejunostomy, it was decided to provide main feeding through the distal stoma (intubated jejunostomy) and a minimum volume orally. Finally, the elective closure of the jejunostomy was performed at four months of life, with discharge at five months of life. Currently, with 2 years of life, the patient has evolved favorably, the abdominal wall is intact, with intestinal sufficiency, adequate weight gain and developmental milestones according to his chronological age.",
    "summary": "We present the case of a full term newborn with simple gastroschisis who presented multiple gastrointestinal complications acquired during initial management. He was admitted to our institution with open abdomen, frozen, with entero-atmospheric fistulas and loss of abdominal dominance. During three months, different combined techniques (primary intestinal sutures, jejunostomy with realimenta-tion of the distal stoma, botulinum toxin, polypropylene silo construction) were used in response to the appearance of complications until total abdominal reconstruction. After a favorable evolution, the patient was discharged at five months of life, with oral tolerance and adequate weight gain.\n"
  },
  {
    "id": "multiclinsum_gs_en_200.txt",
    "fulltext": "18-year-old male, smoker of tobacco and marijuana. He started 4 days prior to the consultation with general malaise, myalgia and fever. He consulted the emergency unit for added dyspnoea class functional II-III. On admission he presented tachycardia, tachypnea and rales were heard in both pulmonary bases. He was in respiratory failure with the requirement of supplementary oxygen and in the laboratory a leukocytosis and respiratory failure with normocapnic hypoxaemia were found. On the examination he reported that he recently started to use electronic cigarette. In the computerised tomography (CT) of the thorax performed on admission to hospital, extensive areas with increased attenuation in \"frosted glass\" were observed distributed in both pulmonary fields, predominantly right with areas of consolidation and air bronchogram. The polymerase chain reaction (PCR) for SARS-CoV-2 was negative. The serology for HIV, anti-myeloperoxidase antibodies (p-ANCA), anti-neutrophil cytoplasmic antibodies (c-ANCA) and antinuclear antibodies (ANA) were negative. No microorganisms were identified in the direct observation and culture of the serial sputum and tracheal aspirate. Empirical antibiotic treatment with ampicillin sulbactam and clarithromycin was initiated.  In the absence of improvement, video fibrobronchoscopy was performed, showing haematotic debris in the lower airway, without endoluminal bronchial lesions. In the bronchoalveolar lavage (BAL) liquid was progressively recovered haematotic. The bacteriology of the BAL was negative and in the cytology there was a predominance of macrophages (50%) without evidence of haematofagia. It was interpreted as EVALI. The patient completed 7 days of antibiotic therapy and 3 consecutive pulses of methylprednisolone 1 mg/kg/day intravenous were indicated. He evolved favourably and was discharged 48 hours after the corticoid pulse. In the control CT of the thorax performed ambulatory one month after the hospital discharge, an improvement in pulmonary lesions visualised during the hospital admission was observed.\n",
    "summary": "A 18-year-old male smoker presented with shortness of breath and fever. He had hypoxemic respiratory failure and leukocytosis and reported recently using an e-cigarette. A computed tomography (CT) scan of the chest showed extensive bilateral ground glass opacities and areas of consolidation with air bronchograms. Antibiotics were initiated and a fibrobronchoscopy was performed that showed blood stains without endoluminal lesions. It was interpreted as EVALI and systemic corticosteroids were indicated. The patient recovered and was discharged 48 hours after the end of treatment. A follow-up CT scan showed improvement of the lesions. The diagnosis of EVALI is excluded.\n"
  },
  {
    "id": "multiclinsum_gs_en_417.txt",
    "fulltext": "A 10-month-old Sudanese male infant was brought to our pediatric immunology department with a history of fever and recurrent chest infections for the past six months. His parents are 1st degree consanguineous. There is a family history of recurrent chest infections requiring hospitalizations and intravenous antibiotics, along with recurrent oral thrush. The family reported three infantile deaths due to undiagnosed febrile illness as well as recurrent febrile illness with convulsions. The proband had received all vaccinations recommended for his age. On physical examination, he appeared very ill with respiratory distress, and he required oxygen therapy at five liters/minute via face mask to maintain normal oxygen saturation. The patient’s weight was below the 3rd percentile, while his height and head circumference were on the 10th and 25th percentiles, respectively. His abdomen was slightly distended, and hepatomegaly was noted, with a palpable liver at two centimeters below the costal margin. Bilateral wheezing with poor air entry was noted during chest examination. Examination of the BCG vaccine site revealed a discharging sinus with an enlarged axillary lymph node on the same side, measuring 3 × 2.5 cm; chest X-ray showed bilateral pneumonic infiltrates, while abdominal ultrasound was normal apart from an enlarged liver.\n\nInvestigations\nThe possibility of disseminated BCG infection with probable immunodeficiency was discussed as a potential diagnosis for this patient. Smears from gastric lavage fluid were collected over two consecutive days, were negative for acid-fast bacilli. However, the fine needle aspiration cytology (FNAC) tissue (lymph-node) displayed caseating granuloma, and both blood and sputum polymerase chain reaction (PCR) using two primers (IS6110 & mtp40) were positive to M. tuberculosis complex, most likely M. bovis based on the patient’s history and examination findings. Further workup revealed a normocytic-normochromic red blood cell count of 8.9 g/dL, and Immunophenotyping analysis.\n\nMaterials and Methods\nA blood sample from the patient was sent for the INVITAE platform to test for 429 genes in the primary immunodeficiency (PID) panel using Illumina technology. This comprehensive genetic testing panel was used to identify various genetic variants associated with SCIDs. Protein functions were predicted in response to missense variants using the SIFT, PolyPhen-2, and Align-GVGD algorithms. After the result emerged, we mutated the normal-human ZAP70 protein obtained from uniport with the ZAP70 variants identified in the patient’s result, here, we created a comparative bioinformatic analysis, and 3D homology modeling of ZAP70 protein structures using SWISS-MODEL, while Chimera 1.16 software was used to visualize the protein and its affected domain, and the mutated protein sequence was illustrated and compared to wild type using Jalview 2.11 software.\n\nGenetic Results\nThe panel test result reported 17 gene variants of uncertain significance (VUS), including compound heterozygous (trans) missense variants in exons 7 and 8 of ZAP70 (c.833C > T, p.Thr278Ile, and c.871G > A, p.Gly291Arg, respectively), both are affecting interdomain B region of the protein. These ZAP70 variants are on opposite chromatids and are associated with autosomal recessive SCID (MedGen UID: 376544). Accordingly, we proposed a diagnosis of ZAP70 deficiency based on compound biallelic variants affecting the ZAP70 gene, which was confirmed by platform-targeted exome sequencing and computational analysis of the gene.\n\nThe first sequence change replaces threonine, which is a small polar, neutral side chain, with isoleucine: a non-polar, large, aliphatic, and hydrophobic amino acid (p.Thr278Ile). This variant is exceedingly rare in population databases. The second variant causes a replacement of glycine, which is a non-polar tiny amino acid with no side chain, with arginine: a basic, polar, large amino acid with a positively charged side chain, at codon 291 of the ZAP70 protein. This variant is unavailable in population databases (gnomAD AF 0) and may disrupt the consensus splice site.\n\nThe American College of Medical Genetics (ACMG) verdicts for both variants are uncertain significance, since no ZAP70 deficiency patients have been reported with them, and there is no functional evidence of pathogenicity; however, the patient’s clinical phenotype is consistent with ZAP70 deficiency. Moreover, the panel identified other heterozygous genetic mutations in several genes including C8B, CD59, CR2, CTC1, DEF6, DOCK8, DUOX2, LYST, MCM4, PARN, UNC13D, and ZNF341, also, the patient has hemizygous G6PD and TLR7 variants. However, aside from the ZAP70 variants, the remaining genetic variations are VUS and do not align with the patient’s clinical phenotypes.\n\nTreatment\nThe patient was initiated on a combination therapy of Isoniazid, Rifampicin, and Ethambutol with Levofloxacin, as well as on regular intravenous immunoglobulin (IVIG) replacement and Trimethoprim/sulfamethoxazole prophylaxis, which led to excellent response and good weight gain. The patient now is free from infections and is planned for 36 months of BCG-related infection treatments.",
    "summary": "A 10-month-old boy whose parents were first degree relatives, presented with a six-month history of repeated chest infections and fever. Physical examination revealed a very ill-looking boy with respiratory distress dependent on oxygen, had slight abdominal distention and hepatomegaly. Investigations revealed positive polymerase chain reaction (PCR) for M. tuberculosis complex infection and low CD4+ and CD8+ cells. Genetic testing showed compound heterozygosity in trans for two variants in the Zeta-chain Associated Protein Kinase 70 (ZAP70) gene associated with autosomal recessive SCID. The patient was started on BCG-related infection treatment, intravenous immunoglobulin (IVIG) replacement and trimethoprim/sulfamethoxazole prophylaxis with an excellent response and the patient responded well to the treatment."
  },
  {
    "id": "multiclinsum_gs_en_390.txt",
    "fulltext": "A 53-year-old male, who initiated dialysis for end-stage renal dysfunction due to diabetic nephropathy or nephrosclerosis at our nephrology department 10 years prior, underwent annual follow-up echocardiography for progressive aortic valve stenosis (AVS) and moderate regurgitation with normal left ventricular (LV) ejection fraction (LVEF). One year before, calcifications suggesting MAC were observed in the posterior mitral annulus, which were not seen two years before. At the latest follow-up, echocardiography revealed a round, smooth-surfaced 22 × 17-mm mass with high echogenicity in the surrounding area and slightly decreased internal brightness on the posterior mitral annular ring of the left atrial side. The patient had no significant symptoms and physical findings, except for systolic murmur.\n\nEchocardiography also revealed moderate AVS with a transaortic valvular peak flow of 3.76 m/s and moderate aortic valve regurgitation. Mild mitral valve regurgitation but no stenosis was observed. The LV inflow velocity pattern showed a pseudo-normal pattern with 47-mm diameter left atrial enlargement. Serial echocardiography over two years revealed LV enlargement and decreasing LVEF. The LV end-diastolic/end-systolic diameter and LVEF were 50/33 mm and 64%, respectively, 2 years ago; 57/41 mm and 52% 1 year ago; and 59/47 mm and 42% at the latest follow-up.\n\nConsidering haemodialysis status, we predicted progression to near-severe AVS, with worsening LV systolic dysfunction, becoming an indication for aortic valve replacement (AVR) in the near future.\n\nComputed tomography (CT) revealed a high-density mass with no contrast enhancement. Magnetic resonance imaging (MRI) showed a well-defined mass of high intensity at the centre, with a hypointense rim on T1 imaging and a devoid signal on T2. Neoplasms, including myxomas and papillary fibroelastomas, were excluded based on their imaging features. Laboratory findings did not indicate infection, and vegetation with infectious endocarditis was not suspected. Considering end-stage renal dysfunction on haemodialysis and imaging findings, CCMA was suspected. The rapid mass enlargement raised concerns about potential embolism. Consequently, the mass was resected with AVR.\n\nIncision of the left atrium revealed a mass beneath the atrial endocardium in the mitral valve ring (P1–2); creamy substances were observed on the incision of the mass, suggesting CCMA. After thorough tissue removal and debridement, the incision site was sutured by proline. Aortic valve replacement was performed using a 21-mm SJM valve. The weaning from cardiopulmonary bypass was relatively smooth. At discharge, warfarin and aspirin were prescribed, along with bisoprolol for the paroxysmal atrial fibrillation after surgery.\n\nNo embolic events were observed before or after the surgery.\n\nHistopathological examination revealed scattered granular and nodular calcifications, mostly consisting of inflammatory cell infiltration and vascular proliferation of neutrophils, lymphocytes, foam cells, tissue macrophages, and plasma cells, with partial ossification compatible with CAT. LV myocardial biopsy to rule out secondary cardiomyopathy and resected aortic valve showed inflammatory cells similar to those observed in CAT. Therefore, CICMP was diagnosed based on decreased wall motion and myocardial fibrosis, with inflammatory cell infiltration > 14 mm2, CD3-positive T cells > 7/mm2, and tenascin C (4C8) negativity.7 However, the cause of CICMP could not be determined.\n\nEchocardiography 6 months after resection showed no tumour recurrence (see Supplementary material online), no progression of mitral regurgitation, normal function of aortic prosthetic valve, and no improvement of LVEF (41%)\n\n",
    "summary": " A 52-year-old man with end-stage renal failure requiring haemodialysis underwent annual follow-up echocardiography for aortic valvular dysfunction. Echocardiography revealed a well-defined 22 × 17-mm circular mass on the annulus of the posterior mitral leaflet that had not been detected 2 years previously. Based on imaging characteristics, the mass was suspected to be a CCMA. It had rapidly enlarged and posed a potential risk for embolism; therefore, it was resected concurrently with aortic valve replacement. Although CCMA was suspected based on the intraoperative findings, the histopathological diagnosis was a CAT. Upon histological analysis of the left ventricular myocardial specimen and excised aortic valve, chronic inflammatory cell infiltration was observed; therefore, chronic inflammatory cardiomyopathy was diagnosed."
  },
  {
    "id": "multiclinsum_gs_en_425.txt",
    "fulltext": "An 82-year-old woman presented to the emergency department with abdominal pain, diarrhea, confusion, and a deteriorating general condition of several days' duration. Her medical history included hypertension under treatment and hypothyroidism under replacement therapy. No surgical history or toxic habits of interest were noted. On physical examination, the heart rate was 84 bpm, blood pressure 105/82 mmHg, temperature 38°C, and oxygen saturation 95% in room air. The mucous membranes were dry, and the abdomen was diffusely painful on palpation with no palpable masses or peritoneal reaction. The laboratory findings showed a hemoglobin of 13.1 g/dL, C-reactive protein of 122.9 mg/L without leukocytosis (8.9 × 10^9/L), hyponatraemia (130 mmol/L), hypokalemia (2.9 mmol/L), normal renal, hepatic, lipase, and cardiac enzyme tests. The swab for SARSCoV-2 was negative. The urine was foul-smelling with positive nitrites, red blood cells (+++) and leukocytes (+) so the sample was sent for microbiological culture. In view of these findings, probabilistic antibiotic therapy was initiated with ceftriaxone on suspicion of a possible urinary infection and a thoraco-abdomino-pelvic tomography was performed to rule out the presence of a deep infectious focus. This examination revealed signs of chronic bronchopathy and a parietal vesical pneumatosis at abdominal level compatible with an emphysematous cystitis. The urine culture revealed the presence of Escherichia coli (> 100 000 CFU/m) sensitive to the empirically prescribed antibiotic therapy and the blood cultures were positive to the same germ. The patient was admitted to the internal medicine department and the antibiotic therapy was continued for 7 days with a favorable clinical and analytical evolution, allowing the hospital discharge.\n",
    "summary": "An 82-year-old woman with a history of hypertension and hypothyroidism presented to the emergency department with abdominal pain, diarrhea, confusion, and a multi-day history of deterioration in her general condition. On admission, the patient was febrile and the blood work showed a C-reactive protein elevation without leukocytosis (8.9 × 10^9/L). In this context, a nasopharyngeal swab for SARS-CoV-2 was performed and was negative. With these results, the initial suspicion was of a digestive-origin infectious disease. The urine sample was foul-smelling with the presence of leukocytes and nitrites and was sent for microbiological culture. Empirical antibiotic treatment was initiated with a third-generation cephalosporin due to the suspicion of a possible urinary infection. It was decided to perform a thoraco-abdomino-pelvic tomography with the objective of evaluating the presence of other infectious foci in an elderly patient. This study showed an emphysematous cystitis, a rare disease in a patient without any of the classic risk factors for this entity. The urine and blood cultures were positive for Escherichia coli sensitive to the empirical antibiotic, so treatment was continued for a total of 7 days. The clinical evolution was favorable.\n"
  },
  {
    "id": "multiclinsum_gs_en_434.txt",
    "fulltext": "We present a 15-min-old male neonate born to a para-four mother who did not remember her LNMP but claimed to be amenorrheic for the past nine months. His mother had antenatal care at the nearby health center twice and was uneventful. However, she had no early obstetric ultrasound. Otherwise, she has no history of chronic medical illnesses like diabetes mellitus and hypertension. During her current pregnancy, she had no fever, headache or blurring of vision. She had never used any drug other than ferrous sulfate throughout this pregnancy. Her prior children are all healthy and alive. On her arrival at our hospital, she had vaginal bleeding of two hours duration. Subsequently, she was admitted with a diagnosis of third-trimester pregnancy plus multigravida plus antepartum hemorrhage secondary to abruptio placentae plus severe oligohydramnios plus breech presentation.\n\nOn pelvic examination, she had active vaginal bleeding. Obstetric ultrasound was done on arrival. Accordingly, the gestational age was 34 weeks, the placenta was fundal with a retroplacental clot, and amniotic fluid was significantly decreased with a single deepest pocket of 1.5 cm. The estimated fetal weight was 2.4 kg and breech presentation. Other investigations of the mother are blood group AB+, VDRL=negative, RBS=120 mg/dL, on CBC, white blood cells=9000, hemoglobin=11 gm/dL, platelet=180,000 and neutrophil=60%.\n\nAfter informed written consent was taken emergency cesarean section was done for already mentioned indications to extract a live neonate weighing 2.01 kg with APGAR scores of 5 and 6 at first and fifth minutes, respectively.\n\nThe neonate did not cry and was resuscitated for five minutes. He was then transferred to neonatal intensive care unit for further management and investigations. On arrival, the neonate was in respiratory distress. His vital signs were pulse rate 160 beats per minute, respiratory rate 70 breaths per minute, temperature 33.4 degrees centigrade and saturation was 60% off oxygen. On HEENT anterior fontanelle measures 2 cm by 2 cm and has micrognathia and short neck. On the respiratory system, there were intercostal and subcostal retractions, labored breathing and grunting. On precordial examination, s1 and s2 well heard, no murmur or gallop rhythm. On the musculoskeletal system there is bilateral upper extremity shortening, the right lower limb was normal in position and structure, the left leg rotated inward (bent in medially) at the knee joint and foot was normal in structure. On neurologic examination he was lethargic, the tone was normotonic on lower right extremity and the Moro reflex was difficult to assess. Laboratory investigation showed blood group=A+, CRP=reactive, WBC=30,000, neutrophil=54%, lymphocytes=21.1%, HGB=8 gm/dL and platelet=150,000. X-ray imaging was done and it shows extreme shortening of upper extremities. The left lower limb is internally rotated. Echocardiography was normal. With an assessment of late preterm (34–36 weeks by Ballard score) plus low birth weight plus appropriate for gestational age plus phocomelia plus perinatal asphyxia plus early onset neonatal sepsis he was managed with oxygen support, maintenance fluid, and intravenous antibiotics. The neonate died after three days of hospital stay.",
    "summary": "We present a 15-min-old male neonate born to a para-four mother who did not remember her LNMP but claimed to be amenorrheic for the past nine months. The mode of delivery was by cesarean section to extract alive neonate weighing 2.01 kg with APGAR scores of 5 and 6 at first and fifth minutes, respectively. The neonate did not cry and was resuscitated for five minutes. He was then transferred to neonatal intensive care unit for further management and investigations. His vital signs were pulse rate 160 beats per minute, respiratory rate 70 breaths per minute, temperature 33.4 degrees centigrade and saturation was 60% off oxygen. On HEENT anterior fontanelle measures 2 cm by 2 cm and has micrognathia and short neck. On the respiratory system, there were intercostal and subcostal retractions, labored breathing and grunting. On the musculoskeletal system there is bilateral upper extremity shortening, the right lower limb was normal in position and structure, the left leg rotated inward (bent in medially) at the knee joint and foot was normal in structure."
  },
  {
    "id": "multiclinsum_gs_en_7.txt",
    "fulltext": "27-year-old male with a history of HIV infection on antiretroviral therapy, recurrent genital herpes and late latent syphilis treated with benzatin penicillin 2.4 million weekly IM for three times 10 months ago, with good serological response during follow-up. In the last four months he started with a firm increase in volume in the right inguinal region of approximately 4 cm, sensitive to palpation, partially adhered to deep planes, associated with a herpetiform ulcerated lesion on the body of the penis of 1 cm size, on an erythematous, painful and scarcely indurated base, without superficial secretion. The patient did not refer to anorectal or systemic symptoms. The patient did not refer to other mucous involvement. He was evaluated in the emergency department, where he was prescribed acyclovir and amoxicillin for two weeks, with no clinical response. The right inguinal lesion evolved with two fistulous tracts on the skin surface, with abundant seropurulent secretion. He also received cefadroxil and amoxicillin-clavulanic acid for four weeks, with no improvement. Among the laboratory examinations, a normocytic, normochromic anaemia with a haemoglobin of 11.9 g/dl, a haematocrit of 35.1%, a leukocytes of 10810 cells/mm3 and a VHS of 83 mm/h stood out. The study of hepatitis B (HbsAg) and hepatitis C (Ac VHC) was negative. The VDRL was weakly reactive and MHA-TP reactive. The HIV viral load was undetectable, with CD4 lymphocytes of 911 cells/mm3. In the directed anamnesis he referred to three male sexual partners in the last year, of Chilean nationality, with insertive and receptive oral and anal sexual relations, with occasional use of condom. In addition, he consumed marijuana and cocaine occasionally.\n\nGiven the clinical suspicion of LGV and active genital herpes, PCR was requested for C. trachomatis (commercial kit, LightMix Kit Neisseria gonorrhoeae and Chlamydia trachomatis 3.0; TIB Molbiol, Roche) in the secretion of the inguinal fistulas in the reference center, which was positive. Treatment with doxycycline 100 mg every 12 h orally, for three weeks, and acyclovir 400 mg every 8 h orally for five days, with progressive decrease in the size of the inguinal lesions, and disappearance of both the fistulous tracts and the genital ulcerated lesion, was indicated. Treatment with doxycycline was maintained for three additional weeks given the persistence of the adenopathies, evolving without alterations or signs of local or systemic complications. The control examinations showed improvement of the anaemia, with haemoglobin of 12.3 g/dl, haematocrit 38.9%, without leukocytosis and decrease of the VHS (30 mm/h). A clinical evaluation and treatment of sexual contacts was performed, without presenting symptoms suggestive of genital or anorectal infection at the time of the evaluation.\n",
    "summary": "We present the case of a MSM with HIV infection on antiretroviral therapy, recurrent genital herpes and treated latent syphilis, with no recent travel abroad, with fistulized inguinal adenopathies to skin, associated with a painful genital ulcer, without anorectal or systemic symptoms, refractory to multiple antibacterial and antiviral treatments. The PCR study of the secretion of the fistula was positive for C. trachomatis. He was treated with doxycycline for six weeks, with a good clinical response, without complications.\n"
  },
  {
    "id": "multiclinsum_gs_en_115.txt",
    "fulltext": "75-year-old woman, self-sufficient, with a history of arterial hypertension under treatment with losartan, presents a one-day history of generalized myalgia associated with weakness in the lower extremities (LEE) and a holocranial headache. She goes to emergency in an extra-system, is found to be hypertensive and is hospitalized; a CT scan and a magnetic resonance of the brain (MRI) are requested, which describe a non-compressive meningioma, without signs of posterior reversible encephalopathy. Symptomatic treatment is prescribed and she is discharged 48 hours later. However, the weakness progresses compromising bipedalism and affecting the upper extremities (UEE), along with increased pain in the extremities and a recurrence of headaches. On the fifth day of evolution, she consults in the emergency department of the Hospital Clínico de la Universidad de Chile.\n\nHe reports urinary and faecal retention two days ago. He denies episodes of loss of consciousness, dizziness, palpitations, hyperhidrosis or other indicative of dysautonomia. He also does not present respiratory difficulty, dysphonia or dysphagia. He denies recent respiratory or digestive infectious pictures or having received vaccinations in the last month.\n\nPhysical examination describes patient alert, oriented, hypertensive (172/86 mmHg), heart rate 90 bpm and resting vital signs normal. Neurological examination by specialist describes:\n\nVisual acuity and fields are preserved.\n\nIsochoric pupils, direct consensual photomotor reflex preserved, no nystagmus.\n\nRight nasolabial fold obliterated, ipsilateral labial commissure droop.\n\nBilateral decreased gag reflex, no uvula deviation or palatal paresis.\n\nEsternocleidomastoid and trapezius with M3 force.\n\nPreserved tongue mobility, without atrophy or fasciculations.\n\nEESS: Right: Global M2. Left: Proximal M2 and Distal M3.\n\nEEII: Right: Global M2 force. Left: Global M3 force.\n\nCranial nerves without alterations; no pain or stiffness to neck movement.\n\nSensitivity preserved.\n\nOsteotendinous reflexes (ROT) diminished in EESS and abolished in EEII.\n\nPlantar flexor reflex (-).\n\nMeningeal signs (-).\n\nLaboratory tests showed leukocytosis (12,750/mL) and thrombocytosis (505,000/mL), normal range C-reactive protein, moderate hyponatraemia and hypocalcaemia. The lumbar puncture revealed a clear, colourless fluid with glucose of 80 mg/dL, protein of 232 mg/dL, no erythrocytes or leukocytes, Gram stain negative and culture negative.\n\nA diagnosis of progressive flaccid arrhythmic tetraparesis with an albumin/citologic dissociation in the CSF compatible with GBS was made. In the context of a high risk of ventilatory failure due to early cephaloparesis and an EGRIS score of 5 points, admission to the Intensive Care Unit (ICU) was decided.\n\nThe study was extended with electromyography revealing mixed polyradiculoneuropathic alteration with demyelinating and axonal components, in addition to active denervating elements in EESS. Treatment with IVIg was initiated for 5 days (0.4 g/kg/day), monitoring and supportive measures (including urinary catheter), in addition to assistance from kinesiology and occupational therapy.\n\nThe patient was admitted to the ICU with a urinary septic shock due to E. coli MS, and was started on antibiotics. She then developed a C. difficile infection without haemodynamic compromise, which was treated with oral metronidazole.\n\nHe is doing well, without respiratory difficulty, with gradual recovery of strength. However, he continues to have intense, burning, intermittent pain in his extremities that increases with movement. He was initially managed with a continuous infusion pump of fentanyl, which was later changed to SOS and paracetamol was added orally, pregabalin orally and metamizole intravenously at regular intervals. During his hospitalisation, there were 2 failed attempts to remove the urinary catheter.\n\nShe is transferred to the internal medicine department due to clinical stability.\n\nEvolution and management of pain\n\nGiven the persistence of the pain, paracetamol was administered orally, pregabalin was administered orally (150 mg), was changed to metamizol IV SOS and it was suggested to initiate tramadol orally SOS which the patient rejected, indicating a fentanyl patch (6.25 mcg/hour). Possible pharmacological interactions between fentanyl and pregabalin were evaluated (increased risk of depressing the CNS), deciding to maintain and monitor.\n\nHe is progressing favorably, with intermittent pain persisting at a lower intensity that increases with active mobilization, so fentanyl 25 mcg IV is indicated prior to rehabilitation.\n\nDischarge after 5 weeks of hospitalisation, maintaining transdermal fentanyl at the same dose every 72 hours and paracetamol 1 g po as needed; discontinuation of pregabalin.\n\nEvolution and management of urinary retention\n\nGiven the persistence of urinary retention, urology suggested initiating tamsulosin 0.4 mg/day prior to discharge for relaxation of the bladder neck and catheter removal was scheduled one week post discharge, which was successful.\n",
    "summary": "We present the case of a 75-year-old woman with an acute picture of arreflective flaccid tetraparesis compatible with GBS; she is receiving treatment with intravenous immunoglobulin (IVIG) with which the motor component improves, but she also has refractory pain to non-steroidal anti-inflammatory drugs and pregabalin, as well as persistent urinary retention with failed attempts to remove the urinary catheter. Transdermal fentanyl is indicated with good response and tolerance, as well as tamsulosin and intermittent catheterisation, achieving removal of the catheter after six weeks. Based on the case, individualised evaluation of pain and urinary retention in GBS is suggested, considering the use of transdermal opioids and non-invasive bladder emptying measures respectively.\n"
  },
  {
    "id": "multiclinsum_gs_en_291.txt",
    "fulltext": "A 64-year-old male pig farmer presented to our hospital an hour after the jaws of a farm forklift hit his face, including his left eye. His chief complaint was loss of vision in the left eye. He had been regularly followed up at our hospital for fundus examination for diabetes mellitus, hypertension, and dyslipidemia after cataract surgery. On admission, the patient was conscious, afebrile, and in a stable condition. His blood pressure was 164/98 mmHg, heart rate was 68 beats/min, and oxygen saturation was 98 %. On initial examination, an open globe injury was noted, and the left eye was shrunken with a scleral laceration. The intraocular pressure was unmeasurable. A slit-lamp examination revealed that the anterior chamber was deep; however, cells and blood were observed. The intraocular lens was lost. Fundus examination was difficult because of the edematous cornea and blood in the anterior chamber. B-scan ultrasonography revealed a hypotonic, antero-posteriorly shrunken eyeball. The Ocular Trauma Score raw point was calculated to be 26, based on a previous report. The right eye was intact, with a best-corrected visual acuity of 20/20 and an intraocular pressure of 13 mmHg.\n\nOn the same day, we performed scleral suturing with irrigation of the anterior chamber with vancomycin and ceftazidime to prevent endophthalmitis under local anesthesia. The ruptured sclera on the superior temporal side was accessed after temporary disinsertion of the lateral rectus muscle. Postoperatively, meropenem (3 g/day) was administered intravenously, along with topical instillation of 1.5 % levofloxacin six times daily, 0.1 % betamethasone six times daily, and tropicamide/phenylephrine once daily. Computed tomography of the head revealed no bone fractures around the eyes. Postoperatively, the ocular shape was maintained; however, bleeding in the anterior chamber continued, and prominent vitreous hemorrhage was observed on B-scan ultrasonography. Prominent folds in the Descemet's membrane were also observed. Two days later, there was no leakage from the sutured wound, and the intraocular pressure improved to 7.1 mmHg; however, the fundus could not be observed. An electroretinogram obtained 10 days postoperatively showed poor response to light in the left eye. Visual acuity was limited to light perception. Subsequently, intravenous antibiotics were discontinued, and the patient was discharged.\n\nAlthough vitreous surgery was planned to remove vitreous hemorrhage and observe the fundus, the patient was undecided on undergoing further surgery because the visual prognosis was uncertain. However, he requested surgery 3 weeks later, and vitrectomy of the left eye was performed under topical anesthesia. Owing to severe corneal edema and poor visibility, the surgery was performed with the 25-gauge Constellation Vision System (Alcon) after debriding the corneal epithelium. The proliferative membranes were treated, the retina was reinstated with perfluorocarbon, and retinal photocoagulation was performed (200 mW, 0.2 s, 400 shots). The surgery was completed with intraocular silicone oil replacement and suturing of the sclera and conjunctiva with 8–0 Vicryl, followed by ofloxacin eye ointment application. Postoperatively, the patient was treated with 1.5 % levofloxacin four times daily, 0.1 % betamethasone four times daily, and 0.1 % bromfenac twice daily.\n\nOne month after vitrectomy, postoperative inflammation gradually subsided, and only light perception was noted. A wide-field fundus camera revealed retinal hemorrhage. The intraocular pressure was 3 mmHg. Levofloxacin and betamethasone were discontinued; however, bromfenac was continued. Two months after vitrectomy, inflammation in the anterior chamber stabilized, and there was no intraocular bleeding. However, proliferative vitreoretinopathy recurred, and tractional retinal detachment progressed. As visual function could not be maintained, the patient chose to avoid additional surgery, and a follow-up plan was decided. Topical 0.1 % bromfenac was discontinued 5 months postoperatively. Two years postoperatively, the left eye showed no light perception, and the intraocular pressure was 4.7 mmHg with severe proliferative vitreoretinopathy. No sympathetic ophthalmitis was observed in the right eye for 2.5 years postoperatively without additional immunosuppressant use.",
    "summary": "A 64-year-old man presented to the ophthalmology hospital shortly after the jaws of a forklift struck his left eye. The left eye was shrunken with a full-thickness scleral laceration. B-scan ultrasonography revealed a hypotonic eyeball with antero-posterior shrinkage. We promptly performed scleral suturing to maintain the ocular shape. The patient's intraocular pressure improved to 7.1 mmHg, and visual acuity was limited to light perception. Despite this, intraocular hemorrhage in the anterior chamber persisted, and an electroretinogram demonstrated poor response to light. Subsequently, the patient underwent a vitrectomy with silicone oil tamponade to address the vitreous hemorrhage, proliferative membranes, and retinal detachment. However, proliferative vitreoretinopathy with tractional retinal detachment progressed postoperatively, resulting in the loss of light perception."
  },
  {
    "id": "multiclinsum_gs_en_589.txt",
    "fulltext": "A 28-year-old Caucasian woman was admitted to the obstetric department with PPROM at a gestational age (GA) of 32 weeks and six days. At admission the amniotic fluid was clear, there were no uterine contractions and the cardiotocography (CTG) was normal. The ultrasound (US) revealed a diagnosis of anhydramnios, with the fetus in a transverse position with the back in a caudal position, and a cervical length of 43 mm. Screening for Group B Streptococcus was negative. The white blood cell count was 12.5 × 109 mmol/L and the C-reactive protein (CRP) level was found to be 36 mg/L.\n\nPrior to the admission, the pregnancy had been uneventful. Ultrasounds at 12 and 20 weeks GA and the first trimester non-invasive prenatal test (NIPT) showed no abnormalities. Fetal biometry at 30 weeks GA showed normal fetal growth, with fetal abdominal circumference (FAC) at the 69th and estimated fetal weight (EFW) at the 48th percentile.\n\nWhen admitted to the ward, betamethasone and nifedipine were prescribed for lung maturation and tocolysis was administered during the first two days of admission according the local protocol. At 33 weeks GA, fetal biometry was repeated, which showed reduced growth velocity; with a stable FAC, yet an EFW at the 23th percentile. The pulsatility index of the umbilical artery was normal. While performing the biometry, there were no signs of fetal abnormalities.\n\nOn day six of admission, the patient started to have increasing irregular contractions. The fetus became tachycardic without the presence of maternal fever. Tachycardia persisted the next day, with an increase in white blood cell count to 14.6 × 109 mmol/L and CRP 70 mg/L. With the suspicion of chorioamnionitis the next day, a caesarean section was performed at GA 33 weeks and 6 days.\n\nThe C-section was complicated by the anhydramnios, the fetus being in transverse position and an unknown large mass on fetus’ back, which was the presenting part in the uterotomy. Assessing the fetus’ exact position was challenging due to the mass. An internal version to either a cephalic or a breech presentation was not possible without expanding the laparotomy and uterotomy. After the extension, the fetus was delivered in a cephalic position.\n\nA female infant, weighing 2945 g (>P97) was born with a moderate start with APGAR scores of one and seven at one and five minutes of life, respectively. The umbilical blood gas showed a venous pH of 7.06 with a base excess of −8.3 mmol/L. The child received five inflation breaths with consequent ventilation for four minutes before sufficient respiratory drive. Despite non-invasive respiratory support, endotracheal intubation was performed due to respiratory insufficiency and intratracheal surfactant (150 mg/kg body weight) was administered due to infant respiratory distress syndrome.\n\nDirectly after birth, a prominent dorsal mass of solid-elastic consistence with a diameter of about 12 cm was noticed at the thoracic level. Multiple skin lesions were present around the swelling.\n\nA few hours after birth, a complete blood count and inflammatory parameters showed no abnormalities. Tumor markers were determined and showed a carcinoembryonic antigen (CEA) of 1.59 μg/L (<5 μg/L), cancer antigen (CA) 125 of 12 kU/L (<35 kU/L), beta human chorionic gonadotropin (beta- HCG) of 32.5 IU/L (<1 IU/L), AFP (alpha-fetoprotein) of 1,100,964 ng/mL (5,000–105000 ng/mL). At day 5, beta HCG and AFP were not detectable anymore. Differential diagnosis included a vascular malformation, congenital malignancy, benign tumoral masses like teratoma and hemangioma, and spina bifida occulta.\n\nDue to the noticeable mass, further imaging was performed on day two, including chest radiograph (CR), US and MRI. The CR revealed a significant soft tissue asymmetry in the left posterior chest wall. The US indicated diffuse edema in the subcutaneous fat tissue of the left chest wall and an asymmetrical thickening of the thorax wall muscles. The MRI revealed that the soft tissue mass was comprised of asymmetrically thickened dorsal thorax wall muscles, particularly the serratus anterior and latissimus dorsi. Additionally, several fluid collections were found in various layers of the subcutis, extending to the left upper limb and to the gluteal muscles. The post-contrast MRI series did not show any enhancing soft tissue masses. The spontaneous decrease of the mass by the time of imaging was noteworthy and supported the diagnosis of a traumatic origin for the lesion.\n\nOn day six, a significant reduction in soft tissue edema, fluid collections, and chest wall musculature thickening was seen, as confirmed by US. By day eight, the swelling had disappeared clinically.\n\nThe infant was extubated after three days and remained on high flow respiratory support. The weight decreased significantly to 2200 g (P50-90) after a few days, in part due to the decrease in swelling.\n\nEmpiric antimicrobial therapy was started at birth because of prematurity and suspected chorioamnionitis and could be stopped after 48 h. At day eight, the child was transferred to a level two hospital for further care because of prematurity.\n\n",
    "summary": "A 32 weeks 6 days pregnant Caucasian woman was admitted after premature prelabor rupture of membranes (PPROM). Fetal ultrasound showed no abnormalities, the infant was born by a caesarean section. The delivery was complicated by the infant’s transverse position. A female infant was born with a large left-sided dorsal soft tissue mass at the thoracic level with elastic consistency, and multiple skin lacerations. A broad differential diagnosis was made. Additional imaging was suggestive for a posttraumatic swelling due to transverse position during birth. The mass decreased and disappeared over three days."
  },
  {
    "id": "multiclinsum_gs_en_478.txt",
    "fulltext": "This is a case of a 38 year right-handed newly diagnosed HIV + male patient with no history of medications or hospitalizations. He presented with a sudden paresis of the right upper and lower extremities, along with facial deviation to the left and demonstrated low verbal output, limitation in constructing sentences, and conveying thoughts or ideas effectively. He otherwise had no loss of consciousness or abnormal body movements. There was no fever or history of head trauma. The patient had no prior history of hypertension, diabetes, or hyperlipidemia. He denied any high-risk sexual contact.\n\nUpon admission, the patient’s neurological examination revealed a FOUR coma scale of 16.3 He exhibited motor aphasia, right facial paralysis sparing the forehead, and right upper and lower extremity spastic hemiparesis with a strength of 3 out of 5 on the Medical Research Council scale. The plantar reflex was positive on the right, and Kerning’s sign, Brudzinski’s sign and Neck rigidity were all negative. The rest of the physical examination was within the normal range.\n\n\nDiagnostic Assessment\nGiven the acute presentation of focal neurological deficit, magnetic resonance imaging (MRI) of the brain was performed. The results revealed left middle cerebral artery infarction (fronto-temporo-parieto-insular) and lenticulostriate territory (acute infarction). A week after his initial presentation, the patient exhibited new-onset visual disturbance and headache, promoting the decision to conduct a follow-up imaging CT scan. A new focus of hypodensity is noted involving the medial part of the right occipitotemporal lobe suggestive of right PCA territory acute infarction. The middle cerebral artery segments and its branches showed normal caliber, smooth wall, and patent lumen.\n\nA complete blood count (CBC) was conducted, showing a normal white blood cell count (4.8 *10^3). Further investigation of conventional cardiovascular risk factors yielded unremarkable results. Trans thoracic echocardiography did not reveal any embolic source, and routine ECG did not detect any arrhythmia. Due to the atypical stroke presentation without traditional risk factors, further investigation was pursued.\n\nSerological testing for infectious etiologies, including syphilis and HIV (human immunodeficiency virus), was ordered. Serum RPR (Rapid plasma regain) and subsequent TPPA (Treponema Pallidum Particle Agglutination) tests were reactive; however, the titer was not reported. There was a reactive HIV antibody test, and the absolute CD4+ lymphocyte count was 451 cells/mm3. This led to the decision to perform a lumbar puncture, a lumbar puncture detected cerebrospinal fluid positive for VDRL (Venereal Disease Research Laboratory). There is no CSF pleocytosis, and all other CSF parameters were within normal limits.\n\n\nTreatment and Outcome\nThe patient was prescribed a daily dose of 81mg aspirin and 80 mg atorvastatin, assuming that it was an ischemic stroke. In the context of the reactive syphilis and HIV serology, antimicrobial therapy of ceftriaxone 2 g intravenously (i.v.) daily for 14 days was administered, followed by benzathine penicillin intramuscularly (i.m.) at a dose of 2.4 million International Units once a week for an additional three weeks. Dolutegravir based regimen (DTG/3TC/TDF) Antiretroviral treatment was also intiated, and later, the patient was discharged for rehabilitation.\n\nCurrently, he is under long-term follow-up for HIV and neurosyphilis. The patient was regularly followed up in the outpatient clinic. A recent follow-up showed partial recovery from aphasia, and he has regained the ability to walk. The CD4 cell count remains stable.",
    "summary": "A right-handed male patient presented with a sudden paresis of the right upper and lower extremities, along with facial deviation to the left, and demonstrated low verbal output, limitation in constructing sentences, and conveying thoughts or ideas effectively. Upon admission, the patient's neurological examination revealed a FOUR coma scale of 16. He exhibited motor aphasia, right facial paralysis sparing the forehead, and right upper and lower extremity spastic hemiparesis with a strength of 3 out of 5 on the Medical Research Council scale. The Plantar reflex was positive on the affected side. Brain magnetic resonance imaging revealed left middle cerebral artery infarction (cortical and lenticulostriate territory acute infarction)."
  },
  {
    "id": "multiclinsum_gs_en_578.txt",
    "fulltext": "A 52-year-old Japanese woman experienced respiratory discomfort and cough for several months. Because her symptoms did not improve, she presented to a local hospital. Computed tomography (CT) suggested multiple systemic metastases of right renal cell carcinoma; therefore, the axillary lymph node biopsy was performed, and she was referred to our department.\n\nAlthough the blood biochemical test results revealed elevated levels of aspartate aminotransferase (to 137 IU/L) and alanine aminotransferase (to 166 IU/L) that were likely caused by liver metastasis, other remarkable findings were not observed. A pathological examination of lymph node biopsy specimens performed at the previous hospital showed an infiltration pattern and positivity for paired box 8, suggesting metastases of tumors arising from the Müllerian duct or renal cell carcinoma. Lymph node metastases of renal cell carcinoma were suspected because of negative estrogen receptor and progesterone receptor results.\n\nCT revealed a tumorous lesion with irregular margins at the inferior pole of the right kidney. Positron emission tomography-CT revealed a mass in the right kidney and multiple metastases throughout the body.\n\nWhen the patient presented to our department, the presumed condition was advanced renal cancer; therefore, we did not perform nephrectomy. Instead, we initiated drug therapy after the CT-guided biopsy results confirmed the histological type.\n\nThe patient's general condition deteriorated 1 week after the biopsy was performed. Although the pathological diagnosis had not yet been confirmed, nivolumab treatment was administered. However, the patient's general condition did not improve, and she died 1 week after treatment initiation.\n\nSubsequently, the pathological diagnosis was confirmed, and the histological examination revealed an invasive renal tumor. Large tumor cells with papillary and tubular growth and large vacuolated and irregular nuclei were observed. Additionally, strong inflammatory cell infiltration in the stroma was observed without obvious sickle cell changes in the erythrocytes.\n\nDifferentiation of the renal tumors indicated renal invasive urothelial carcinoma, papillary renal cell carcinoma, fumarate hydratase-deficient renal cell carcinoma, anaplastic lymphoma kinase-rearranged renal cell carcinoma, collecting duct carcinoma, and SMARCB1-deficient renal medullary carcinoma. Immunostaining results indicated a diagnosis of RMC without SCH.",
    "summary": "A 52-year-old Japanese woman presented to her general physician with symptoms of cough and respiratory distress. A primary malignant tumor of the right kidney and multiple metastases were suspected during imaging; therefore, she was referred to our department for consultation. The results of a computed tomography-guided tumor biopsy revealed a diagnosis of renal medullary carcinoma without sickle cell hemoglobinopathy."
  },
  {
    "id": "multiclinsum_gs_en_108.txt",
    "fulltext": "Patient information: Mr. B.C, 58 years old, of Afro-Caribbean origin with untreated hypertension as a cardiovascular risk factor and active smoking of 40 packs per year. He is being treated for psoriasis, chronic obstructive pulmonary disease (COPD) with digital hypocratism, and a nodule in the upper left lobe that raises the suspicion of lung cancer. He is hospitalized for malaise without loss of consciousness or chest pain.\n\nClinical findings: initial neurological examination found right hemiplegia with facial paralysis, phasic disorders and temporo-spatial disorientation with a NIHSS score of 21.\n\nDiagnostic evaluation: brain magnetic resonance imaging (MRI) showed multiple infarctions in different territories: left superficial sylvian with occlusion of a branch of the M2 trifurcation, left anterior and right posterior junction. He was thrombolysed with Actilyse 1.5 hours after the onset of symptoms, allowing neurological recovery with a NIHSS score of 2 (a lack of speech and intelligible dysarthria at 24 hours) despite the occurrence of a haemorrhagic remodelling.\n\nTransthoracic echocardiography (ETT) found a mass intra atrial left (OG), on sessile pedicle inserting on the inter atrial septum. This mass prolabated in the mitral orifice in diastole, causing an obstacle with a mean gradient OG-VG of 6 mmHg. The other cardiac cavities were normal. Trans esophageal echocardiography (ETO) and thoraco-abdomino-pelvic scanner found the same conclusions. The hypothesis of a myxoma of the left atrium was emitted.\n\nTherapeutic intervention: an indication of surgical resection of the mass was retained. The intervention was performed a month later to mitigate any risk of hemorrhagic transformation induced by the extracorporeal circulation (ECV). The intervention found a voluminous gelatinous mass whose base of insertion was resected. No other lesion was found.\n\nFollow-up and results: the postoperative results are simple. The histological analysis confirms the complete excision of a polypoid pedicled lesion, with few non-atypical cells, ovoid or stellate, arranged in nests or cords, with a regular nucleus, rounded or oval, surrounded by a moderate amount of eosinophilic cytoplasm. These cells stand out against a fibromyxoid background, dissociated in places by hemorrhagic suffusions and punctuated by a slight polymorphic inflammatory infiltrate. The lesion contains a large number of non-atypical vessels, sometimes surrounded by myxoid material and by the cells previously described. At the base of the implantation, there were hemorrhagic and inflammatory changes. The axis of the lesion was the site of necrotic-hemorrhagic changes. In immunohistochemistry, calretinin is positive, confirming the diagnosis of myxoma.\n",
    "summary": "We report the case of a 58-year-old hypertensive man, active smoker, who was being monitored for psoriasis, chronic obstructive pulmonary disease (COPD) and a nodule in the upper left lobe with suspicion of lung cancer. He was hospitalised for an ischaemic stroke that was thrombolysed with a haemorrageous remodelling. Systematic echocardiography revealed a large intra-auricular mass on the left that was suggestive of an intra-auricular myxoma. Histological analysis of the surgical piece confirmed this diagnosis. Left auricular myxomas can remain asymptomatic for a long time and be revealed by systemic embolic complications. Echocardiography guides the diagnosis and the histological analysis confirms it. The management must be multidisciplinary.\n"
  },
  {
    "id": "multiclinsum_gs_en_211.txt",
    "fulltext": "We present a case of right-sided unilateral pulmonary edema in an 86-year-old Sinhalese Sri Lankan woman who presented with acute onset dyspnea with cardiogenic shock due to acute non-ST elevation myocardial infarction, complicated with grade 3 mitral regurgitation. She had clinical features of heart failure and pulmonary edema, but a chest X-ray showed unilateral infiltrates only on the right side. Distinguishing pneumonia from pulmonary edema according to chest X-ray findings was a challenge initially, and she was therefore initially treated for both conditions. She had remarkable clinical and radiological improvement after 12 hours of intravenously administered furosemide and glyceryl trinitrate therapy. Her brain natriuretic peptide level was elevated and further supported and confirmed the diagnosis retrospectively.nAn 86-year-old Sinhalese Sri Lankan woman who had been previously diagnosed as having hypertension, grade 2 MR, and ischemic heart disease with congestive cardiac failure, presented to our preliminary care unit with sudden onset shortness of breath at night while sleeping. She had eaten her dinner and taken her usual medications before sleeping. She had a New York Heart Association (NYHA) heart failure grade of class 2, and could manage her day-to-day activities without support. She could walk 25 meters and could climb 3–4 steps without becoming dyspneic. Apart from her usual symptoms she did not have fever, cough, or chest pain before admission. She is a housewife and mother of five children. She does not smoke tobacco or drink alcohol. At presentation she was on captopril 12.5 mg twice a day, atorvastatin 20 mg at night, soluble aspirin 75 mg at night, bisoprolol 2.5 mg once a day, and furosemide 40 mg in the morning.\n\nOn examination, she was found to be dyspneic, drowsy, pale, diaphoretic, and restless. Her body temperature was 37.0 °C. Her blood pressure (BP) was 90/60 mmHg, with a regular, low volume pulse rate of 102 beats per minute. Her heart sounds were unremarkable. Cardiac apex was not palpable. There was a pansystolic murmur at cardiac apex. Her respiratory rate was 26/minute. Her trachea was central and right-sided chest expansion was reduced. Bilateral crepitations and rhonchi were present more significantly on the right side. Her initial oxygen saturation checked by pulse-oximetry was 56% in room air. Her abdomen was not distended and there was mild right hypochondrial tenderness. There was no hepatosplenomegaly. Her cranial nerve examination was normal. Her limbs examination was normal with normal tone, power, and reflexes.\n\nAn electrocardiogram showed ST depression in leads V5–V6 and poor R wave progression in leads V1–V4. Her chest X-ray revealed alveolar-interstitial infiltrates and a fluid collection around horizontal fissure in her right lung. Laboratory tests showed a white blood cell count of 12,000/μL with 91.8% neutrophils, hemoglobin of 9.5 g/dL, packed cell volume of 30.3, mean corpuscular volume of 75 fl, mean corpuscular hemoglobin of 23.8 pg, mean corpuscular hemoglobin concentration of 31.4 g/dl, creatinine of 221.5 μmol/l, sodium level of 139 mEq/L, potassium level of 4.4 mEq/L, B-natriuretic peptide (BNP) of 2437.2 pg/ml (normal 450 for NYHA class 2), C-reactive protein (CRP) 7.56 mg/dL (< 10), and troponin I 59.2 ng/mL (< 0.01).\n\nAlthough our patient’s temperature was normal, pneumonia could not be initially excluded in this older patient in the presence of a unilateral pulmonary infiltrate with effusion along the horizontal fissure, in combination with leukocytosis and awaiting CRP level (which took 4 hours to get the report), treatment with intravenously administered broad spectrum antibiotics (ceftriaxone 1 g twice a day and clarithromycin 500 mg twice a day) was initiated to cover severe community acquired pneumonia, and oseltamivir was started since there was an epidemic of influenza H1N1 at the time.\n\nAn emergency two-dimensional echocardiogram facility is not available in the preliminary care unit in our set up and our patient was not in a condition to be transferred to a place where a good quality echocardiogram machine was available to assess the severity of MR accurately. Echocardiography was done on third day of admission which disclosed: an ejection fraction of 25–30% with severe left ventricular (LV) dysfunction; and hypokinesia of anterior wall, LV apex, and lower 2/3 of interventricular septum, with an apical aneurysm. A two-dimensional echocardiogram showed grade 3 MR. Although her BNP level was found to be high it took 4 days to get the report due to delays in laboratory processing. Therefore it helped us to support the diagnosis retrospectively.\n\nWith all these challenges our patient was treated for severe acute on chronic heart failure although radiological evidence was unfavorable. Interestingly, she showed a remarkable improvement with preload reduction with loop diuretics and nitrates. After availability of troponin I levels she was treated for a NSTEMI on top of heart failure with intravenous heparin 500 units/hour infusion (her weight was 40 kg). Her condition was stabilized with adjustment of medical therapy for heart failure including diuretics, nitrates, and opioids. She had persistently low BP for which she needed inotropic support with dopamine and dobutamine which were tailed off subsequently. Repeat chest radiography taken 12 hours later showed complete resolution of the UPE. Subsequently, her CRP was normal and antibiotics were de-escalated after 24 hours, but oseltamivir was continued. She had a fast and remarkable recovery to her preadmission state on day 5 of admission after which she was discharged. She refused any further cardiac intervention. Two weeks after discharge she was reviewed at a medical clinic and found to have NYHA class 2 heart failure. Her BP was120/80 mmHg and pulse rate was 70/minute. Her medications were uptitrated and she was followed up in a medical clinic. After 6 month she had a two-dimensional echocardiogram and revealed ejection fraction of 40% with grade 2–3 MR.",
    "summary": "We present a case of right-sided unilateral pulmonary edema in an 86-year-old Sinhalese Sri Lankan woman who presented with acute onset dyspnea with cardiogenic shock due to acute non-ST elevation myocardial infarction, complicated with grade 3 mitral regurgitation. She had clinical features of heart failure and pulmonary edema, but a chest X-ray showed unilateral infiltrates only on the right side. Distinguishing pneumonia from pulmonary edema according to chest X-ray findings was a challenge initially, and she was therefore initially treated for both conditions. She had remarkable clinical and radiological improvement after 12 hours of intravenously administered furosemide and glyceryl trinitrate therapy. Her brain natriuretic peptide level was elevated and further supported and confirmed the diagnosis retrospectively."
  },
  {
    "id": "multiclinsum_gs_en_326.txt",
    "fulltext": "The patient was an 87-year-old male with a long-standing history of chronic heart failure spanning three decades. After suffering from acute myocardial infarction and heart failure for 20 days, the patient developed a pulmonary infection and was transferred to our medical center (Emergency Department, Chinese PLA ). On admission, the patient presented with poor general characteristics but was conscious. His vital signs were as follows: blood pressure, 143/71 mmHg; respiratory rate, 18 breaths/min; heart rate, 57 beats/min; oxygen saturation, 99% in ambient air; and body temperature, 39 °C. Blood tests revealed the following values: white blood cells (WBCs), 8.75 × 109/l (neutrophils, 88.2%; lymphocytes, 5.9%; and monocytes, 4.7%); creatinine, 1.393 mg/dl; interleukin-6, 22.7 pg/ml; procalcitonin, 0.083 ng/ml; and pro-brain natriuretic peptide (pro-BNP), 15,648 pg/ml. The remaining blood parameters were within normal limits. A bedside chest radiograph revealed bilateral pulmonary infection. We referred to the laboratory results from the previous hospital and treated the patient with meropenem for anti-infection. And diuretic, vasodilator, and cardiotonic drugs were given to correct heart failure. The patient’s levels of infection markers, troponin, and urinary natriuretic peptide precursors exhibited a persistent increasing trend. On hospital day (HD)10, the patient’s white blood cells increased to 13.3 × 109/l (neutrophils, 88.3%; lymphocytes, 7.7%; and monocytes, 7.7%). Other parameters were as follows: C-reactive protein, 7.8 mg/dl; interleukin-6, 5.9 pg/ml; procalcitonin, 2.04 ng/ml; troponin T, 0.595 ng/ml; and pro-BNP, 33,418 pg/ml. Echocardiography revealed frequent wide QRS waves, and the heart rate increased to 124 beats/min. Sputum culture showed growth of C.gilardii (Table 1). After a comprehensive assessment, we modified the antibiotic regimen to cefoperazone sulbactam and minocycline on the basis of the results of drug sensitivity testing. The levels of infection markers and pro-BNP continued to decrease. Subsequent sputum culture did not show growth of C.gilardii. However, on HD 17, fever developed, levels of infection markers and pro-BNP again increased, and a set of cultures were performed from blood obtained from an upper-extremity vein. On HD 20, a blood culture revealed a critical number of Gram-positive cocci, and linezolid was added to the treatment regimen. On HD 21, the patient died. Later blood culture revealed growth of Staphylococcus epidermidis. The patient’s pressure sores did not suppurate, therefore, no culture was performed. Given that Staphylococcus epidermidis routinely lives on the skin, we speculate that Staphylococcus epidermidis may have entered the bloodstream through pressure sores.\n\nMicrobiological analysis\nThe bacterial isolates were cultured in a 35 °C incubator on Columbia blood agar plates incubated for 24 h, there were small, grey–white, round, raised, opaque colonies with neat edges. Gram staining was negative, and the bacterial cells were arranged singly or in pairs, without spores, and were medium−sized and rod shaped. The VITEK mass spectrometry detection system identified the strain as C. gilardii, with a confidence level of 99.9%.",
    "summary": "We encountered a case of pulmonary infection after myocardial infarction and heart failure. The initial empirical treatment with meropenem was ineffective. After cultured Cupriavidus gilardii, cefoperazone sulbactam and minocycline were used, and the infection and heart failure was improved for few days. Unfortunately, the patient eventually died of heart failure exacerbated by infection with Staphylococcus Epidermidis."
  },
  {
    "id": "multiclinsum_gs_en_8.txt",
    "fulltext": "80-year-old woman with previous diagnoses of colonic diverticulosis and stage IV breast cancer with liver, bone and lung metastases, for which she began treatment with ribociclib and fulvestrant 3 years ago; currently in complete remission. She reported twenty days prior to the consultation abdominal pain, localized in epigastrium and left hypaxomenum, intermittent, aggravated after eating, associated with biliary nausea and vomiting that alleviated the pain. She denied fever or other accompanying symptoms. She consulted our center 10 days prior to admission, where ultrasound and laboratory studies were performed without pathological findings. Due to persistence of symptoms, she was admitted to the institution.  The following was found: BP 140/90 mmHg, Fc 100 LPM, Fr 18 RPM, Sat 98% (0.21), afebrile. Good peripheral perfusion, distended abdomen, not painful to superficial or deep palpation, without signs of peritoneal reaction. Laboratory: HTO 34%, Hb 11.8 g/dl, GB 4500/mm3, platelets 230 000/mm3, Cr 0.6 mg/dl, Ur 13 mg/dl, Na 139 mEq/l, K 3.7 mEq/l, Cl 101 mEq/l, pH 7.37, HCO3- 22, lactate 1.6 mmol/ and LDH 212 IU/l. In the abdominal and pelvic tomography with intravenous contrast, pneumoperitoneum was evident with predominance of the upper abdomen and parietal pneumatosis of intestinal loops and calcifications in the abdominal aorta. No free peritoneal fluid was observed. Due to suspicion of intestinal ischemia, emergency laparotomy was performed, where cupuliform structures were found in the small intestine, from 10 cm distal to the Treitz angle to 1 meter of the ileocecal valve, compatible with air cysts that crackled to the touch.\n\nVitality was preserved and there were no signs of necrosis or perforation (Fig. 2 A and B). It was decided not to resect. In the postoperative period, ceftriaxone metronidazole was administered, which was discontinued on day five after the negative result of the culture of abdominal fluid. She also completed a period of digestive rest associated with total parenteral nutrition. She evolved without the requirement of vasoactive drugs and without signs of peritoneal irritation. The patient was discharged on day ten without the antineoplastic medication. She was evaluated one month after admission, a new tomography of the abdomen and pelvis was performed which showed complete resolution of the abdominal picture.\n",
    "summary": "The case of an 80-year-old woman with a diagnosis of stage IV breast cancer undergoing treatment with fulvestrant and ribociclib, who was admitted to our center for abdominal pain and vomiting, is presented. Intestinal pneumatosis and pneumoperitoneum were diagnosed, and exploratory laparotomy was performed for suspected intestinal ischemia. There was no evidence of intestinal necrosis or perforation, so resection was not performed. She progressed satisfactorily during the hospital stay, and at the tomographic control one month after discharge, there was complete resolution of the condition.\n"
  },
  {
    "id": "multiclinsum_gs_en_350.txt",
    "fulltext": "A 55-year-old Asian man, who was taking treatment irregularly (patient was non-compliant) for DCMP for last 6 months came with complaints of dyspnoea on exertion for 1 week and decreased urine output for 2 days. The patient was apparently well 1 week ago when he started to develop shortness of breath, insidious onset, gradually progressive, initially New York Heart Association (NYHA) grade II but progressed to NYHA grade IV associated with heaviness of chest. History of orthopnoea and paroxysmal nocturnal dyspnoea was present. This was associated with cough with a moderate amount of frothy, non-purulent expectoration. The patient also complained of swelling of bilateral lower limbs. No history of periorbital puffiness, frothy urine or haematuria. There was no history of palpitation, syncope, chest pain or haemoptysis. The patient also gave a history of a tingling sensation of both hands and feet for 1 month.\n\nThe patient had similar episode 6 months ago for which he was hospitalised and managed conservatively as a case of DCMP. He had cataract surgery both eyes 15 years ago.\n\nOn general physical examination, the patient was conscious and oriented to time, place and person and afebrile with a blood pressure of 90/60 mm Hg in the right arm in supine position and pulse rate 110/min which was low volume and all peripheral pulses were palpable. He was tachypnoeic with a respiratory rate of 28/min and pallor was present. He had B/L pedal oedema which was slow pitting type with raised jugular venous pressure (JVP). No icterus, cyanosis, clubbing, lymphadenopathy was seen. While measuring blood pressure, the patient started having carpal spasm which gave us a clue to examine further revealing a positive Chvostek sign. Trousseau’s sign was also positive at 10 s.\n\nCardiovascular system (CVS) examination revealed Apex beat localised in left sixth intercostal space 1 cm outside the mid-clavicular line, hyperdynamic in character. S1 and S2 were heard normally in all the areas.\n\nRespiratory system examination revealed reduced air entry in bilateral lung bases with fine end-inspiratory crepitation bilaterally. Abdominal and central nervous system examination was unremarkable.\n\n\nInvestigations\n\nAt the time of admission, ECG showed complete left bundle branch block (LBBB) with a prolonged QT interval. Haemoglobin was 58 g/L (133–162) with dimorphic picture. Mean corpuscular volume was 110 fL (80.0–100.0 fL), mean corpuscular haemoglobin was 34 pg (27.0–32.0 pg), mean corpuscular haemoglobin concentration was 36.2 g/dL (32.0–35.0 g/dL). Further workup revealed serum vitamin B12 levels of 135 pg/mL (211–911 pg/mL). Serum folic acid was 5.40 ng/mL (>5.38 ng/mL). Blood urea was 53 mg/dL (10–50) with creatinine of 0.8 mg/dL (0.7–1.3). Liver function tests (LFTs) were within normal limits. Calcium profile showed S.calcium 4.3 mg/dL (8.5–10.5), phosphate 7.1 mg/dL (2.5–4.5), S.albumin 3.06 g/dL (3.5–5.5). In view of hypocalcemia and hyperphosphatemia, intact parathyroid hormone level was done, which came out to be <0.23 pg/mL (14–72). S.magnesium was 2.0 mg/dL (1.7–2.2). Arterial blood gas (ABG) analysis was suggestive of mild metabolic acidosis. Thyroid profile and IgAtTG levels were within normal limits. Serum ferritin and ceruloplasmin levels were within normal limits. Ultrasound abdomen and chest showed B/L pleural effusion in the supine position. Inferior venacava (IVC) and hepatic veins were prominent. Rest within normal limits. Chest X-ray showed blunting of bilateral costophrenic angles suggestive of bilateral pleural effusion. Echocardiography revealed dilated left ventricle (LV) with l eft ventricle ejection fraction of 15% which was suggestive of DCMP with severe LV dysfunction. A baseline coronary arteriogram was performed which was normal. Non-contrast CT of head showed bilateral (B/L) symmetric calcification in B/L cerebellar hemisphere, B/L basal ganglia and cortical/subcortical calcification in B/L fronto-parieto-occipital region. Rest was within normal limits.\n\n\nTreatment\n\nFor CHF, the patient was started on dobutamine intravenous injection at the dose of 6 µg/kg and furosemide intravenous injection 20 mg BD for decongestion. However, patient did not show significant improvement with the above treatment. In view of hypocalcemia with hyperphosphataemia and low parathyroid hormone levels, a diagnosis of hypocalcemic cardiomyopathy with hypoparathyroidism was considered and patient was started on calcium gluconate injection 1 g (90 mg of elemental calcium) given stat followed by calcium gluconate infusion in 500 mL of 5% dextrose at the rate of 37.5 mg/hour of elemental calcium. The patient showed significant improvement after starting calcium gluconate. The patient was discharged in stable condition on oral calcium tablets 3 g/day along with calcitriol 0.5 µg/day. Tablet benzthiazide with triamterene (25/50 mg) OD, tablet ramipril 5 mg once daily, and carvedilol 3.125 mg twice daily was also started. For megaloblastic anaemia, cyanocobalamin injections were given as per protocol.\n\n\nOutcome and follow-up\n\nOn follow-up at 3 months, patient was improved markedly.\n\nInvestigations showed S.calcium 7.7, S.phosphate 6.0 and albumin 3.6. Haemoglobin was 10.1 g/dL. Echo showed an improvement in LV function with ejection fraction being 25%. Endomyocardial biopsy was planned but the patient denied so, could not be performed.",
    "summary": "We present here a case of 55-year-old Asian man who was a known case of dilated cardiomyopathy for 6 months, presented with the chief complaints of shortness of breath on exertion and decreased urine output. On general physical examination, features suggestive of CHF were seen. Chvostek and Trousseau’s sign was positive. The patient had a history of cataract surgery of both eyes 15 years ago. Further investigations revealed hypocalcemia. Echo showed severe global hypokinesia of left ventricle with left ventricle ejection fraction 15%. This CHF was refractory to conventional treatment, though, with calcium supplementation, the patient improved symptomatically. On follow-up after 3 months, an improvement was seen in the echocardiographic parameters with ejection fraction improving to 25%."
  },
  {
    "id": "multiclinsum_gs_en_487.txt",
    "fulltext": "A 25-year-old male presented to the emergency medicine unit with progressive weakness of all 4 limbs over 4 days. The motor weakness had an acute onset, initially affecting the right upper limb and then rapidly progressing to the right lower, left lower, and finally the left upper limb within 2-3 days. The weakness was proximal at onset, causing difficulty in lifting his arm and getting up from a sitting position, before progressing distally, leading to grip weakness and slippage of footwear. One day before presentation, he developed difficulty breathing and speaking. His condition progressively deteriorated, and he was unable to speak in complete sentences, gasping for breath between words.\n\nHe did not experience difficulty swallowing, ptosis, visual disturbances, or diurnal symptom variation. There was no history of sensory disturbances, bowel or bladder dysfunction, back pain, band-like sensations, seizures, or altered sensorium. Additionally, there was no preceding history of fever, coryza, sore throat, rash, abdominal pain, diarrhea, vaccination, trauma, or falls. He had no history of similar past episodes, nor a family history of paralysis or unexplained neuropsychiatric illness.\n\nOn examination, he was conscious and oriented, with a pulse of 64 per min, blood pressure of 130/80 mmHg, and a respiratory rate of 28 per min, with rapid, shallow breathing. Neurological evaluation revealed decreased muscle tone in all 4 limbs, motor power graded 1/5 bilaterally, and areflexia with flexor plantar responses. Cranial nerve and sensory examinations were normal. Systemic examination was unremarkable.\n\nLaboratory findings demonstrated hyponatremia (serum sodium 126 mmol/L), consistent with syndrome of inappropriate antidiuresis (SIAD), as evidenced by reduced serum osmolarity (274 mOsm/L), increased urine osmolarity (561 mOsm/L), elevated urinary sodium excretion (21 mmol/L), and normal adrenal and thyroid function tests. Liver and renal function tests were normal. Nerve conduction studies revealed acute motor axonal neuropathy. Lumbar puncture showed acellular cerebrospinal fluid with mildly elevated protein levels (70 mg/dL) and normal glucose (83 mg/dL). Contrast-enhanced magnetic resonance imaging of the brain and spine was unremarkable.\n\nThe patient required mechanical ventilation due to respiratory paralysis. Intravenous immunoglobulin (IVIg) was initiated for suspected GBS. However, screening for acute HP was performed using the Watson–Schwartz test, a qualitative spot urine test for porphobilinogen (PBG), which returned positive. Treatment was initiated with carbohydrate loading with intravenous dextrose (300 g/day), as hemin therapy was not available. Subsequent quantitative PBG testing confirmed elevated levels (3.3 μmol/mmol creatinine, normal <2.6), confirming a diagnosis of acute HP. SIAD was managed with fluid restriction. The patient gradually improved and was successfully weaned off ventilator support. He was educated on porphyria, including its known triggers, drugs to avoid, and the risk of recurrent attacks. At the 6-week follow-up, motor power improved to 4-/5.",
    "summary": "We report a case of a 25-year-old male who presented with progressive weakness of all 4 limbs over 4 days, culminating in respiratory paralysis requiring mechanical ventilation. Neurological examination revealed acute flaccid paralysis with areflexia, and nerve conduction studies showed acute motor axonal neuropathy, initially supporting a diagnosis of GBS. However, the patient's young post-pubertal age, onset in the upper limb with proximal weakness, pure motor axonal neuropathy, and presence of hyponatremia due to the syndrome of inappropriate antidiuresis raised suspicion of acute HP. Screening with qualitative urine porphobilinogen testing, followed by quantitative confirmation, diagnosed acute HP. The patient was treated with intravenous dextrose in the absence of hemin, resulting in gradual clinical improvement."
  },
  {
    "id": "multiclinsum_gs_en_531.txt",
    "fulltext": "We present the case of the management of a giant omphalocele, in a patient with prenatal diagnosis in week 14. After the initial diagnosis, chromosomal anomalies were ruled out. The service of prenatal diagnosis of the Gynecology and Obstetrics department contacted the service of Pediatric Surgery for prenatal evaluation and the infiltration of botulinum toxin was considered. In week 37, the infiltration of botulinum toxin was scheduled in the transverse plane of the abdomen (TAP) of the foetus. This process was performed by a multidisciplinary team formed by gynecologists, pediatric surgeons, neonatologists and anesthetists, with the pregnant woman under sedation. Fetal sedation was performed with an intramuscular injection of atropine, fentanyl and rocuronium. Given the position of the foetus intrauterine, only the transverse plane of the abdomen on the right side of the foetus could be infiltrated. Through a single placental infiltration, botulinum toxin was infiltrated (dose 12 IU/kg) at the subcostal level, 10th rib and right iliac fossa. During the process and in the following days, no complications were evidenced. The caesarean section was scheduled in week 39. At birth, a silo was placed with a plastic bag over the defect and once the patient was relaxed and intubated, botulinum toxin was infiltrated on the left side and the relaxation test was performed, achieving total reduction of the eviscerated content and inversion of the amnion on the first day of life. The intra-abdominal pressure (IAP) was monitored at all times by bladder catheterisation and by control of renal flow by INVOS system. A hydrocolloid dressing (Varihesive Gel ControlTM) was placed over the defect, which was changed every 48 hours. On the third day of life, trophic feeding was initiated and on the fourth day, the patient was extubated without observing incidences, and breast feeding was initiated. On the eighth day of life, the definitive wall closure was scheduled and the separation of components technique (Ramírez technique) was performed, by which the semilunar line is incised to separate the rectus muscle from the external oblique muscle. At the end of the intervention, intra-abdominal pressure was 10 and good renal flow was observed. The patient remained intubated for the first 24 hours postoperatively. Tolerance was initiated on the first postoperative day, and the evolution was favourable, with the patient being discharged home on the 14th day of life.\n",
    "summary": "We present a case of hepatoonfalocele with prenatal diagnosis, without associated anomalies. In week 37 under maternal and fetal sedation, botulinum toxin was injected into the right hemiabdomen. After the scheduled cesarean section in week 39, injection into the left hemiabdomen was completed and a complete reduction of the hepatic content and total inversion of the amnion was achieved. Definitive repair was performed with separation of components on the eighth day of life and discharge on the fourteenth day of life.\n"
  },
  {
    "id": "multiclinsum_gs_en_96.txt",
    "fulltext": "A 31-year-old woman felt epigastric discomfort without any obvious cause, along with glutted, nausea and vomit on December 28, 2018. She went to hospital two days later and treated with acid-inhibitory drug. However, there was no improvement with the patient. She underwent a gastroscopy showing chronic gastritis on January 4, 2019 and taken omeprazole and domperidone. There was also no remission. On January 7, 2019, she felt tolerable abdominal pain without any treatment. Then she felt abdominal pain intensified along with anus stopping exhaust and defecate on the next day. The patient went to the emergency room and taken a series of examinations. Blood routine examination showed leukocyte 7.4*10^9/L, neutrophil 80%, hemoglobin 94g/L. Routine urine test showed urine protein (++), ketone body (+), and occult blood (-). Other examinations such as blood electrolytes, abdominal elevation film, and color Doppler ultrasound of liver, bile, pancreas, spleen, and urinary system were normal. The patient felt better after treated by analgesia.\n\nThe next day, severe abdominal pain attacked the patient again. On examination, the urine pregnancy experiment was negative and the abdominal computerized tomography (CT) scan was also normal. The abdomen was soft, and there was tenderness in hypogastrium without rebound pain and muscle tension. She was treated by enema and anti-infection with no anesis. A repeat blood routine examination showed leukocyte 9.9*10^9/L, neutrophil 84.2%, hemoglobin 102g/L. Liver function showed abnormal liver function (alanine transaminase [ALT] 401U/L, aspartate transaminase [AST] 77 U/L, total bilirubin [TB] 30.8umol/L, direct bilirubin [DB] 2.6 umol/L, indirect bilirubin [IB] 28.2 umol/L, glutamyl transpeptidase [GGT] 138 U/L). Routine urine test and gynecological sonography provided no positive result. As the patient’s symptoms could not be improved and cause was unclear, she presented to the emergency department at our hospital on January 11, 2019.\n\nWhen in our hospital, her abdominal pain was worse with anus stopping exhaust defecate. On examination, the vital signs were normal. The blood routine examination showed leukocyte 14.8*10^9/L, neutrophil 88.1%, hemoglobin 100g/L. The abdominal CT scan revealed intestinal obstruction and small amount of pelvic effusion. The electrocardiography was sinus rhythm. A diagnosis of acute intestinal obstruction was made, and she was dealt with ambrosia, anti-inflammation, acid-inhibitory, spasmolysis, and analgesia. That evening, the abdominal pain was recurrent and markedly increased, and the peregoric, such as dezocine or tramadol hydrochloride could remit briefly. Later, imageological examination of superior mesenteric blood vessels reconstruction was made, which showed no abnormal change in the blood vessels. The emergency department also could not get a definitive diagnosis, and the patient was transferred to colorectal surgery.\n\nOn examination, the temperature was 37.2°C, the blood pressure was 131/83mmHg, the pulse was 71/min, and breathe was 20/min. There was pressing pain in the hypogastrium and the bowel sound was weak; the remainder of the examination was normal. The primary diagnosis was intestinal obstruction and the patient was treated with fast, anti-infection, acid-inhibitory, inhibition of enzyme, spasmolysis, and nutrition support. Magnesium sulfate and racolamine hydrochloride could relieve the abdominal pain, while the dezocine could not.\n\nOn January 13, 2019, A repeat blood routine examination showed leukocyte 12.1*109/L, neutrophil 83.9%, hemoglobin 94g/L. Liver function showed abnormal liver function (ALT 181.2 U/L, AST 32 U/L, TB 23.3umol/L, DB 9.6 umol/L, GGT 138 U/L). The infectious disease indicators were all normal. Repeated severe abdominal pain attacked the patient today and magnesium sulfate helped her momentarily. The patient defecated today. Then she was treated with enema and taken for an electronic colonoscopy with nothing unusual.\n\nUp to now, the course of the disease continued for 16 days without a definite diagnosis. The common causes of acute abdominal diseases, such as gastrointestinal perforation, acute cholecystitis, acute pancreatitis, gynecological disease, and urologic diseases were all excluded. A series of test results mentioned above showed anemia and abnormal liver function. So we should consider the rare cause of abdominal pains, such as Porphyria, abdominal epilepsy, herpes zoster, heavy metal poisoning, and so on. We have made the physical examination carefully and found no herpes, so the herpes zoster was excluded. The electroencephalogram was normal and the abdominal epilepsy was not considered. Then, we took the patient’s urine and place it in the sun for an hour without color change. So the Porphyria was also excluded. Blood levels of heavy metals were detected and the lead was 463.17 µg/L, which was very high (normal value was less than 100 µg/L). Therefore, the diagnosis of lead poisoning was made.\n\nThe patient was treated with intravenous drip of calcium sodium edentate. The frequency of abdominal pain decreased gradually. She felt pain once a day on January 15 and 16. Later, she felt comfortable and resumed eating. Test results indicated an improvement in liver function. A week later, the blood level of lead dropped to 443.79 µg/L. According to the treatment guidelines, she should continue to receive intravenous drip of calcium sodium edentate.\n\nIn addition, we have also paid attention to the source of lead poisoning. Combing the common causes of lead poisoning and living habit of the patient, we focused on a set of cosmetics without trademark. She have used the cosmetics for more than half a year and got a very good whitening effect. We test the lead content of this cosmetic and found that the lead concentration was 65.3mg/kg, which was higher than the national safety standard significantly. Therefore, we thought this set of cosmetics was the cause of lead poisoning. She stopped using this set of cosmetics immediately.",
    "summary": "A 31-year-old woman presented with epigastric discomfort without any obvious cause. The patient was diagnosed with lead poisoning, as the blood levels of heavy metals were detected and the lead was 463.17 µg/L, which was very high (normal value was less than 100 µg/L). The patient was treated with intravenous drip of calcium sodium edentate and got better. The patient achieved good recovery and there was no recurrence."
  },
  {
    "id": "multiclinsum_gs_en_129.txt",
    "fulltext": "Patient presentation: This is a 37-year-old female patient who presented with a mixed dysphagia of gradual onset in the context of weight loss and altered general condition. The history was unremarkable. The evolution was marked by a progressive worsening of inspiratory dyspnoea. The patient presented with laryngeal dyspnoea which led to an emergency tracheotomy.\n\nClinical findings: the general clinical examination found a patient well oriented in time and space, with a stable haemodynamic state. The ENT examination revealed a right parapharyngeal mass that almost completely filled the pharyngeal lumen and obstructed the upper airway.\n\nTimeline: After the clinical examination, the patient underwent a cervical MRI and a biopsy of the parapharyngeal mass under local anaesthesia. The pathological examination of the biopsy led to the performance of a thoraco-abdomino-pelvic tomodensitometry (TDM) and bone scintigraphy.\n\nDiagnostic approach: MRI of the cervical region showed a tumour process in the right parapharyngeal space bulging into the pharynx with a T2 hyper signal with diffusion restriction and enhancement after gadolinium injection. It measures 47 x 40 x 50 mm. The tumour occupies almost the entire pharyngeal lumen and invades the upper palatal arch. The latter is swollen with areas of necrosis. A biopsy of the mass with histopathological examination showed basophilic round tumour cells. The immunohistochemical study was positive for CD99, anti-S100 antibodies and Ki67. In addition, a cytogenetic study was performed on the sample to look for a EWS/FLI1 translocation, which was positive. The final pathological result concluded that it was an extraosseous Ewing sarcoma of the parapharyngeal space. The extension assessment was negative.\n\nTherapeutic intervention: the patient was referred to oncology for first-line chemotherapy with vincristine, ifosfamide, doxorubicin and etoposide.\n\nFollow-up and results of therapeutic interventions: after 6 courses of chemotherapy, the progression of the tumour continued and the patient died due to the extension of the disease to the base of the skull.\n",
    "summary": "We report the clinical case of a 37-year-old female patient who was admitted as an emergency for inspiratory dyspnoea in a picture of asthenia and anorexia. The cervical magnetic resonance imaging (MRI) objectified a process that was obstructing almost the entire pharyngeal lumen. The anatomopathological, immunohistochemical and cytogenetic study concluded that it was an extraskeletal Ewing sarcoma. The extension assessment was negative. The patient received chemotherapy.\n"
  },
  {
    "id": "multiclinsum_gs_en_245.txt",
    "fulltext": "The patient was a 48-year-old man with no prior history of hierarchy, referred from a low complexity center for the study and treatment of pulmonary tumors. The chest radiograph showed a single radiopaque lesion in the right pulmonary field, in relation to the hilum. The computed tomography scan showed a compromise of the posterior segments of the lower right lobe. The clinical and imaging study ruled out the compromise of other organs, so it was decided to perform a lower right lobectomy with lymph node emptying. The intraoperative diagnosis of the surgical piece was of a poorly differentiated neoplastic lesion. The surgical piece showed a solid tumor lesion with irregular edges, hard-firm consistency and whitish tone, 7 cm in major diameter, compromising the pulmonary hilum and visceral pleura. Five hiliar lymph nodes were received without macroscopic alterations. The microscopic study revealed a neoplastic malignant lesion, consisting of primitive mesenchymal cells that acquired abundant acidophilic cytoplasm, eccentric nuclei and occasional cytoplasmic striations. The mitotic count was 10-15/10 high magnification fields, and necrosis foci were observed. The lymph nodes did not show tumor compromise. Among the differential diagnoses raised, we can mention: large cell carcinoma with rhabdoid findings, carcinosarcoma and mainly soft tissue metastatic sarcomas. In order to define the lineage, immunohistochemical studies were performed, the results of which were: desmin, muscle-specific actin, myogenin, vimentin and S100 positive, cytokeratins, CD34, smooth muscle actin and TTF1 negative. The histological image added to the immunohistochemical profile allowed the diagnosis of embryonic rhabdomyosarcoma. In view of the need to define the primary or metastatic origin of the pulmonary lesion, the patient was studied by various imaging techniques. Taking into account that they did not reveal tumor lesions in other organs, the neoplasia was considered a primitive pulmonary rhabdomyosarcoma (AJCC) pT2b pn0 pMx; IRSG staging: Clinical Stage 3+ Clinical Group Ib: Low Risk Clinical Group. The patient initiated chemotherapy (carboplatin + etoposide). Three months after the surgery, a tumor mass was identified in the upper right lobe. A right pneumonectomy was performed. The surgical piece presented a 5 cm diameter nodule in relation to the hilum, with histomorphological and immunohistochemical findings similar to those previously described. The patient continued with the chemotherapy cycles, and in a clinical follow-up at 11 months of the original surgery, a tumor lesion was detected in the right adrenal gland. The cytological study demonstrated the presence of atypical elements with an immunohistochemical profile similar to that obtained in the pulmonary tumor, so the lesion was interpreted as a secondary adrenal rhabdomyosarcoma. The patient continued with chemotherapy, during which he developed intercurrent infections, and died 20 months after the first surgery.\n",
    "summary": "A 48-year-old male with a pulmonary tumour was presented. Histological examination revealed a primary pulmonary embryonal rhabdomyosarcoma. Given the absence of tumour lesions elsewhere, it was classified as primary pulmonary. The patient received chemotherapy and underwent a pneumonectomy for recurrence of the neoplasm. One year after the initial surgery, he presented a metastasis in the right adrenal gland. He died 20 months after the original diagnosis.\n"
  },
  {
    "id": "multiclinsum_gs_en_184.txt",
    "fulltext": "10-year-old female patient with no family history of thyroid disease, who had a goiter diagnosed at the age of 9 years (thyroid ultrasound with compatible signs of chronic thyroiditis) and had positive antithyroid antibodies. She was not being treated at the time of admission. She presented with 5 days of foamy urine associated with abdominal pain, profuse vomiting and diarrhea. She had developed eyelid and limb edema, decreased diuresis, weakness and a fever of 38° C the day before admission. She presented with bilateral and pretibial eyelid edema, an obvious goiter (painless and without palpable nodules) and a systolic ejection murmur in the IV/VI pulmonary focus without irradiation. The rest of the examination was normal. Blood pressure 120/78 mmHg (95th percentile), temperature 38.1° C, weight: 33.9 kg, height: 131.5 cm (p7), BMI 19.8 (p83).\n\nThe admission tests included a complete urine test with proteinuria +++, no bacteria, no nitrites, 7 leukocytes/uL (VN: 0-10 leukocytes/uL), 4 leukocytes/uL (VN: 0-15 leukocytes/uL), protein/creatinine ratio (IPC) 2 mg/mg, total protein of 3.8 g/dL, hypoalbuminemia of 2.1 g/dL, hypercholesterolemia of 416 mg/dL, hypertriglyceridemia of 127 mg/dL and plasma creatinine of 0.46 mg/dL (creatinine clearance calculated by Schwartz formula: 125 ml/min/1.73 m2). Venous gases, plasma electrolytes and blood counts were within normal ranges. The immunological study included: immunoglobulin A 181 mg/dL (VN 45-236), immunoglobulin M 131 mg/dL (VN 52-242), immunoglobulin G 208 (VN 608-1572) mg/dL, C3 125 mg/dL (VN 80-150), C4 37.3 mg/dL (VN 12-36). Normal renal ultrasound. The patient was admitted with a diagnosis of SN and autoimmune thyroiditis.\n\nIn the context of NS, treatment with prednisone (60 mg/m2/day) was initiated with a good response, achieving melting of edema and a progressive decrease in proteinuria until normal ranges were reached prior to discharge (IPC of discharge: 0.09, after 6 days).\n\nFrom the thyroid function point of view, his study showed thyroid stimulating hormone (TSH) 4.4 IU/ml (VN: 0.67-4.16 IU/ml), free thyroxine (T4) 0.80 ng/dL (VN: 0.86-1.4 ng/dL), antiperoxidase antibodies (Anti Tpo) 120 U/ml (VN: 0-60 U/ml), antithyroglobulin antibodies (Anti-Tg) 82 U/ml (VN: 0-60 U/ ml), so replacement therapy with levothyroxine (25 mcg/day) was initiated. Thyroid ultrasound described normal size thyroid with mild increase of diffuse vascularisation to Doppler, without solid or cystic focal lesions, these findings suggestive of thyroiditis. Rest of the study (PCR for SARS CoV-2, anti neutrophil cytoplasmic antibodies, anti nuclear antibodies, anti DNA antibodies, anti streptolysin O antibodies, anti cardiolipin antibodies, anti myeloperoxidase antibodies and anti proteinase 3 antibodies) was negative.\n\nThe patient was in good condition 6 days after admission and was discharged with prednisone (60 mg daily) and levothyroxine (25 mcg daily). At the 12-month follow-up, the patient was asymptomatic, with her thyroid disease under control (TSH 1.11 IU/ml) with replacement treatment. She has not had a relapse of the NS (urine examination without proteinuria and creatinine 0.44 mg/dL).\n",
    "summary": "10-year-old patient presenting with nephrotic syndrome and goiter. There was a history of autoimmune thyroiditis and untreated hypothyroidism. Corticosteroid and thyroid replacement therapy (levothyroxine) was initiated, with a good clinical and laboratory response.\n"
  },
  {
    "id": "multiclinsum_gs_en_403.txt",
    "fulltext": "A 25-year-old Ethiopian girl presented to the Emergency Department of St. Paul's Hospital Millennium Medical College, Addis Ababa, with a history of progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitation, and easy fatigabilityof two weeks duration. She had no history of fever, loss of appetite, weight loss or sweating. There was no history of hypertension, diabetes mellitus, dyslipidemia, kidney disease, smokingor any cardiac illness in the family.\n\nOn general examination, she was acutely sick-looking, and had blood pressure of 90/60 mmHg and regular heart rate of 96 beats per minute. On respiratory examination, there was bilateral fine crepitation and reduced air entry on both the lower one-third lung fields. The cardiovascular evaluation revealed elevated jugular venous pressure,displaced apical impulse, soft S1, and grade 4/6holo-systolic murmur at the apex that radiated to the left axilla. There was also grade 2 pan-systolic murmur at the left lower sternal border which increased in intensity during inspiration.\n\nLaboratory examination showed white cell count 13,500/ µL, hemoglobin 12.5 g/dl, and ESR 15mm/1sthr. Liver, renal and thyroid function tests were normal. Abdominal ultrasound study was also normal. Chest x-ray showed cardiomegaly, grade 2 pulmonary edema, and bilateral pleural effusion. Electrocardiogram showed normal sinus rhythm and trans-thoracic echocardiogram revealed 4.0 cm by 3.9 cm single submitral aneurysm on the posterolateral wall of the left ventricle. The patient also had severe eccentric mitral valve regurgitationand dilated left atrium and left ventricle. There was also mild left ventricular systolic dysfunction with an ejection fraction of about 40%, organized thrombus inside the aneurysm and mild tricuspid regurgitation. Due to lack of other diagnostic facilities and definitive surgical treatment in the country, the patient was managed with furosemide, enalapril, metoprolol, and warfarin. Moreover, she could not afford treatment abroad. After three months of medical management with the above medications, she had improvement of heart failure symptoms and resolution of the left ventricular thrombus. However, there was persistent severe mitral regurgitation and submitral aneurysm.",
    "summary": "In April 2017, a 25-year-old patient havingsubmitral left ventricular aneurysm with New York Heart Association (NYHA) class IV heart failure and mild left ventricular systolic dysfunctionreceived medical treatment at our institution. She had severe mitral regurgitation and aneurysmal thrombus. The diagnosis was easily made using GE Vivid E9 transthoracic echocardiography. She was given drugs for management of heart failure and anticoagulation.\n\nOur patient was discharged with a stable condition, and she had no early mortality. At 3 months' follow-up,shehad clinical improvement with NYHA class II heart failure, slight improvement of left ventricular systolic function, and resolution of the left ventricular thrombus. However, there waspersistent severe mitral regurgitation and aneurysm."
  },
  {
    "id": "multiclinsum_gs_en_414.txt",
    "fulltext": "We present a case of extensive calcified neurocysticercosis in an asymptomatic 47-year-old male living with HIV. The patient was recruited through the CYSTINET-Africa study in January 2021. In this study, people living with HIV (PLHIV) attending HIV Care and Treatment Centers (CTC) clinics in Chunya and Tossamaganga (southern highlands of Tanzania) were offered serological testing for T. solium cysticercosis. If results were positive (but also for a subset of serological negatives), patients were offered a CT scan. For every PLHIV, also an HIV-negative control (matched by age, sex, and location of residence) was recruited to compare the accuracy of the serological test and NCC disease presentation between HIV-positive and negative persons. The patient we presented was recruited through the HIV care and treatment center clinic in Chunya.\n\nIn 2012, he was diagnosed with HIV. His CD4 count at diagnosis was 31 cells per cubic millimeter of blood, and he was categorized as in WHO stage II. Immediately after diagnosis and complete medical assessment, he was started on antiretroviral therapy consisting of Azidothymidine (AZT) + Lamivudine (3TC) + Efavirenz (EFZ) on the 3rd April 2012. In 2017, he was changed to another ARV drug combination ie, started on a new drug combination consisting of Tenofovir disoproxil fumarate (TDF) +3TC+EFZ; this was due to the changes in the national guidelines in the first-line ARV treatment. Six months after the initiation (TDF +3TC+EFZ) combination, his viral load was undetectable. On the 5th of August 2019, his antiretroviral treatment regime was again changed into Tenofovir disoproxil fumarate (TDF) + Lamivudine (3TC) + DTG (Dolutegravir) to avoid different side effects experienced from the regime he was using. His viral load was undetectable and remained undetectable in all subsequent viral load tests in 2018, 2020, and 2021.\n\nSerological testing for T. solium was positive for cysticercosis antibodies using the LDBIO Cysticercosis IgG Western Blot test, but negative for cysticercosis antigen by the apDia Cysticercosis Antigen (Ag) ELISA test. The cerebral CT scan examination was performed at Mbeya consultant hospital on 5 November 2021. The patient was examined neurologically on the day of the CT scan, and an in-depth history was taken.\n\nPersonal History, Risk Factors, and History of the Risk Factors for the Taenia Solium Infection\nThis patient has been an artisanal miner (small-scale gold mining worker) since 2010, with a history of keeping pigs from 2009 to 2019. He has been married with 4 children; screening of the family members for T. solium infection was done, and the patient denied anyone in the family having neurological signs and symptoms of NCC (ie severe progressive headache and epileptic seizures). The patient reported known risk factors for T. solium infection, such as eating pork and never boiling water. He reported always using the pit latrine at his home and regular handwashing after the toilet and before eating.\n\nMedical History of Taenia Solium Infection and Neurological Examination\nThe patient denied having experienced any loss of consciousnessor involuntary movements of limbs or having been diagnosed with epilepsy. Any episodes of severe progressive headache, mental state alterations, or other signs/symptoms that could be associated with NCC (or taeniasis) were also denied. The overall physical examination was normal, the patient looked healthy, not pale, not jaundiced and there were no palpable nodules (head/neck, trunk, and extremities). The examination did not reveal any focal neurological deficit.\n\nFundoscopic Examination\nThe patient’s red reflex was normal, blood vessels were normal, and macular reflex was normal. The optic nerve and disc appeared normal, vitreous body, and choroid. No floaters were detected.\n\nChest X-Ray Examinations\nCardiac shadow was normal in size and configuration, and both lung fields and costophrenic angles were clear. No focal pulmonary lesion was seen with the intact bony thorax. Therefore, the chest radiograph was classified as normal.\n\nComputerized Tomographic (CT) Scan Examination of the Brain\nTechnique\nContinuous axial cuts were obtained through the skull with intravenous contrast. Multiple calcifications typical for neurocysticercosis were seen in the cerebral parenchyma, basal ganglia, and cerebellum. Bilateral orbital calcifications and calcifications involving the skin, soft palate, oropharynx, and skull base soft tissue were noted. No midline shift was observed. The features were suggestive of diffuse inyracranial and extracranial calcifications.\n\nImpression\nFeatures were suggestive of diffuse intracranial and extracranial calcification.",
    "summary": "A 47-year-old male African patient was recruited in the CYSTINET Africa study at Chunya District Hospital, Mbeya. He was an artisan and has been living with HIV since 2012, and he has been compliant with antiretroviral treatment, hence with undetectable viral load during 2018, 2020, and 2021. Taenia solium serology was done by LDBIO Cysticercosis IgG Western Blot test, which tested positive for antibodies, but the apDia Cysticercosis Antigen (Ag) ELISA antigen test was negative. His computed tomography (CT) scan of the brain showed approximately 138 calcified neurocysticercosis typical lesions, 108 being located in the parenchyma, 15 in the extra parenchyma, and 15 in the subarachnoid space, consistent with a diagnosis of extensive calcified NCC. He reported no history of headaches or epileptic seizures. Neurological examination did not reveal any deficit."
  },
  {
    "id": "multiclinsum_gs_en_255.txt",
    "fulltext": "Female patient, 12 years old, diagnosed with cytotoxic T lymphocyte antigen 4 (CTLA-4) deficiency. She had a history of recurrent sinusitis, otitis media and tonsillitis since the age of 3. Between the ages of 7 and 9, the patient had recurrent episodes of autoimmune haemolytic anaemia and an episode of immune thrombocytopenia. Since the diagnosis of primary immunodeficiency (PID) with hypogamaglobulinemia at the age of 9, she received IVIG infusion every 3 weeks and antimicrobial prophylaxis with sulphamethoxazole-trimethoprim.\n\nAt 10 years of age, the patient developed granulomatous-lymphocytic interstitial lung disease (GLILD), a non-infectious pulmonary complication, for which she received treatment with rituximab and mycophenolate mofetil. A few months after discontinuing immunosuppressive therapy, the patient developed fungal pneumonia.\n\nIn the sixth week of treatment with voriconazole for pulmonary infection with Aspergillus sp, the patient was hospitalized to receive a regular dose of IVIG (580 mg/kg), but the product available (3%, Sandoglobulin®, CSL Behring, lot 4302500091) was different from that used in previous infusions. Physical examination was normal, with 95% oxygen saturation (SatO2) at room temperature. Laboratory tests performed on the same day showed normal renal function. The IVIG infusion began at 1 ml/kg/hour, and the infusion rate was increased every 30 minutes, until it reached 6.7 ml/kg/h. The patient received a total of 600 ml of the immunoglobulin solution (concentration 3%), and remained without symptoms during the infusion.\n\nAbout 30 minutes after the end of the administration, the patient reported increased dyspnoea and had bilateral rales on auscultation, hypoxaemia (SatO2 of 88% to 89% at room temperature), respiratory rate of 28bpm, heart rate of 125bpm, blood pressure of 114x68mmHg, axillary temperature of 37.1°C, with no other symptoms or signs. Non-invasive oxygen support at an inspired oxygen fraction of 50% was offered, resulting in SatO2 of 99%, and the patient was transferred to the emergency unit. The chest radiograph showed signs of bilateral diffuse infiltrate, mostly at the base of the lungs, with normal cardiac silhouette.\n\nThe patient received a single dose of intravenous furosemide (0.5 mg/kg) due to the initial hypothesis of volume overload. The echocardiogram did not show signs of abnormality, with an ejection fraction of 79%. The patient did not demonstrate other signs of congestion. After 24 hours, she presented SatO2>93% in ambient air, without other complaints, and, after 36 hours of the event, remained asymptomatic and was discharged from hospital.\n\nAfter 3 weeks, the patient received IVIG infusion with the same product as used prior to the reaction without adverse effects. One year after the adverse effect was reported, the patient continues on regular IVIG replacement without further complications.\n",
    "summary": "Case report of a patient with immunodeficiency who required regular intravenous immunoglobulin replacement. She presented an episode of acute pulmonary injury related to transfusion after use of an immunoglobulin product different from the one she received habitually. She developed respiratory changes (hypoxia, dyspnea and altered pulmonary auscultation) minutes after the end of the infusion, requiring non-invasive respiratory support. The patient was discharged from hospital after 36 hours, with a good evolution. She recovered fully from the symptoms, without further reactions to subsequent infusions of immunoglobulin (and it was decided not to prescribe the product that was used when the episode of acute pulmonary injury related to transfusion occurred).\n"
  },
  {
    "id": "multiclinsum_gs_en_404.txt",
    "fulltext": "A 66-year-old male known to have diabetes mellitus type II, chronic obstructive airway disease, and hypertension presented to the emergency department with severe retrosternal chest pain and progressive shortness of breath. His physical examination was unremarkable apart from oxygen saturation of 91–92% on room air, BP 220/120 mmHg, and tachycardia with a pulse rate of 120 beats/minute.\n\nInitial work-up prior to intervention showed Hb 14.7 g/dL, platelet 229 × 109/L, troponin 309 ng/mL, PTT 32 seconds, and creatinine 0.9 mg/dL. Furthermore, the 4T-score of our patient was low; therefore, testing for a heparin-induced thrombocytopenia (HIT) antibody panel was not pursued. An electrocardiogram showed ST elevation in the anterior-lateral leads and reciprocal ST depression in the inferior ones. Further, an echocardiography showed a reduced ejection fraction of 45% and left anterior descending artery (LAD) territory hypokinesia. As a bridge to percutaneous coronary intervention (PCI), the patient received aspirin and beta-blockers as part of an initial anti-ischemic measure in addition to intravenous nitroglycerin to control hypertension.\n\nOn the coronary angiography prior to stent placement, total thrombotic occlusion of LAD at its midsegment was seen, along with 30% stenosis of the left circumflex artery (LCX) followed by subtotal occlusion after giving obtuse marginal artery. Therefore, balloon angioplasty was performed, and a drug-eluting stent was deployed. During the procedure, intravenous unfractionated heparin and a 180 mg loading dose of ticagrelor were given. The patient was to be maintained on ticagrelor plus aspirin; however, the platelet count 6 hours post procedure was done as per hospital protocol and revealed a platelet count of 70 × 109/L on two occasions with no active bleeding. The peripheral blood smear was unremarkable, and fragmented red blood cells could not be seen. Additionally, other laboratory parameters including hemoglobin and creatine were within normal ranges and comparable to the baseline line which makes the possibility of microangiopathic hemolytic anemia less likely. We attributed the platelet drop to ticagrelor. Therefore, an additional dose was withheld, and the patient was placed on both aspirin and clopidogrel instead twelve hours following the initial loading dose of ticagrelor. Fortunately, the patient’s platelet count recovered gradually, with complete resolution four days after the initial presentation, reaching 168 × 109/L without need for a blood component transfusion or other supportive measures, and he was discharged thereafter.",
    "summary": "A 66-year-old male known to have diabetes mellitus type II, chronic obstructive airway disease, and hypertension presented to the emergency department with retrosternal chest pain and dyspnea. Work-up on presentation showed Hb 14.7 g/dL, platelet 229 × 109/L, and troponin 309 ng/mL. The electrocardiogram showed ST elevation in the anterior-lateral leads. The patient underwent balloon angioplasty, and a drug-eluting stent was deployed. During the procedure, intravenous unfractionated heparin and a 180 mg loading dose of ticagrelor were given. Six hours post procedure, the platelet count was 70 × 109/L without active bleeding. Blood smear was unremarkable, and no schistocytes could be seen. So, ticagrelor was stopped, and the patient's platelet count completely recovered four days after discontinuation."
  },
  {
    "id": "multiclinsum_gs_en_99.txt",
    "fulltext": "21-year-old Brazilian national, resident in Portugal for two years, mason, admitted to the emergency department with polyarthralgia of an additive and symmetrical character involving large and medium joints, namely tibio-tarsi, knees, elbows and metacarpo-phalangeal, with two weeks of evolution. He reported fever with chills, asthenia, anorexia and night sweats. He denied headaches, odynophagia, abdominal pain, changes in urine or faeces characteristics, recent travel, risky sexual behaviours, consumption of handmade products, contact with wild animals, insect or tick bites. He denied a history of illness or usual therapy, reporting smoking habits and occasional consumption of cannabis. On admission he presented oriented, febrile, normotensive, eupnoeic, showing inflammatory signs and intense pain of the tibio-tarsi, knees, elbows and metacarpo-phalangeal joints, fluctuation of the interligamentous knee joint and signs of bilateral Aquilian enthesopathy. On neurological examination, the left foot was hanging down with asymmetrical decrease of muscular strength in dorsiflexion (grade 4/5), without other focal deficits, hypesthesia or peripheral nerve engorgement. There were prominent erythematous papules and plaques of circular conformation and well defined border, painful, with bubbles and central necrosis, without epidermal detachment (Nikolsky's sign), symmetrically distributed on the affected articular surfaces, namely knees and elbows. There were no ophthalmological changes, adenopathies or changes in anorectal examination. The study highlighted a sinus rhythm electrocardiogram, chest radiograph and abdominal ultrasound without changes and a transthoracic echocardiogram negative for endocarditis. Analytically, he presented leukocytosis 15.4 x 109 with neutrophilia 12,400 /mm3, elevated PCR (31.9 mg/dL) and hepatic cholestasis without hyperbilirubinaemia.\n\nThe viral serologies, autoimmunity, ACE and IGRA levels were only slightly elevated (73.47 mcg/L; N < 40 mcg/L) and rheumatoid factor (16U/mL; N < 14 U/mL). Dermatology was requested to collaborate, and a skin biopsy was performed for histopathological, immunofluorescence and microbiological studies. After taking blood cultures and urine cultures, empirical antibiotic therapy with ceftriaxone 2 g/day was initiated. After eight days of antibiotic therapy without significant clinical response, and considering the hypothesis of neutrophilic dermatosis (Sweet's syndrome), prednisolone 40 mg/day PO was initiated with favorable evolution, resolution of joint complaints and fever, significant improvement of inflammatory skin signs and residual scars and sustained reduction of inflammatory parameters. The biopsies performed on the tenth day of admission revealed intense inflammatory lymphohistiocytic infiltrate with non-caseous granulomas of perineural distribution and presence of acid-alcohol-resistant bacilli (ARAB). Nasal and auricular lymph exudate was examined by smear microscopy, which confirmed the presence of ARAB, establishing the diagnosis of leprosy, multibacillary form with immunological reaction type 2 (erythema nodosum leprosum). The patient was discharged on the seventeenth day of admission under oral corticosteroid therapy, and was referred to a specific dermatology consultation, and did not initiate antibacillary therapy due to abandonment of that consultation.\n",
    "summary": "We present the case of a 21-year-old man who presented to the emergency department with polyarthralgia of an additive character involving large joints, erythematous papules and plaques on the limbs with blisters and central necrosis and fever with chills of a week's duration. A skin biopsy was performed which revealed neutrophilic infiltrate with granulomas of perineural distribution and a smear was positive for acid-fast bacilli. The diagnosis of multibacillary leprosy with lepromatous reaction type 2 (erythema nodosum leprosum) was established and clinical improvement was observed with corticosteroid therapy.\n"
  },
  {
    "id": "multiclinsum_gs_en_231.txt",
    "fulltext": "65-year-old woman with no significant medical history who in 2004 initiated lancinating paroxysms in the right V2 and V3 territories with classic triggers, for which she was diagnosed with right trigeminal neuralgia. In the brain MRI scans up to 2021, the sequences that allow to identify if there is a neurovascular crossing were not performed. From the beginning, pain control with carboxamides was difficult. In 2021, she presented exacerbation of previous paroxysms that appeared in V1. The neuralgia became refractory, with no response to carboxamides and lamotrigine, and very little response to clonazepam, for which she required phenytoin and/or lidocaine infusions in severe exacerbations. Simultaneously, she initiated lancinating paroxysms in the posterior part of the tongue and the right lateral wall of the oropharynx, which were exacerbated with swallowing and which progressively increased in intensity and frequency. It was considered the beginning of a classic trigeminal neuralgia and glossopharyngeal neuralgia, concomitant and refractory. A double microvascular decompression in one time was considered the best therapeutic option.\n\nIn March 2021, a right retrosigmoid craniectomy was performed with exposure of the perimesencephalic cistern and the basal cisterns. The release of the fifth cranial nerve was performed, and a close contact with the superior cerebellar artery in its sensory part and thinning in the entrance area of the nerve root was observed. Teflon was placed between the superior cerebellar artery and the fifth cranial nerve along its entire length. Subsequently, the basal cistern was explored and a vascular loop of the anterior inferior cerebellar artery was observed in close contact with the fifth cranial nerve, where teflon and dural sealant were placed. The postoperative course was without incident, with complete resolution of the trigeminal neuralgia and a reduction of >50% of the intensity of the paroxysms in the glosso-pharyngeal territory. After two years, he continues without trigeminal paroxysms and presents <1 paroxysm/month of tolerable intensity in the glosso-pharyngeal territory triggered by swallowing. The pharmacological treatment continues in a descending pattern without the reappearance of the paroxysms.\n",
    "summary": "65-year-old woman with right NT (initially in V2-V3) since 2004 with regular control with carboxamides. Seventeen years later, paroxysms worsened in V2-V3, also appeared in V1 and in the territory of the right glossopharyngeal nerve (right ear and fossa amygdala when speaking and swallowing). The brain MRI showed significant arterial contact between the superior cerebellar artery (SCA) with origin of the right cranial pair V and the anterior inferior cerebellar artery (AICA) with origin of the right lower cranial pairs. Both cranial pairs were examined by MRI at the same surgical time by retrosigmoid craniotomy, and the release of the cranial pair V, in intimate contact with the SCA, and the cranial pair IX in contact with the right AICA was performed, for which teflon was placed between them. The patient had an immediate resolution of trigeminal paroxysms and a considerable improvement in intensity and frequency of glossopharyngeal paroxysms. Two years after the intervention, neuromodulatory treatment was continued with good response.\n"
  },
  {
    "id": "multiclinsum_gs_en_170.txt",
    "fulltext": "32-year-old female patient, farmer, admitted on 8 June 2022 for fever and altered consciousness. Her symptomatology was of progressive onset for about ten days, preceded by a permanent fever, headaches and vomiting. She appeared after a uterine revision in a Guinean health facility on 25 May 2022 for spontaneous abortion of a pregnancy of 18 weeks of amenorrhea. She was treated before admission for bacterial meningitis and suspected genital infection with ceftriaxone and metronidazole injections. She had no known medical-surgical history or notion of use of immunosuppressors. The physical examination of the patient objectified a body mass index (BMI) of 20.9 kg/m2 for a weight of 61 kg, a fever of 39.2°C, a SOFA (Sequential Organ Failure Assessment) score of 3 (1 for mean arterial pressure at 65 mmHg and 2 for the Glasgow score at 11/15), generalised tonic-clonic convulsions, meningal stiffness, right hemiplegia. There was a genital infection: purulent lochia, non-retracted pelvic uterus.\n\nA craniocerebral CT scan revealed a large range of hypodensity in the left hemisphere, enhanced by the contrast agent with a significant mass effect. The biochemical profile showed a capillary hypoglycaemia of 3.2 mmol/l, a creatinine clearance (CKDEPI formula) of 155.32 ml/min for a creatinine of 38.5 µmol/l, ALT transaminases of 58 Ul/l, and a blood group of O positive. The cerebrospinal fluid (CSF) examination showed a purulent fluid, a hyperleucocytopenia of 1,100/mm3 with a neutrophil predominance, a hypoglycorachia of 1.2 mmol/l, a hyperproteinaemia of 1.8 g/l, gram negative E. coli bacilli resistant to penicillin (amoxicillin, ampicillin, amoxicillin clavulanate), to carboxypenicillin (ticarcillin), to cephalosporins (ceftriaxone, cefixime, cephalotine, cefepime), to quinolones (ciprofloxacin, norfloxacin), to cyclic (tetracycline) and to cotrimoxazole.\n\nThe blood culture on aerobic medium and the examination of the vaginal sample isolated the same strain. The blood count showed severe anaemia (4.2 g/dl of haemoglobin), normocytic (VGM at 85.2 fl), normochromic (CCMH at 32.7 g/dl), regenerative (reticulocytes at 160 g/l), leukocytes at 8000/mm3 (neutrophils at 6200/mm3, lymphocytes at 1000/mm3) and platelets at 14000/µl. Two HIV serologies were negative, and the CD4 level was at 850 cells/mm3 of blood. The diagnosis of sepsis post abortum, complicated by meningococcal encephalitis and severe anaemia was then retained.\n\nShe was admitted on admission and was given amoxicillin-clavulanic acid 2 g every 8 hours and amikacin 1 g/day intravenous. On day 4, following the results of the antibiogram, treatment with meropenem was initiated at 2 g every 8 hours intravenous for 21 days. Severe anaemia was corrected by daily transfusion of 450 ml of isogroup-isoresus erythrocyte concentrate for 6 days. Hypoglycaemia was corrected by infusion of 500 ml of 10% glucose serum, convulsions by administration of diazepam. In addition, daily genital hygiene with chlorhexidine was performed for 5 days and physiotherapy on day 8 of meropenem treatment. The evolution was favourable, marked by apyrexia on day 4 of bi-antibiotic therapy, the amendment of convulsions, and the recovery of consciousness respectively on day 2 and 7 of meropenem treatment. The control haemoglobin returned to 11.9 g/ dl on day 7 of blood transfusion. The motor strength of the right limbs with deficits was measured at 1/5 and 3/5 respectively on day 7 and 4 of physiotherapy. Exeat was authorised on 5 July 2022, with physiotherapy in outpatient and an appointment fourteen days later. At this appointment, the evolution was globally favourable with a motor strength of the initially deficits limbs at 5/5.\n",
    "summary": "The first, who had recently miscarried, was on ceftriaxone when she was admitted for meningitic syndrome and pyramidal syndrome related to a brain injury. Cephalorachidian fluid (CSF), blood and a swab of purulent genital secretions were isolated E. coli resistant to penicillin and cephalosporins. She recovered on treatment with meropenem for 21 days, with few sequelae.\n"
  },
  {
    "id": "multiclinsum_gs_en_577.txt",
    "fulltext": "Patient information: he was a 17-year-old patient, a mechanic by profession, with no particular medical history, who had been stabbed in the back during a fight. He immediately presented with a sharp mid-thoracic pain without dyspnoea, cough or haemoptysis and a small amount of bleeding from the wound. He was transported to our facility as an emergency.\n\nClinical findings: On admission, at six hours of the trauma, the patient was stable neurologically, haemodynamically and respiratory. The conjunctival mucous membranes were discoloured. Locally, the examination had objectified a posterior thoracic linear wound of approximately 3 cm in length, in the right paravertebral area at the level of D4-D5, non-bleeding, without active bleeding, with visualisation of the end of the knife blade intra-thoracic. The pulmonary fields were free. The heart sounds were well perceived, regular, without additional noise, not deviated. The pulses were well perceived and symmetrical at all sites. There was no sensory or motor deficit in the upper and lower limbs.\n\nDiagnostic approach: the radiograph of the thorax from the front and profile showed the knife that passed through the thorax from back to front, from bottom to top and from left to right, with the point of entry in front of D5 and the tip just above the carina. There was no pneumomediastinum or mediastinal enlargement or pleural effusion. The thoracic scanner showed the foreign body at the right paraspinal entry point at the level of D5 with its distal end in front of the thoracic outlet without damage to the thoracic outlet. It passed over the heart, through the esophagus and trachea from back to front. There were also air bubbles in the mediastinum, a right pneumothorax with low abundance and a subcutaneous emphysema in front of the entry point. The preoperative assessment was without particularities apart from a hyperleucocytosis of 16100/mm3.\n\nTreatment: He was admitted to the operating theatre at 14 o'clock. Surgical exploration by right posterior lateral thoracotomy had revealed a knife about 15 cm long and 4 cm wide, passing through the thorax from back to front with its distal end at the level of the Barety's recess. It had caused a wound in the cross of the azygos vein, a right upper lobe pulmonary wound about 4 cm, a transfixing oesophageal wound with an oeso-tracheal fistula about 3 cm x 2 cm, just above the carina (between the anterior wall of the oesophagus and the posterior membranous wall of the trachea).\n\nThe foreign body was removed. The fistula was repaired by direct closure of the 2 tracheal and esophageal orifices with separate stitches in Monocryl 3/0: in 2 planes for the esophagus and in one plane for the trachea. A test with methylene blue through a naso-gastric tube and a test with SSI with air insufflation through the intubation tracheal tube allowed the seal of the sutures to be verified. A plastic covering of the tracheal and bronchial sutures with mediastinal pleura was performed. He also received a ligature of the azygos vein and a suture of the parenchymal wound. A thorough cleaning of the cavity was performed. A thoracic drain in a mediastinal position and another in the basal position as well as a naso-gastric tube were placed. A triple antibioprophylaxis with ceftriaxone, gentamycin and metronidazole was established for 10 days. A liquid and semi-liquid diet was started on day 2 post-operatively through the naso-gastric tube.\n\nEvolution: postoperative complications were simple with a chest X-ray at J1 and then at J4 showing a minimal right apical pneumothorax with a blunted costo-diaphragmatic cul-de-sac; the control esophagogastroduodenal transit (EGDT) at J14 did not find a residual fistula. The drains and naso-gastric tube were removed at J14 and oral feeding was started without incident. He was discharged at J14 with follow-up in outpatient care.\n\nFollow-up: at the last post-operative check at J45, he had no complaints, the physical examination was normal with a healed surgical wound and the chest X-ray was unremarkable.\n",
    "summary": "We report a case of a patient who developed a FOP after being stabbed in the back. He was admitted at 6 o'clock in the morning and complained of mid-thoracic pain. Examination revealed a right paravertebral wound with the knife blade intrathoracic. Imaging showed the blade passing through the upper mediastinum, a right hemopneumothorax and mediastinal air bubbles. Surgical exploration revealed a small FOP that was repaired by direct suturing of the tracheal and esophageal orifices with a plastic cover. Feeding was allowed on day 14 after a check that did not show any residual fistula. The postoperative course was simple.\n"
  },
  {
    "id": "multiclinsum_gs_en_480.txt",
    "fulltext": "A 36-year-old woman, gravida 2 para 1, with no significant medical history except for one prior low-transverse cesarean delivery at term for arrest of dilatation, presented at a gestational age of 24 weeks 5 days for preterm premature rupture of membranes (PPROM) and chorioamnionitis. She underwent an emergent classical cesarean delivery due to non-reassuring fetal heart tones within 1 h of admission. Placental abruption and Couvelaire uterus were diagnosed intraoperatively, with the fetus and anterior placenta delivered en caul. Pathologic examination of the placenta indicated “abnormal placental separation” and ascending infection. She completed standard antibiotic therapy with ampicillin 2 g every 6 h and gentamicin 5 mg/kg every 24 h for her intrauterine infection until she was afebrile for 24 h, and had an otherwise uncomplicated postpartum course with discharge home in good condition on postoperative day 3.\n\nShe presented again on postoperative day 16 complaining of severe lower abdominal pain and foul-smelling vaginal discharge and was evaluated by a new team of physicians. Upon presentation, her physical examination revealed a well-healed skin incision, no abdominal distention, and marked fundal tenderness. She was afebrile and normotensive and had a high-normal white blood cell count at 9.85 × 109/L (normal: 4.5–11.0 × 109). Her urinalysis and urine cultures were negative, and there was no other obvious source of abdominal pain. She was diagnosed with postpartum endometritis, admitted, and started on intravenous gentamycin and clindamycin. After 36 h of antibiotic therapy, her lower abdominal pain persisted and she continued to have abnormal dark vaginal discharge, so transvaginal and transabdominal ultrasound were performed to investigate for retained products of conception as a potential cause. The ultrasound demonstrated an ill-defined, infiltrating echogenicity extending from the anterior junctional zone into the subserosal myometrium that protruded into the endometrial canal proximally. The endometrial canal otherwise appeared unremarkable, without evidence of abnormal fluid or air. These findings were not felt to be consistent with endometrial infection, but rather with postsurgical changes. Because of the immediate clinical presentation, ultrasound findings, and the pathology report reading “abnormal placental separation”, initially there was concern for focal placenta accreta. However, the patient had not experienced significant vaginal bleeding and her placenta had delivered intact without difficulty – in fact, it had delivered en caul and the intrauterine cavity was cleared of clots and debris, and the mass seen on ultrasound was avascular, atypical for focally invasive placenta. Upon closer review of the complete pathology report, the “abnormal placental separation” appeared to describe premature placental separation rather than lack of separation, which was initially presumed. Serum quantitative beta-hCG was drawn and resulted at less than 1.5 milli-international units, below the limit of detection, and supportive of complete placental removal.\n\nBy hospital day four, pain and dark vaginal discharge persisted, despite normalization of the white blood cell count and continued absence of fever. Her prolonged clinical course with only subtle improvement with antibiotic therapy raised concern for myometrial necrosis, septic pelvic thrombophlebitis, or a non-gynecologic intraabdominal pathology such as appendicitis. Magnetic resonance imaging (MRI) with and without contrast was performed on post-operative day 20 to evaluate for these diagnoses. Therapeutic low-molecular weight heparin was initiated, and her antibiotic coverage was broadened with a plan to continue antibiotic therapy until 48 h without fever and with improvement in fundal tenderness. MRI revealed no evidence of septic pelvic thrombophlebitis but did show a large area of non-enhancement predominantly in the midline of the anterior myometrium, with a sharp posterior margin at the anterior junctional zone. This area revealed an infiltrating pattern of poorly defined T1 hyperintensity on the pre-contrast sequences that corresponded with the area of ill-defined avascular echogenicity seen on the prior ultrasound. Such an appearance is not typical for focal accreta which typically appears as an infiltrating mass-like process with areas of internal vascularity. Non-enhancing T1 hyperintensity involving the previously retroplacental myometrium indicates blood products in this clinical context, and imaging findings were hence considered consistent with a large, dissecting anterior intramural hematoma, likely related to Couvelaire uterus or postsurgical changes following classical cesarean delivery. Myometrial necrosis was considered due to the lack of enhancement in the affected anterior myometrium, which is an expected finding in a recent hematoma. There was no evidence of extra-serosal extension of the hematoma and no hemoperitoneum was identified. A contrast-enhanced computed tomography (CT) of the abdomen and pelvis was performed the same day because the MRI showed trace fluid around the cecum and appendix, which was concerning for an inflammatory process. On CT the appendix was unremarkable and these findings were ultimately thought to be consistent with a susceptibility artifact. The CT images also showed a large, relatively hypodense area in the anterior myometrium that corresponded with the same area of abnormality on ultrasound and MRI. On correlation with the intraoperative observations, the findings on multimodality imaging of a large dissecting anterior intramural hematoma were ruled most consistent with the diagnosis of Couvelaire uterus.\n\nBy hospital day six, the patient’s pain markedly improved, her vital signs and laboratory findings normalized, and she was discharged home with oral clindamycin to complete a ten-day course of antibiotics, in case of infection of the intramural hematoma. A follow-up MRI performed 2 weeks after the initial study showed interval evolution of the hematoma, without evidence of infection or abscess formation in the anterior myometrium.",
    "summary": "In this report, we discuss the case of a multipara who presented with abdominal pain and vaginal discharge several days after a classical cesarean delivery. Her prolonged and complex clinical course led to evaluation via several radiologic modalities. At first, a focal placenta accreta or retained products of conception were suspected, however these diagnoses did not correlate with the patient’s reported intraoperative findings of a clean endometrial cavity or with histopathology that was consistent with massive abruption."
  },
  {
    "id": "multiclinsum_gs_en_575.txt",
    "fulltext": "Our patient is a 21-year-old G1P0 female with genetic testing confirmatory of SCD. Both parents were found to be carriers. She arrived at the obstetric service at 31-weeks gestation, citing difficulty in obtaining prenatal care due to her recent arrival to the U.S. and the COVID-19 pandemic. She was born without a shoulder blade and six missing ribs on her left side. In childhood, she had two spinal surgeries including a cervical spine fusion and an attempted correction of kyphoscoliosis at the ages of 1 and 13, respectively.\n\nThe obstetrics team arranged for consultations with pulmonology and anesthesiology. A new chest x-ray revealed a displaced left scapula and diaphragm, along with findings consistent with left lung hypoplasia. The patient had a baseline oxygen saturation of 94% and remained at this saturation throughout her third trimester office visits. She reported a history of recurrent pulmonary infections, with her most recent hospitalization for pneumonia occurring at 7-weeks gestation, but denied any active infections since then. The patient’s spirometry results were consistent with a severely restricted lung disease pattern with FEV1 28% of predicted value, FVC 29% of predicted value, and FEV1/FVC 98% of predicted value. The results of the echocardiogram were grossly normal, with an ejection fraction of 60%, minimal mitral and tricuspid valve regurgitation, and no evidence of right-heart strain.\n\nDuring the anesthesiology consultation, it was noted that the patient had spinal deformities with disproportionate shoulders and a severely limited range of motion around the neck. Examination of the lumbar region revealed a surgical scar that extended downwards to the L1-L2 level. The patient reported having chronic back pain pre-dating the pregnancy and that she had been taking oxycodone/acetaminophen (Percocet) for the past several years. Her airway examination was notable for a Mallampati-2 score, > 3 finger-breadths thyromental distance, and adequate mouth opening. The patient’s height was 155 cm and her body mass index was 24.6 kg/m2. There were no anesthetic records available from her previous spine surgeries discussing airway management.\n\nThe patient went into latent labor at 37-weeks gestation, presenting with minimal cervical change, irregular contractions, and intact membranes. She was not able to obtain her outpatient MRI in time. At the time of presentation, the patient denied any respiratory complaints. A focused cervical and lumbar MRI (excluding the thoracic region for expediency) was obtained while the patient was still in latent labor to assure that there were no findings that might preclude neuraxial analgesia for labor. MRI of the cervical spine was significant for vertebral body fusion from C7-T6 and multilevel degenerative changes. A disc osteophyte was identified at the C4-C5 level causing mild spinal canal stenosis and indentation of the spinal cord. MRI of the lumbar spine confirmed the presence of surgical rods extending to L2. It was otherwise unremarkable, with no significant spinal canal or neural foraminal stenosis. The thecal sac ended at the level of the L5 vertebral body, and the conus medullaris ended near the L2–L3 interspace.\n\nIt was determined that the patient was at her baseline functional status therefore she could attempt a trial of labor, with the possibility of an assisted second stage if there was any change in her functional status. Difficult airway equipment, including a C-MAC fiberoptic scope, was prepared in a dedicated operating room. An ENT specialist was on standby in case a surgical airway was needed. The patient’s cervical exam indicated 4 cm of cervical dilation, 80% cervical effacement, and a score of -3 for fetal station. She experienced regular contractions every six minutes upon return from the MRI. The placenta was left-lateral and the fetal heart rate tracing was category I at this time. An amniotomy was performed and a fetal scalp electrode was placed for better fetal monitoring during the labor epidural placement.\n\nThe patient required additional positioning maneuvers to be seated for the epidural placement. Following recommendations for parturients with scoliosis, the doctors focused on maximally flexing the spine, to widen the interspinous spaces and align the iliac crests as effectively as possible. During standard epidural positioning, multiple adjustments were needed to minimize her pain and discomfort. The anesthesiologist first attempted a traditional midline approach for labor epidural anesthesia. A dural puncture with a Gertie-Marx spinal needle was attempted but there was no return of cerebrospinal fluid (CSF) following a loss of resistance to air injection. The anesthesiologist then attempted a paramedian approach, positioning the needle 1–2 cm lateral to the spinal process on the convex side of the spinal curvature. A 9 cm epidural Tuohy needle was re-positioned and another attempt was made but there was no return of CSF. At this time, the anesthesiologist decided to thread the catheter and carefully assess analgesia with a slow load of 10 ml of 0.25% bupivacaine. The needle insertion depth was 6 cm, the catheter type was multiport 19G, and the catheter at skin depth was 11 cm.\n\nWithin twenty minutes of administration of the epidural, the patient was insensate to ice to the level of T9 and bilateral analgesic block was achieved. Her analgesia scores were 9 out of 10 prior to the epidural and 1 out of 10 within 15 min of the loading dose. She did not require any epidural “top-offs” (additional doses of medication through the catheter). Epidural analgesia was maintained with an injection of fentanyl preservative-free 100MCG through the epidural and a continuous infusion of 0.0625% bupivacaine combined with 2 mcg of fentanyl per mL.\n\nThe patient progressed to full dilation within two hours without the need for oxytocin augmentation and had a successful spontaneous vaginal delivery after twenty minutes of pushing unassisted. The newborn male weighed 2.565 kg and had an Apgar score of 9 at one and five minutes. The umbilical vein pH was 7.26. Approximately 2.5 h after delivery, a post-anesthesia evaluation was performed. The patient was awake and alert with no anesthetic complications. She was hemodynamically stable and breathing spontaneously without the need for assisted ventilation. 9 h post-delivery, the patient was in a stable condition with no headache or neurological issues. She was ambulating with no deficits. The patient had an uneventful hospital course and was discharged on postpartum day 2.",
    "summary": "The patient is a 21-year-old woman with JLS, spondylocostal dysostosis (SCD) subtype, who went through a full-term vaginal delivery with labor neuraxial analgesia. This case report details a successful trial of labor and delivery, which was permitted after an extensive testing of her baseline functional status, as well as a review of the difficulties present in the provision of both neuraxial and general anesthesia. There was an emphasis on multidisciplinary collaboration and planning throughout the patient's peripartum course."
  },
  {
    "id": "multiclinsum_gs_en_451.txt",
    "fulltext": "A 13-year-old otherwise healthy male sustained an injury after falling. Upon initial assessment by emergency services personnel, the patient exhibited signs of hypoxia and shock. Consequently, he was intubated, a chest tube was placed on the left side, and he received an intravenous bolus of tranexamic acid from a helicopter emergency medical service. Radiography revealed a large bilateral pulmonary contusion and left femoral fracture. Enhanced computed tomography (CT) revealed a thoracic aortic injury with a pseudoaneurysm (SVS grade III), in addition to multiple thoracic vertebral fractures with extravasation and bilateral pulmonary contusions. The pseudoaneurysm was situated at the aortic isthmus 8 mm distal to the left subclavian artery.\n\nAfter initial fluid resuscitation and blood pressure control, his oxygenation level decreased to P/F 140 (FiO2: 0.8). As we suspected pulmonary contusion progression, venovenous extracorporeal membrane oxygenation (VV-ECMO) was considered, and ECMO catheters were inserted into the internal jugular and common femoral veins before TEVAR. The patient was 163 cm tall, weighed 48 kg, and had a body surface area of 1.5 m [2] (estimated using the Du Bois formula). The native proximal aortic diameter was 15 mm; we chose a 21-mm diameter stent graft (TAG TGM212110J; Gore, Arizona, US), as it was the smallest device available at the time. Because of the small diameter of the common femoral arteries on both sides (4 mm), we approached the left common iliac artery (8 mm) under laparotomy. In addition, the proximal landing zone of the stent graft on the thoracic pseudoaneurysm was relatively short (8 mm). To prevent endoleaks, the pseudoaneurysm was filled with a 33% mixture of n-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) and iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France) after stent graft deployment. The final stent graft diameter was 15 mm. The patient was postoperatively admitted to the ICU. Subsequent CT scans performed on postoperative days (POD) 3 and 25 revealed no endoleaks, resolution of the mediastinal hematoma, distal migration of the stent graft, or other postoperative complications.\n\nA heparin-coated circuit was used for VV-ECMO; anticoagulants were not used immediately after induction because of the risk of bleeding. Unfractionated heparin was initiated on POD 2, with a target activated clotting time of 140–180 s. However, heparin was discontinued owing to worsening of the left hemothorax on POD 3; subsequently, open chest hemostasis and temporary chest closure were performed. Nonetheless, on POD 5, the ECMO circuit was occluded twice, and heparin administration was resumed. A left hemothorax reoperation was performed, and the thoracotomy was closed on POD 7, after which the patient was on stable VV-ECMO with unfractionated heparin at 10,000 units/day. The patient was weaned off VV-ECMO on POD 16 and discharged on POD 110.",
    "summary": "We report a case of TEVAR for BTAI performed under laparotomy with n-butyl-2-cyanoacrylate (NBCA) injection in an adolescent patient. The patient was a 13-year-old male who sustained injuries due to a fall and presented with severe hypoxia and shock on admission. Computed tomography (CT) showed a thoracic aortic injury with a pseudoaneurysm (SVS grade III) and bilateral pulmonary contusions. We planned to perform TEVAR after venovenous extracorporeal membrane oxygenation (ECMO); however, because of the small diameters of the bilateral common femoral arteries, we placed a stent graft through the left common iliac artery under laparotomy. In addition, the proximal landing zone of the stent graft to the thoracic pseudoaneurysm was short, and we filled the pseudoaneurysm with NBCA after deploying the stent graft to prevent endoleaks. Subsequent CTs showed no endoleaks, and the patient was discharged on day 110."
  },
  {
    "id": "multiclinsum_gs_en_408.txt",
    "fulltext": "A 39-year-old pregnant Ethiopian refugee (Gravida 3 Para 2+0) was referred to our internal medicine emergency department at Gadarif Teaching Hospital, Gadarif State, Sudan, with progressive generalized body swelling, shortness of breath, and fatigability for 6 weeks and an unremarkable systemic review. The patient was admitted to the critical cases admission site and her history, taken with the help of a language interpreter later on admission, revealed an initially undisclosed remote episode of three unprovoked generalized tonic-clonic seizures 21 years ago which was treated traditionally. However, there was no history of head trauma or a family history of seizures. General examination of the patient has revealed a left-sided PWS involving the ophthalmic division of the trigeminal nerve. However, this finding was initially missed on inspection but later confirmed by the patient’s spouse to be present since birth. The patient was also severely pale and had bilateral pleural effusions, tender hepatomegaly, and bilateral lower limb swelling.\n\nInitial investigations revealed a hemoglobin level of 8.84 g/dl. Thus, heart failure due to anemia was diagnosed, and the patient was treated accordingly. However, eight days after admission, the patient had developed approximately six episodes of focal to bilateral tonic-clonic seizures that responded well to phenytoin but rendered the patient in a deep comatose state with a GCS of three. She was subsequently admitted to the intensive care unit (ICU) and a nasogastric tube was inserted to aid with her nutrition and drug administration. Moreover, to prevent further seizures, she was commenced on carbamazepine tablets 200 mg administered through the nasogastric tube.\n\nA non-contrast computed tomography (CT) scan of the brain was delayed to the day after stabilization because there was only a single CT scan machine in the state of Gadarif and it was operated intermittently due to the unavailability of a sufficient number of radiology technicians. The CT scan revealed cortical calcifications in the posterior part of the left parietal area raising the differential diagnosis of SWS. Consequently, a repeat physical examination was performed, which showed the presence of a faint left-sided red to purple colored flat lesion on her forehead and eye. Upon questioning her spouse, this lesion was confirmed to be present and unchanged since birth, which helped us rule out the diagnosis of a salmon patch because this lesion did not fade, thus it was diagnosed as a PWS. Additionally, she had no features of megalencephaly capillary malformation syndrome which usually includes a large head or brain size, joint problems, and capillary malformations on the skin. Moreover, the patient had no limb hypertrophy, lymphatic drainage abnormalities, or bone or soft-tissue outgrowths suggestive of Klippel-Trenaunay-Weber syndrome. Thus, based on the CT scan findings and the typical presentation, we concluded the diagnosis of SWS.\n\nTwo days after ICU admission, the patient experienced a fluctuating change in consciousness and a new-onset contralateral hemiparesis (contralateral to the PWS), as well as aphasia, and emotional lability. Unfortunately, four days after admission to the ICU, the patient started to experience vaginal bleeding; hence, the obstetrics and gynecology department was consulted, and the patient was found to have a non-viable pregnancy (28 weeks + 1 d), and an uneventful induction was performed. During the same period, she became combative and uncooperative, which led to physical restraining. Three days later, the patient developed new focal to bilateral seizures that started as facial myoclonic episodes, and after consultation with the neurology department, the patient’s dose of carbamazepine was increased to 1000 mg daily, which helped in preventing seizure recurrence. It is worth mentioning that in her second trimester, and before receiving the CT scan result, a diagnosis of eclampsia was explored, but her consistent blood pressure readings with an upper normal systolic blood pressure of 139 on most days and a diastolic pressure with a maximum of 97 mmHg and a low range of proteinuria, as well as the absence of systemic features such as renal or liver impairment, excluded this diagnosis. After reaching the diagnosis of SWS, a multidisciplinary team (MDT) approach was put into play; hence, an ophthalmology consultation was performed to exclude glaucoma. However, the patient was very irritable and difficult to perform a fundoscopy examination. Moreover, the patient was transferred to the internal medicine wards after stabilization.",
    "summary": "We report a 39-year-old, non-diabetic, non-hypertensive female refugee who presented initially with heart failure due to anemia for which she received blood transfusions. Later on admission, she developed multiple focal to bilateral seizures, severe irritability, aphasia, and right-sided hemiplegia, leading to admission to the ICU. A repeat medical history and examination revealed a faint left-sided ophthalmic port-wine stain that was initially unnoticed and a remote history of unprovoked seizures 20 years ago. Imaging revealed parietal calcifications and confirmed the diagnosis of SWS. Thus, a multidisciplinary approach was taken to fully understand the patient's diagnosis and determine a treatment strategy, involving consultations with the neurology, ophthalmology, otolaryngology, and physiotherapy departments. Successful seizure control was achieved by administering IV phenytoin for 3 days and the up-titrating of oral carbamazepine to 1g daily through a nasogastric tube. Unfortunately, due to the unavailability of personnel or resources, other important assessments for patients with SWS, such as advanced neuroimaging, psychiatric, plastic and neuro-surgery evaluations, as well as dentistry reviews, could not be conducted."
  },
  {
    "id": "multiclinsum_gs_en_454.txt",
    "fulltext": "Three days prior to admission, a 11-year-old girl complained about pain on the upper back her neck after her father accidentally fell on her neck during play. No specific pain location was noted, but the patient reported no radiating pain to her extremities. The pain was accompanied with weakness on the right upper and right lower limbs immediately after the accident. Although mobility on all extremities was preserved, there was a decrease in strength observed specifically on the right side, along with numbness and tingling on her right leg. There were no further complaints and she was still able to control her micturition and defecation. The patient was immediately brought to a local private hospital, where she was treated by a pediatrician and underwent Brain CT scan with normal result. Her injury was then managed as Guillain-Barre Syndrome (GBS) and received antibiotic, anticonvulsant, and neuroprotectant as medication. However, her condition did not improve after 2 days and she was finally referred to a tertiary hospital for further treatment. There was no remarkable past medical history.\nNo visible deformities were noted upon physical examination, but there was a midline tenderness on the back of her upper neck and paraspinal muscle spasm on the right side. ASIA Score showed decreased both sensory and motor function on the right side, but reflexes and autonomic function were within normal. Plain radiography did not show any abnormalities. However, CT-Scan revealed retrolisthesis of C2, causing canal stenosis on level VC1–2. MRI confirmed severe spinal stenosis on C2 level with spinal cord edema.\n\nPatient was finally diagnosed with incomplete spinal cord injury at the level of C2 AIS C with suspected anterior cord syndrome and odontoid fracture on C2 spine Anderson D'Alonzo type II. She then underwent posterior C1-C2 fusion using Modified Gallie Procedure and decompression. Patient was put in prone position and the exact location of the incision is identified using a C-arm. The dissection is carried down the midline through the subcutaneous tissue and the fascia to the tips of the spinous processes to decrease bleeding. The vertebra level was confirmed intra-operatively with fluoroscopy as soon as bony structures are visible, which was done prior to any further dissection. Self-retaining retractors are used to maintain tension on soft tissues during exposure. The paraspinal muscles are elevated subperiosteally from the underlying laminae, using a Cobb elevator. Dissection is performed along the spinous processes, lamina, and lateral mass (bilaterally), which functions to minimize bleeding and muscle damage. After we identified the fracture site, two 1.0 mm SS-wires were inserted from the inferior posterior arch of C1 and the superior posterior arch of C2. Both wires were then secured to ensure symmetrical position of external occipital protuberance dan the spinous process. After stabilization was achieved, decompression was done by hemilaminectomy of the right C1 and hemilaminotomy of the right C2, which resected axis was utilized as the onlay bone graft and inserted between arch of C1 and lamina of the C2. The graft was secured by sublaminar wires and the wound was closed. These procedures were done by an orthopaedic surgeon specializing in spine surgery.\n\nHer condition was stable postoperatively and immobilization was done using soft collar neck measured from the angle of the mandible up to the jugular notch for 12 weeks. Upon 3 months follow-up, ASIA Score showed both motor and sensory improvement. Patient no longer complained of numbness, weak right-hand grip has returned, and mobilization was recovered with assistance from a walker. The parent also reported that the patient had returned to school to continue her studies.",
    "summary": "A 11-year-old girl present with weakness on right upper and lower limb due to hyperflexion injury after her father accidentally fell on her neck. Initial radiology workup showed normal bony alignments and led to the misdiagnosis of Guillain-Barre Syndrome. However, further CT and MRI workup revealed odontoid fracture compromising the spinal canal, which caused anterior cord syndrome. She was managed by Modified Gallie procedure, which involves passing a sublaminar wire in C1-C2 and using the resected part of C2 from the subsequent decompression as an onlay type graft. Her condition was stable post-operatively and 3-months follow up showed improved motor and sensory function in ASIA Score. Patient had even returned to school and regained mobilization using a walker."
  },
  {
    "id": "multiclinsum_gs_en_192.txt",
    "fulltext": "A 13-year-old female with no medical history of interest presented to the emergency department with pain and functional impairment in her left wrist after a fall while skating. Diagnosed with a distal radius metaphyseal fracture with a fissure extending to the distal radius classified as a Peterson type I fracture, she was immobilized for four weeks with an antebrachiopalmarian splint. Two weeks after the splint was removed, she presented again to the emergency department with a crunch in her wrist, no associated overexertion and an inability to move the first finger of her left hand. She presented with a clinical deficit of active interphalangeal extension, a pathological tenodesis effect, local oedema and a macroscopic asymmetry when compared to the contralateral limb. She was examined with a magnetic resonance imaging (MRI) scan, which identified a discontinuity in the EPL. Under general anaesthesia, the patient underwent surgical treatment with tendon transfer of the extensor digiti proprius (EDP) to the distal remnant of the EPL with a non-absorbable monofilament Pulvertaft type suture. The limb was immobilized for the first four weeks after surgery.\n\nAfter four weeks, mobility was allowed, showing recovery of extension of the first finger of the left hand and discreetly hypertrophic scars, without pain. Follow-up at six, twelve weeks and one year reported no complications, with a complete restoration of function and a 0 score on the PRWE (Patient Rated Wrist Evaluation) scale.\n",
    "summary": "The case of a female adolescent patient who, after conservative treatment with a splint for a Peterson type I fisar fracture in the radius, suffered acute deficit of extension of the thumb six weeks later, diagnosed by clinical and radiological examination of a spontaneous rupture of the extensor pollicis longus. She was treated by transfer of the extensor proprius of the index finger (EPI) with satisfactory results and recovery of her usual activity one month postoperatively.\n"
  },
  {
    "id": "multiclinsum_gs_en_111.txt",
    "fulltext": "Chief Complaints\nA 35-year-old pregnant woman was admitted due to abdominal discomfort 3 hours before admission.\n\nHistory of Present Illness\nShe initially came to the midwife with labor pain that was getting more frequent one day before admission. After an overnight observation, she felt the labor pain getting more frequent and stronger until she felt an abdominal discomfort, no fetal movement felt, and the fetal heart rate was hard to find by the midwife. Later she was referred to Otto Iskandar Dinata Hospital due to suspicion of intrauterine fetal death. After an in-depth interview, she gained the water from boiled herbal medicine that her neighbor gave, who suggested she drink the extracted herbal water to help her when the labor comes, which is believed to help for better labor progress. She said the water was made from boiled water of rumput Fatimah from her neighbor. During hospital admission, she complained about abdominal discomfort that felt like a muscle cramp and being torn apart.\n\nPersonal History and Family History\nHer obstetrical history stated that she was G2P1A0, her last menstruation cycle was on 31 September 2022, and current gestation age was 41 weeks. There was no complication in her previous pregnancy; local delivery taker assisted her labor, and the baby weighed 2600 grams. She was married when she was 21 with her current husband, who was eight years older than her. During her pregnancy, she had routine control with the midwife every month. There was no relevant family history.\n\nPhysical Examination\nThe patient’s blood pressure was 80/60 mmHg, heart rate was 128 bpm, respiratory rate was 20 times per minute, body height was 152 cm, body weight was 58 kg, and prior to pregnancy her body weight was 58 kg. The obstetric examination found that her abdomen was stiff and tense, the contraction was hard to access, fetal heart sound was negative, no sign of a ring of bundle, and fundus height was 32 cm. From VT, the membrane was positive, and cervix opening was 3 cm.\n\nFinal Diagnosis\nFinal diagnosis of this case was G2P1A0 parturient aterm latent phase; acute abdomen due to suspicion of placentae abruption dd/ ruptur uteri; and Intrauterine Fetal Death.\n\nTreatment\nExploratory laparotomy was decided due to the acute abdominal pain state. During the procedure, there were no signs of life from the baby, the baby was female, her weight was 2350 grams, and her length was 44 cm. The operator also found that placentae was located outside and her uterus was already ruptured, approximately 15–18 cm. The operator decided to do subtotal hysterectomy on the patient due to the remote setting and a blood transfusion was not available, so it is risky to perform hysterorrhaphy.\n\nOutcome and Follow-Up\nThe baby could not be saved due to stillbirth. Her final diagnosis was spontaneous uterine rupture >15 cm in P2A0 post-term; stillbirth. Later she was hospitalized for few days, and then her condition getting better. The patient was sad about the birth result, but thankful to the doctor because the team were able to rescue her. She said she will become more careful about what she consumes, especially traditional medicine.",
    "summary": " A 35-year-old pregnant woman was referred to hospital due to abdominal discomfort 3 hours before admission due to suspicion of intrauterine fetal death. She drank the extracted herbal water to help her when the labor comes, which was made from boiled water with rumput Fatimah from her neighbor's house. Then, she was diagnosed with G2P1A0 parturient aterm latent phase; acute abdomen due to suspicion of placentae abruption dd/ ruptur uteri; and Intrauterine Fetal Death. Exploratory laparotomy was decided due to acute abdominal pain, and during the procedure the operator decided to do subtotal hysterectomy on the patient. The operator found her uterine was already ruptured, approximately 15-18 cm and the placentae was located outside of the uterus."
  },
  {
    "id": "multiclinsum_gs_en_228.txt",
    "fulltext": "A 30-year-old Emirati female G8P3A2Ep3, with a history of primary infertility for 3 years, had multiple IVF trials. Currently, she is a mother of three children with two previous early miscarriages and three ectopic pregnancies for which she had a bilateral salpingectomy.\n\nShe presented with left lower abdominal pain, vaginal spotting, and 6 weeks of amenorrhea. Upon examination, the patient was found to have a soft, non-tender abdomen and no cervical excitation by vaginal assessment. Pelvic ultrasound revealed a thin endometrium (0.6 cm), normal ovaries, and a suspicious complex mass (2.1 × 1.5 × 1.5 cm) in the left adnexa near the left ovary with a ring-like structure; no intrauterine pregnancy was visualised. Laboratory investigations revealed elevated β-HCG (251 IU/L) which plateaued after 48 hrs (220 IU/L). A diagnosis of EP was reached. Surgical and medical treatment modalities were offered to the patient; the patient opted for medical treatment. As such, methotrexate was administered, within two weeks, β-HCG levels plummeted to insignificant levels.\n\nHer previous history showed that she had had a diagnostic hysteroscopy and laparoscopy in 2014, due to primary infertility, revealing an arcuate uterus, membranous adhesions between the fallopian tubes and ovary, and a left hydrosalpinx, a blue-dye test confirmed right fallopian tube patency only. In 2016, the patient conceived spontaneously following a failed in vitro fertilisation (IVF) trial, which resulted in a full-term spontaneous vaginal delivery. In 2017, the patient had an ectopic pregnancy in the left uterine cornua, which was surgically treated via laparoscopic salpingectomy. In 2018, an ectopic pregnancy in the right fallopian tube was surgically treated by laparotomic salpingectomy for a ruptured EP after failed methotrexate treatment. In 2019, the patient yet again presented with a left scar ectopic pregnancy; laparoscopic removal of the sac with suturing of the cornua part was performed. The clinical diagnoses of all ectopic pregnancies were confirmed histologically. In 2020, the patient had a set of twins conceived via IVF and delivered by c-section.\n\nConsidering the patient’s background of multiple EPs and being liable for more in the future, an x-ray hysterosalpingography was performed to determine the patency of the tubes and prepare a plan to prevent another reoccurrence of EP. The hysterosalpingogram reported the appearance of both tubes with the left tube noticeably shorter than the right, faint spillage on both sides, intravasation into the veins, and possible partial recanalization of both tubes had taken place. The agreed management after counselling the patient about the above findings was to have combined oral contraception and to opt for IVF should she plan to have another pregnancy.",
    "summary": "We present the case of a 30-year-old woman who attended the emergency unit with her second spontaneous ectopic pregnancy following a previous bilateral salpingectomy. She had prior multiple spontaneous ectopic pregnancies: laparoscopic salpingectomy for a left cornual EP in 2017 followed by laparotomic salpingectomy for a ruptured right EP after failed medical management in 2018. Lastly, she had laparoscopic removal of an EP sac in the scar of a previous left cornual EP in 2019. She presented with a history of missed periods, pelvic pain, and vaginal spotting. Her examination revealed left lower abdominal pain, soft, non-tender abdomen, and no cervical excitation. Pelvic ultrasound revealed a thin endometrium and no intrauterine pregnancy visualised. A suspicious complex mass near the left ovary with a ring-like structure was noted. Her β-HCG was (251 IU/L) which plateaued after 48 hrs (220 IU/L). She responded well to methotrexate with no need for surgical intervention this time."
  },
  {
    "id": "multiclinsum_gs_en_44.txt",
    "fulltext": "After written informed consent was achieved by the patient the following data is given: An 18-year-old man with an unknown cause of end stage renal disease started HD 3 years prior to this report. Initially, he had had an upper arm AVF on the left side. This AVF had to be closed due to a local invasive infection. Thus, an upper arm fistula was placed in the right arm and was thereafter used for HD. When arriving at our unit in March 2018, he suffered from intermittent pulmonary congestion that was clinically interpreted to be related to a high degree of IDWG caused by excessive fluid intake and water retention in conjunction with anuria. Body weight was estimated to be 60 kg. The IDWG was approximately 5%. Intermittently, he had to perform additional acute ultrafiltration procedures since pre-dialysis NT-proBNP was above 70,000 ng/L, and blood pressure around 160/105 mmHg. He was prescribed angiotensin receptor blockers and was told to strongly restrict fluid intake with the aim of IDWG towards 2%. He managed to limit IDWG to some extent, resulting in a transient lowering of NT-proBNP. After 5 months NT-proBNP surpassed 70,000 ng/L again. Chest X-ray showed pulmonary fluid retention and the heart size was extensively increased. The patient suffered from progressive breathlessness during activity and was forced to access the dialysis ward by wheelchair; this corresponded to class III-IV of the NYHA functional classification. From October 2018 until March 2019, NT-proBNP levels were above the upper limit of detection and considered a reflection of a severe cardiac strain. Ultrafiltration was increasingly difficult due to intradialytic hypotensive episodes. Blood pressure rose and doses of antihypertensives that included angiotensin receptor blockers, calcium-blockers and alpha-1 receptor antagonists had to be increased.\n\nThe vascular conditions and flow measurements in the brachial artery as well as the flow through cephalic and basilic vein over time. While the patient had an upper arm fistula the flow in the cephalic vein was periodically surpassed by the flow through the basilica vein. In June 2018, the Doppler showed a flow of 2780 ml/min measured in the brachial artery representing 43% of the cardiac output.\n\nEchocardiography showed a dilated left ventricle with reduced systolic function but a maintained stroke volume with an ejection fraction of 45%. A non-significant small pericardial effusion was seen. The extended QRS duration further emphasised the presence of dilated cardiomyopathy and heart failure. The echocardiography showed structural changes, an atrial septum defect, and minor regurgitation of the mitral, tricuspid and pulmonary valves.\n\nIn September 2018, a surgical correction according to Miller et al. was performed. One month later partial ligation of the basilic vein was done. Within 1 month postoperatively brachial artery flow was back at 3023 ml/min despite a reduced diameter of 4 mm of the basilic vein (local flow 760 ml/min. Therefore, a temporary central venous catheter was placed, the upper AVF closed, and a new distal radiocephalic AV-fistula was successfully placed in the right arm in December 2018. Under the new radiocephalic AVF blood flow in the brachial artery decreased to approximately 1344 mL/minute when measured by ultrasound in February 2019. AVF flow measured by Transonic® was in the range of 550–880 ml/min. In March 2019, the dialysis sessions were increased from 3 to 4/week to limit the IDWG. In April 2019, echocardiography showed a slightly improved systolic function of the left ventricle but retained pericardial effusion. The NT-proBNP levels had dropped to 9358 ng/L. The patient still experienced breathlessness during activity, but it was less than before. No grading of the symptoms were registered. The echocardiographic findings and QRS duration improved at follow-up 8 months later (January 2020) and his clinical condition corresponded to NYHA I. Since then he felt well. After changing from upper arm to lower arm AVF, the AVF fistula flow (data by Transonic®) decreased as well as the NT-proBNP levels.",
    "summary": "An 18 years old patient performed HD via an upper arm AVF before he was admitted to our unit. NT-proBNP was above the upper detection level of 70,000 ng/L. Echocardiography revealed a left-ventricular cardiac insufficiency. Interdialytic weight gain (IDWG) was above 5%. He was instructed to lower fluid intake and IDWG towards 2%. Four months later NT-proBNP surpassed 70,000 ng/L again. Flow in the brachial artery was at 3034 ml/min. Reconstructive surgery of the AVF did not reduce flow and NT-proBNP in the long run. Clinically, he worsened to NYHA class III-IV. It was decided to close the upper arm AVF and to replace it with a lower arm AVF leading to a reduced artery flow of 1344 mL/min. The clinical condition successively recovered and NT-proBNP decreased to 7000 ng/L."
  },
  {
    "id": "multiclinsum_gs_en_57.txt",
    "fulltext": "63-year-old patient with a diagnosis of diabetes, hypertension and hypercholesterolemia, with a history of myocardial infarction, who takes 9 medicines, and presents the chronic treatment plan.\n\nStudy and Evaluation\nOn 22/12/22 the patient went to the Emergency Department (ED) presenting redness, itching and eye inflammation, with both eyes affected. She later went to the FC with a diagnosis of conjunctivitis to withdraw the treatment prescribed in an electronic prescription (EP).\n\nThe dispensing service (SD) is used to intervene with pharmacological advice in order to guarantee the correct use of both drugs. Therefore, in addition to dispensing both drugs, a series of recommendations are made aimed at achieving correct administration of both the eye drops and the ophthalmic ointment. (1,2)\n\nIn addition, when there is a time coincidence in some of the applications of the drugs, special emphasis is placed on the fact that in the case of co-administration of both forms of the medicine, it is correct to always apply the eye drops first and wait between 5 and 10 minutes for the application of the ointment (3).\n\nAfter 6 days of treatment with no improvement, the patient comes back to the ED, where a new antibiotic is prescribed in ER.\n\nIn this case, a possible error of prescription was detected through the FC Dispensation Service, which could compromise the safety of the patient, as ear drops were prescribed instead of ophthalmic eye drops.\n\nThe product information for the medicine is reviewed, and it is noted that the only indication for the prescribed medicine is the treatment of acute external otitis and the administration route is the auricular route. The use of this route and not another is reiterated in the warnings and precautions section. This would therefore be a Problem Related to the Medicinal Product (PRM) of error in the prescription, which could have an associated Negative Result associated with the medication (RNM) in the case of using the prescribed medicine if it is administered ophthalmically.\n\nIntervention\nFollowing the detection of the error, in the absence of an effective communication channel between doctors and pharmacists and given the impossibility, despite trying, of contacting the emergency department by telephone, a verbal referral is made from the pharmacist to the emergency doctor through the patient herself, attaching a copy of the RE indicating the error, urging him to go back to the emergency department so that the doctor can assess the pharmacological substitution for an appropriate pharmaceutical form for administration by ophthalmic route, as there is an alternative therapeutic option with the same composition, namely ciprofloxacin 3 mg/ml eye drops in solution.\n\nAfter a few hours, the patient returned to the pharmacy with the unchanged RE after going to the emergency room, as the doctor reiterated that these drops can be used without problems by ophthalmic route. She even commented that the doctor himself consulted another emergency doctor, both confirming the use by the previously indicated route.\n\nIn view of this, the FC printed the leaflet for ciprofloxacin 0.3% 5 ml ear drops, emphasizing the following paragraphs, which reflect the ear as the only authorized route for administration of the drug:\n\nWhat it is and what it is used for. This medicine is used for the treatment of acute external otitis.\n\nWhat you need to know before you start using. Warnings and Precautions: \"Use this medicine only in your ear(s).\n\nHow to use. \"This medicine should only be administered by the otic route, i.e. as ear drops.\"\n\nThis document is given to the patient with the aim of them returning to the SU with documentation to prove the referral.\n\nOn 28/12/22 the patient did not return to the pharmacy, so the pharmacist made a follow-up call on 29/12/22. In this case, and despite the insistence of the pharmacist the day before given the need to start with the new treatment, the patient, given the level of saturation of the emergency department, decided not to go again to the emergency department and wait for the appointment with her Primary Care Physician (PCP) on 30/12/22.\n\nRESULTS\nOn 12/30/22, the patient goes to the appointment with the MAP, to whom she comments on the incident, providing the documentation provided from the SU, including the technical data sheet of the drug provided from the FC.\n\nThe MAP accepted the proposed intervention from the FC and ratified the prescription error detected by the FC, without understanding why the SU did not proceed with the requested pharmacological substitution. However, in this case, given the level of inflammation and ocular redness that the patient presented at the time of the consultation, the MAP prescribed a corticoid eye drop and cancelled the previous prescription of antibiotics.\n\nThe patient went to the pharmacy to pick up the prescribed treatment. She took the opportunity to comment on the similarity of clinical criteria between the pharmacist and the MAP, as well as to thank the MAP for the intervention.\n\nA few days later (03/01/23) the FC contacted the patient by phone to follow up on the health issue, noting an improvement in the reduction of redness and ocular inflammation, and again took the opportunity to thank the pharmacy for its treatment and involvement.\n",
    "summary": "63-year-old patient, diagnosed with diabetes, hypertension and hypercholesterolemia, with a history of myocardial infarction, who takes 9 medicines. She goes to the community pharmacy (FC) to withdraw the treatment prescribed from the Emergency Department to treat a conjunctivitis.\n\nA Problem Related to Medication (PRM) of a potential error in the prescription was detected by the dispensing service, which could have an associated Negative Result to the medication (RNM) when prescribing ear drops for ophthalmic use, compromising the safety of the patient.\n\nShe was referred to the emergency department for a change in treatment due to a potential risk, following the indications in the technical information sheet. In the emergency department, the proposed intervention was rejected and the patient was referred back to the FC to withdraw the drug. The patient decided to wait two days for an appointment with her primary care physician. The proposal made by the FC was accepted by the primary care physician.\n\nFollow-up of the case is carried out, which allows the resolution of the health problem to be verified, as well as the PRM and RNM detected, achieving an improvement in the health of the patient and thus guaranteeing a rational, safe and effective use of the medicine.\n"
  },
  {
    "id": "multiclinsum_gs_en_522.txt",
    "fulltext": "Conway et al. previously described a case of a 39-year-old Kuwaiti man who had a 23 year history of fingernail leukonychia, secondary to a PLCδ1 homozygous missense gene mutation (online suppl. material; for all online suppl. material, see https://doi.org/10.1159/000543032). Physical examination showed milky white discoloration on 9/10 fingernails, which did not blanch with pressure. Hair loss began in the temporal regions at age 24, with a family history of early-onset hair loss. Of note, no additional skin findings or cysts were noted, although some PLCδ1 variants are associated with development of trichilemmal cysts. He reported that his relatives had no history of nail disorders.\n\nThe patient was experiencing stigmatization in his community because it looked like he was wearing nail polish, and he was distressed about the appearance. He was quite desperate for a treatment. A 30% glycolic acid chemical peel was performed to the fingernails, with no improvement. Although not previously described for treatment of leukonychia, we proposed treatment with intramatricial 2.5 mg/cc triamcinolone/lidocaine 1%, with the caveat that it was unlikely to be effective. He was asked to follow-up 5 months later, due to slow physiologic nail growth. Complete resolution of leukonychia was observed in five fingernails, with partial improvement in the remaining four. He did not experience any side effects, other than mild transient pain at the injection site.",
    "summary": "A 39-year-old Kuwaiti male with autosomal recessive variant of PLCδ1-related non-syndromic leukonychia affecting nine fingernails presented for treatment because he was socially stigmatized. Treatment with 30% glycolic acid chemical peel was ineffective. Because there is evidence suggesting a link between PLCδ1-related hereditary leukonychia and abnormal keratinization, we hypothesized that injection of steroids into the nail matrix, which could inhibit keratinocyte activity and reduce nail matrix inflammation, may be an effective treatment. Following treatment with intramatricial triamcinolone, the patient experienced complete resolution of leukonychia in five fingernails and partial improvement in the remaining four."
  },
  {
    "id": "multiclinsum_gs_en_507.txt",
    "fulltext": "We present the case of a 38-year-old white Moroccan male with no cardiovascular risk factors and a prior history of unexplored bilateral cecity, who presented to the emergency department with chronic edema of the limbs and progressive shortness of breath.\n\nThe initial evaluation found a hemodynamically stable patient with a normal blood pressure 105/76 mmHg, a pulse rate at 45 beats per minute, and oxygen saturation at 93% on ambient air. Physical examination showed an external jugular vein distension, extensive legs edema, and ascites. Cardiopulmonary auscultation was notable for a 4/6 holosystolic murmur at the mitral focus with symmetrical bilateral diffuse crackles. The ophthalmological assessment found a visual acuity reduced to light perception.\n\nAn electrocardiogram showed sinus bradycardia with a heart rate of 45 beats per minute and complete right bundle branch block. Chest radiography was notable for cardiomegaly and perihilar congestion. The B-type natriuretic peptide level was 1230 pg/ml (for a normal range under 300 pg/ml), the creatinine level was 9.6 mg/l (for a normal range between 6 and 12.5 mg/l), the albumin level was slightly low at 36 g/l (for a normal range higher than 39 g/l), and there was a high sensitivity troponin at 294 ng/l (for a normal range under 35 ng/l). Other laboratory test results were normal particularly ferritin, TSH, and electrolyte levels.\n\nTransthoracic echocardiography (TTE) showed a dilated left ventricle (end diastolic basal diameter of 60 mm) with a severely reduced ejection fraction at 15% (Simpson biplane), mild mitral regurgitation, and an apical thrombus measuring 19 mm × 18 mm. The right ventricle was severely dilated (end diastolic basal diameter of 51 mm), with systolic dysfunction (Tricuspid Annular Plane Systolic Excursion (TAPSE) of 12 mm and Right Ventricle S' wave on tissue doppler (S’VD) of 5 cm/s) and severe tricuspid regurgitation. The inferior vena cava (IVC) was plethoric with a maximal diameter of 37 mm.\n\nA detailed history revealed that since his early twenties, the patient had troubles walking, hearing loss, and anosmia and that his cecity started with altered night vision, but he had never been assessed or evaluated by an ophthalmologist prior to this presentation. The neurological examinations showed bilateral legs amyotrophy with bilateral ataxia. A fundoscopic examination was performed to explore his cecity and revealed retinitis pigmentosa. The patient’s clinical image associating a dilated cardiomyopathy with the specific neurological signs was strongly suggestive of Refsum's disease. We conducted an assay of plasma phytonic acid concentrations, which revealed a remarkably elevated level of 324 μmol/l, which confirmed the Refsum disease. Initially, the patient was put on intravenous furosemide, which provided subsequent relief from his heart failure symptoms. Following that, he received treatment with oral furosemide [40 mg twice per day (b.i.d)], Angiotensin converting enzyme (ACE) inhibitors (ramipril 2.5 mg b.i.d), spironolactone (25 mg Once daily (o.d)), and an SGLT2 inhibitor (empagliflozine 10 mg o.d.). Beta-blockers were not administered due to sinus bradycardia. Additionally, the patient received vitamin K antagonists for the left ventricular thrombus.\n\nIn terms of the specific treatment for Refsum disease, the patient was counseled to adhere to a dietary restriction regimen designed to eliminate phytol-containing foods, with a daily phytanic acid intake below 10 mg. This involved avoiding the consumption of meat or fats from ruminating animals (such as lamb and beef) and baked goods containing animal fats, as well as dairy products such as butter and cheese.\n\nThe patient recovered and his condition became stabilized with NYHA class 2 symptoms of chronic heart failure; therefore, he was discharged on medical treatment for heart failure, vitamin K antagonists (VKA), and a low phytanic acid regimen.",
    "summary": "We report the case of 38-year-old white Moroccan male who was admitted in our department for an acute decompensated heart failure episode. Transthoracic echocardiography found a dilated cardiomyopathy with a reduced ejection fraction at 15%. Further evaluation showed different features of Refsum disease. High plasma level of phytanic acid confirmed the diagnosis. Cardiac manifestations are frequent in the late course of the adult Refsum disease and include, cardiomyopathy, electrical abnormalities, and sudden cardiac death. Moreover, arrhythmias remain one of the main causes of death in these patients."
  },
  {
    "id": "multiclinsum_gs_en_343.txt",
    "fulltext": "A 52-years-old male presented visual acuity loss of his right eye (OD) 2 days after an uncomplicated ranibizumab IVI with a 30G needle. The past medical history included PE, high myopia, and OD pars plana vitrectomy due to retinal detachment. He was being treated with monthly ranibizumab due to choroidal neovascularization secondary to angioid streaks, with 78 previous injections in the OD. At presentation, his BCVA was 6/18 and the intraocular pressure (IOP) was 3 mmHg. Slit-lamp examination of the anterior segment was unremarkable. Fundoscopy and OCT-scans revealed posterior pole chorioretinal folds. Altogether, the low intraocular pressure and fundoscopic findings led to the diagnosis of hypotony maculopathy. Topical dexamethasone and atropine were prescribed to improve ciliary body function. The IOP normalized within 3 days with a recovery of visual acuity and resolution of the chorioretinal folds. Four months later, a new OD anti-VEGF IVI with a 30G needle was performed in the inferolateral quadrant and the patient reported decreased visual acuity in the day following the injection. BCVA was counting fingers and IOP was 2 mmHg. Chorioretinal folds in the posterior pole were present, even more prominently this time. Slit-lamp examination revealed an open scleral wound at the injection site. The wound was sutured with 10–0 monofilament and topical dexamethasone and atropine were prescribed. The patient recovered well and presented BCVA of 6/12 and an IOP of 12mmHg.",
    "summary": "A 52-year-old male complained of right eye (OD) vision loss 2 days after an uncomplicated anti-VEGF IVI for the treatment of choroidal neovascularization secondary to angioid streaks. Relevant medical history included PE, pathologic myopia, and a previous pars plana vitrectomy (PPV) due to a retinal detachment. OD best-corrected visual acuity (BCVA) dropped from 6/12 to 6/18 after the IVI. Intraocular pressure (IOP) was 3 mmHg and chorioretinal folds were evident in the posterior pole. Topical dexamethasone and atropine were prescribed, and full recovery was noticed after 3 days. Four months later, the patient developed a new episode of vision loss after another IVI. His BCVA was counting fingers, IOP was 2mmHg, and more noticeable chorioretinal folds were found. This time, an open scleral wound at the injection site was evident and a scleral suture was necessary. Once again, the patient recovered well."
  },
  {
    "id": "multiclinsum_gs_en_156.txt",
    "fulltext": "24-year-old male patient with no relevant medical history. Pre-event systemic review was negative. He presented with a 10-day history that began with nasal congestion. On the third day, he participated in a rescue operation in a forest fire, where he did not suffer visible burns. On the fourth day, he developed general systemic involvement and night sweats, red eye with mucopurulent discharge, epiphora, erosive lesions of the upper lip and whitish plaques on the inner walls of the oral cavity, which were painful. He consulted emergency services three times, where he was treated on an outpatient basis with chlorpheniramine, paracetamol and NSAIDs. Despite this, the condition progressed with myalgia, fever of up to 39°C, greater involvement of the general system and oral mucosa that made it difficult to eat, dry cough and vomiting of food.\n\nConsultation for the fourth time, 10 days before the onset of the clinical picture, in the emergency department of our center. On admission he was described as tachycardic (115 bpm), temperature 37.8°C, respiratory rate of 20 bpm, saturating 97% with FIO2 ambient. On physical examination he had conjunctival injection with bipalpebral edema, purulent discharge and epiphora, erosive lesions sensitive with mobile whitish plaques in oral mucosa and urinary meatus. On physical examination he had conjunctival injection with bipalpebral edema, purulent discharge and epiphora, erosive lesions sensitive with mobile whitish plaques in oral mucosa and urinary meatus. Scarce skin lesions (< 5% body surface) in anterior thorax, hyperpigmented, non-pruritic, with negative Nikolsky sign. No other alterations. In his laboratory examinations he had leukocytes at 13,200, without eosinophilia and PCR at 205.4 mg/l (normal < 5). Red series, platelets, plasma electrolytes, renal and hepatic function normal. Complete urine examination and non-inflammatory sediment. He was diagnosed with \"non-oncological mucositis\", and was managed with infusions of physiological serum, ceftriaxone and hospitalization in a room with protective isolation.\n\nIn the study, a naso-fibroscopy was performed that showed congestive mucous from the nose to the hypopharynx with mucopurulent secretion, ruling out burns. The Computed Axial Tomography (TAC) of the thorax showed multiple foci of alveolar filling associated with a budding tree image, compatible with interstitial pneumonia.\n\nIn the etiological study, a respiratory filmArray™ was performed, positive for Chlamydophila pneumoniae and adenovirus. Serology was also requested for hepatitis B and C viruses, HIV, EBV, CMV, Mycoplasma pneumoniae, VDRL, PCR in oral lesions of HSV I and II, culture of current urethral secretion, for Neisseria gonorrhoeae and fungi, PCR urethral secretion, uroculture and blood cultures, all with negative results.\n\nThe patient was treated in a team with dermatology, ophthalmology, immunology and internal medicine. Support was provided with parenteral hydration and nutrition, nursing care, azithromycin associated with hydrocortisone for 5 days, antibiotic eye drops for suspected superinfection, oral rinses with miconazole 20 mg in gel format and protection of lips and urethral meatus with cream based on panthenol, bisabolol and glycerine.\n\nAfter five days of treatment, good clinical and laboratory evolution was observed, so skin biopsy was discarded and oral feeding was gradually initiated.\n\nOn day 12 of hospitalization, the patient was in good general condition, eating properly orally, with clinical resolution of pulmonary condition, healing of oral and urethral mucous lesions.\n\nSo he was discharged with a referral for immunology check-ups.\n",
    "summary": "A 24-year-old patient with extensive mucous and respiratory involvement compatible with mucous respiratory syndrome caused by Chlamydophila pneumoniae is presented. Initially treated with NSAIDs, which makes it difficult to differentiate from other syndromes with mucous and cutaneous involvement caused by these drugs.\n"
  },
  {
    "id": "multiclinsum_gs_en_588.txt",
    "fulltext": "History of Presentation\nAn 88-year-old man presented with generalized weakness and recurrent episodes of dizziness over recent weeks, in the context of de novo atrial fibrillation. At the time of presentation, he was hemodynamically stable with a blood pressure of 113/66 mm Hg, a heart rate of 68 beats/min, and an oxygen saturation of 96%. Physical examination revealed no acute abnormalities; however, findings were consistent with severe symptomatic aortic stenosis (AS).\n\nPast Medical History\nThe patient’s medical history was notable for significant coronary artery disease requiring coronary artery bypass grafting (CABG) 3 decades earlier. He also had a documented first-degree atrioventricular block with incomplete right bundle branch block.\n\nDifferential Diagnosis\nThe clinical presentation raised the possibility of several underlying causes, with decompensated heart failure secondary to severe AS being the primary consideration. Arrhythmia-related symptoms due to atrial fibrillation, including potential hemodynamic compromise, also were evaluated. Noncardiac etiologies, such as neurogenic or metabolic disturbances contributing to dizziness, were considered in the comprehensive differential diagnosis, although with a lower degree of clinical probability.\n\nInvestigations\nTransthoracic echocardiography revealed a normal left ventricular ejection fraction with severe calcified AS (aortic valve area: 0.86 cm2; mean pressure gradient: 45 mm Hg), and moderate tricuspid regurgitation. There was no evidence of aortic dilation at the level of the sinuses of Valsalva or in the proximal ascending aorta. Preprocedural computed tomography (CT) demonstrated severe calcified AS (area: 410 mm2; perimeter: 73 mm) in a horizontal aortic root (52°), with patent bilateral transfemoral access, as well as incidental findings of an infrarenal saccular abdominal aortic aneurysm (37 × 26 mm). The patient was referred to our institution’s heart team and was deemed eligible for a transfemoral transcatheter aortic valve implantation (TAVI).\n\nManagement\nA transfemoral TAVI procedure was performed with a 29-mm Evolut FX valve (Medtronic). Primary access was established at the right common femoral artery with an 18-F Gore Dryseal introducer owing to severe atherosclerotic disease in the abdominal aorta. The aortic valve was crossed with the use of an AL-1 catheter and a straight 0.035-inch guidewire, followed by the placement of an extra-small Safari guidewire (Boston Scientific) in the left ventricle. The initial deployment attempt resulted in valve embolization at 80% deployment owing to the patient’s horizontal aortic root anatomy, but a second deployment was successful and deemed to be stable. The procedure resulted in a marked reduction in the pressure gradient from 41 to 7 mm Hg, with no evidence of paravalvular leak on the final aortogram. However, during the procedure, a possible aortic root dissection and probable contained aortic laceration was noted in the noncoronary sinus. The patient remained hemodynamically stable throughout the entire procedure, with intraprocedural “quick look” transthoracic echocardiography confirming the absence of pericardial effusion. Closure of the primary access was performed with a Manta (Teleflex) device, and a 6-F AngioSeal (Terumo) was used for the secondary femoral access.\n\nImmediate postprocedural CT confirmed an aortic root dissection of the noncoronary sinus of Valsalva and acute mediastinal hematoma surrounding the aortic root, extending along the right atrioventricular groove and the right coronary artery. The patient was not considered to be a suitable surgical candidate for aortic dissection repair owing to extensive aortic calcifications. Despite the presence of an aortic dissection and mediastinal hematoma, he remained hemodynamically stable after the procedure. Initial blood pressure management included intravenous nitroglycerine to maintain systolic blood pressure under 110 mm Hg, aiming to reduce stress on the aortic wall and prevent expansion of the dissection. On postoperative day (POD) 1, 7.25 mg daily oral amlodipine was started for continued blood pressure management, aimed at mitigating further aortic complications. Transthoracic echocardiography performed 24 hours after the procedure revealed a mild paravalvular leak localized at the 3 o’clock position. On POD 2, CT revealed a well defined pseudoaneurysm (16 × 19 × 20 mm) with a small neck (1 mm), with a surrounding hematoma or acute thrombus (11 mm), communicating with the noncoronary sinus of Valsalva at the site of dissection. In addition, the patient developed a new-onset left bundle branch block accompanied by a prolonged PR interval in sinus rhythm and slow-rate atrial fibrillation, leading to the decision to implant a permanent pacemaker. Nitroglycerine was tapered and discontinued by POD 2 as blood pressure stabilized, allowing for the initiation of low-dose carvedilol. On the fourth day after TAVI, CT confirmed a decrease in the size of the pseudoaneurysm and associated hematoma, and the patient was deemed to be stable for discharge with a scheduled outpatient follow-up at the transcatheter valve therapy clinic.\n\nOutcome and Follow-Up\nAt the first outpatient follow-up, 7 days after discharge, there was complete thrombosis of the dissection’s false lumen; however, the patient experienced a recurrence of atrial fibrillation, and a low dose of direct oral anticoagulants (DOACs) was resumed. At the most recent follow-up, 2 months after procedure, the patient exhibited complete resolution of the focal dissection flap, with no evidence of ongoing aortic dissection despite the DOACs.",
    "summary": "We describe an iatrogenic aortic root dissection and contained aortic laceration during TAVI procedure with a 29-mm Evolut FX in an 88-year-old man with a history of coronary artery bypasses. Postprocedural computed tomography revealed a dissection in the noncoronary sinus of Valsalva with a mediastinal hematoma, evolving into a well defined pseudoaneurysm (20 mm). The patient received conservative management, resulting in a favorable clinical outcome."
  },
  {
    "id": "multiclinsum_gs_en_202.txt",
    "fulltext": "A 44-year-old woman with a history of multiple sclerosis who had been treated with interferon beta-1b since the age of 26. She had previously had mild menstrual migraine headaches without aura and had taken rizatriptan once, which she did not tolerate well. She did not use any other medicines.\n\nAbout four episodes of thunderclap headaches occurred in the context of sexual intercourse three years prior to the emergency room visit. The headaches were described as bitemporal, oppressive, explosive onset, with a maximum intensity on the visual analogue scale of 8/10. They were triggered by orgasm, no other symptoms were associated, and they resolved gradually over an hour. These episodes occurred over a period of about one month, and the patient denied headaches in other contexts.\n\nShe reported three episodes of explosive onset headaches similar to the previous ones, but this time exclusively triggered by vigorous physical exercise, one year prior to our evaluation. She did not report headaches in other situations, including sexual activity. She temporarily decreased the intensity of physical exercise and was able to gradually reintroduce her previous exercise without new events in about a month. She did not seek medical attention for any of these episodes.\n\nTwo weeks prior to our evaluation in the emergency department, the patient had a neuritis optica flare that was treated with high-dose methylprednisolone for five days. On the day the course was completed, she awoke at night with a headache that was the worst she had ever had (visual analog scale 10/10) accompanied by nausea, photo- and phonophobia. The headache was bilateral and occipital, with a pressing quality. She went to the emergency department, where she was found to have high blood pressure (180/100 mmHg) and a head CT scan and lumbar puncture were performed, with normal results. After administration of analgesia and correction of blood pressure, the patient improved and was discharged.\n\nShe had three more episodes of thunderclap headaches over the next week. All occurred while she was awake and at rest, with no associated triggers. The intensity of the pain decreased gradually over the next few hours, but did not completely resolve between episodes. She denied other associated symptoms.\n\nOn admission to the emergency department, a head CT scan was performed with contrast administration, which showed focal and segmental narrowing of several intracranial arteries suggestive of cerebral vasoconstriction. The patient was admitted to the neurology unit and oral nimodipine was initiated. A cerebral arteriography was performed, which showed numerous short segments of vascular stenosis followed by post-stenotic dilations in arterial vessels, mainly of medium caliber.\n\nThe patient did not have any headaches in the following days. Autoimmunity and serology studies were negative. She was discharged asymptomatic and a control arteriography at three months, in which all findings had resolved, confirmed the diagnosis of SVCR.\n",
    "summary": "44-year-old woman with a history of multiple sclerosis on interferon beta-1b who presented with four episodes of thunderclap headaches at rest after completing a course of corticosteroids for an optic neuritis flare. Three years earlier, the patient had experienced several episodes of explosive onset headaches during a self-limited one-month period, which occurred only in the context of sexual intercourse. In the year prior to our evaluation, she had three episodes of thunderclap headaches with similar characteristics, but which were exclusively triggered by vigorous physical exercise. She had not sought medical attention for these events. A cranial computed tomography scan was performed after administration of contrast and a cerebral arteriography, which was consistent with a cerebral vasoconstriction syndrome, and its reversibility was confirmed three months later.\n"
  },
  {
    "id": "multiclinsum_gs_en_562.txt",
    "fulltext": "A 26-year-old male weighing 78 kg presented to the nephrology outpatient clinic in the third week of June with a history of rhinitis, low-grade fever, and decreased urinary output for three days. On his general physical examination for work in January 2023, he had a baseline creatinine of 0.7 mg/dL. On evaluation, he was incidentally found to have creatinine of 2.1 mg/dL. He had a history of weight gain of 6 kg with easy fatigue over the last 3 months. The patient had no significant family history and his medication history included two doses of 500 mg of acetaminophen and 5 mg of levocetirizine for rhinitis. He also complained of intermittent myalgia over the last two weeks. The clinical examination revealed euvolemia, pulse rate of 58/minute with blood pressure of 128/68 mmHg and urinary output of approximately 800 mL/day (less than 0.5 mL/kg/hour). There were no bite marks or discoloration of limbs that suggested direct muscle injury. Because of his unexplained renal insufficiency, he was admitted on June 26 and a full evaluation was initiated, which revealed elevated serum creatinine of 2.4 mg/dL with normal sodium levels (136 meq/L), potassium (4.9 meq/L), chloride (102 meq/L), bicarbonate (20 meq/L), and glycaemia. Urinalysis revealed traces of albuminuria with occasional presence of erythrocytes/high magnification field. The haemoglobin was 16.2 grams/dL, the leukocyte count was 8070/mm3, and platelet count was 208,000/mm3. The aspartate aminotransferase (AST) was 69 U/L and the alanine aminotransferase (ALT) was 51 U/L with normal levels of bilirubin. The viral serology tests for hepatitis B surface antigen, anti-HCV and HIV were negative. The abdominal ultrasound revealed normal-sized kidneys with no evidence of obstruction. He had normal complement levels, negative urine culture, and negative antinuclear antibodies. Because of his intermittent myalgia, the total creatine phosphokinase (CPK) was evaluated, revealing a value of 3869 IU/L with normal CPK-MB fraction. There was no history of direct muscle injury, crushing injury, prior history of recurrent muscle weakness or pain, family history of similar muscle pathology, or inadvertent drug abuse, and the glucose and electrolyte levels were normal. In the face of bradycardia, easy fatigue and weight gain, the thyroid profile was evaluated, revealing TSH >150 mIU/L, free T3 of 2.61 picomoles/L (range: 2.1 – 4.4 picomoles/L) and free T4 of 0.81 nanograms/dL (range: 0.80–2.70 nanograms/dL). The abdominal ultrasound revealed heterogeneous, diffusely enlarged thyroid gland with ecogenic septae suggestive of Hashimoto's thyroiditis. The total anti-thyroid peroxidase antibody (anti-TPO) was greater than 1,000 IU/mL and anti-thyroglobulin antibody (anti-Tg) was 1,930 IU/ml. A biopsy of the kidneys was performed due to the uncertain cause of renal insufficiency, which revealed 25 glomeruli with normal cellularity and open capillary loops. The haematoxylin and eosin stain and Masson trichrome stain revealed epithelial tubular cell desquamation with cellular debris in many tubules, which was indicative of acute tubular injury. The immunofluorescence was negative for all antibodies and the immunohistochemistry was positive for myoglobin. The full exome sequencing revealed no genetic predisposing gene for rhabdomyolysis. He was diagnosed with acute tubular injury induced by autoimmune thyroiditis and rhabdomyolysis based on the elevated CPK and was initiated with 75 mcg (1.8 mcg/kg) of sodium thyroxine with adequate hydration for rhabdomyolysis. His creatinine decreased to 1.8 mg/dL after 7 days of admission. The dose of thyroxine was gradually increased by 25 mcg every two weeks. At a one-month follow-up in August 2023, his creatinine had decreased to 1.2 mg/dL with normal CPK (208 IU/L). He is currently being treated with 125 mcg (1.8 mcg/kg) of sodium thyroxine with biweekly follow-up in the nephrology department.\n",
    "summary": "We present the case of a 26-year-old man with no comorbidities who presented with fatigue and weight gain for 2 months. He had creatinine of 2.1 mg/dL with a history of rhinitis treated with anti-histamines three days before the hospital visit. He had symptoms of intermittent myalgia in the previous two weeks. On laboratory evaluation, he had elevated levels of CPK, elevated TSH, normal low T4, and positive anti-TPO and anti-Tg antibodies. Ultrasound of the neck revealed linear echogenic septae in the thyroid gland. Renal biopsy revealed acute tubular injury. Adequate thyroxine supplementation was initiated and his creatinine was reduced to 1.2 mg/dL after one month.\n"
  },
  {
    "id": "multiclinsum_gs_en_448.txt",
    "fulltext": "Patient, 15 months old, female, first daughter of healthy parents, not consanguineous. Her pregnancy was monitored and passed without complications. She was born by vaginal delivery at 40 weeks of gestational age, weighing 2635 grams (2 percentile), height of 48 cm (8 percentile) and head circumference of 33 cm (5 percentile), according to the curves of Alarcón and Pittaluga4 with an APGAR score of 9-10.\n\nShe had normal psychomotor development and no intercurrent illnesses. At 4 months of age, she was auscultated for a heart murmur during a pediatric check-up and was referred to cardiology. An echocardiogram revealed pulmonary artery stenosis, which, together with a prominent forehead on physical examination, led to a referral to clinical genetics.\n\nIn the genetic evaluation, characteristics such as high anterior implantation of hair, straight eyebrows, sunken eyes, prominent auricular pavilions, low nasal bridge, convex nasal profile with bulbous tip, short columella and pointed chin were observed. In addition, a systolic murmur was detected in the pulmonary focus during auscultation. There were no alterations in the abdomen, genitals or extremities.\n\nIn the presence of suspected SALG, additional examinations were performed. Spinal radiographs showed morphologically butterfly-like D4 and D6 vertebrae and an incomplete ossification of the posterior arch of L5. Radiographs of the extremities and pelvis, as well as abdominal and renal ultrasound, showed no abnormalities. In the analyses of hormonal, biochemical parameters, liver and renal function, only a slight elevation of LDH was observed.\n\nThe main diagnostic hypothesis was a commercial panel for congenital heart defects and heterotaxy, which included the two genes associated with SALG (JAG1 and NOTCH2), allowing the study of point variants and copy number variants (CNVs) of the genes analyzed, an aspect relevant to the pathology under study. This analysis identified a pathogenic microdeletion in heterozygosity that covered the entire coding sequence of the JAG1 gene, in addition to three heterozygous variants of uncertain significance in the DNAH11, NME8 and NEK8 genes (associated with primary ciliary dyskinesia and nephronopthisis, both of autosomal recessive inheritance).\n\nAs a complete deletion of the JAG1 gene was identified, and considering reports of contiguous genes associated with pathologies that could require additional interventions in the patient, a more exhaustive study was decided to be performed by a molecular karyotype (Affymetrix CytoScan 750K). The array confirmed the presence of a pathogenic microdeletion, arr[GRCh37] 20p12.2(10414643_10792802)x1, of approximately 378 kb, that included 5 genes: MKKS, SLX4IP, JAG1, MIR6870, LINC01752. This confirmed molecularly the SALG due to the complete deletion of the JAG1 gene.\n\nThe patient fulfilled three of the seven clinical criteria for the diagnosis of SALG, with pulmonary artery branch stenosis, butterfly-shaped thoracic vertebrae, and typical facial features including sunken eyes, bulbous nasal tip, and pointed chin. In subsequent check-ups, no alterations in liver or renal function tests, ophthalmologic anomalies, or xanthomas were observed. Her neurodevelopment is age-appropriate.\n\nThe parents were suggested to undergo a molecular karyotype study to determine the possibility of being carriers of CNVs, which would put them at a 50% risk of having another child with the condition. However, due to financial reasons, this study was not performed.\n\n",
    "summary": "Female patient who was found to have a heart murmur at 4 months of age. An echocardiogram showed pulmonary artery stenosis, which, along with a prominent forehead on physical examination, led to a referral to clinical genetics. Because of the suspicion of SALG, additional studies were performed that revealed butterfly vertebrae and a genetic panel that identified a pathogenic deletion in heterozygosity, covering the entire coding sequence of the JAG1 gene. To rule out a more extensive deletion, a molecular karyotype was performed, confirming a pathogenic microdeletion in chromosome 20 of 378 kb (arr[GRCh37] 20p12.2(10414643_10792802)x1).\n"
  },
  {
    "id": "multiclinsum_gs_en_256.txt",
    "fulltext": "A 66-year-old woman who presented to an ophthalmologist with complaints of metamorphopsia in her right eye. The patient was referred to our hospital for comprehensive eye examination, and her medical history revealed diabetes mellitus. There was no notable ocular or family history. Ophthalmic examination revealed that the best-corrected visual acuity (BCVA) was 20/32 in the right eye and 20/16 in the left eye. The intraocular pressures of both eyes were normal. There were no abnormal findings notable in the anterior segments and the immature cataracts in both eyes were observed. Fundus examination revealed reduced parafoveal gray-colored retinal transparency temporal to the fovea in both eyes. OCT image across the macula revealed a hypo-reflective inner and outer retinal cavity at the foveal center with the overlying ILM drape of the right eye. There were no apparent abnormalities in the retinal layer of the left eye, except for anterior hyaloid attachment both nasal and temporal to the macula. FA revealed hyperfluorescent spots from telangiectatic vessels situated temporal to the fovea in both eyes. Based on these clinical findings, the diagnosis of bilateral MacTel type 2 was confirmed. Thereafter, there was no change in the BCVA or ocular findings in the right eye, so the patient was followed-up without any treatments.\n\nFour years later after the initial visit, the BCVA in the right eye was further impaired to 20/50 and metamorphopsia worsened. Fundus examination showed gray-colored retina temporal to the fovea. OCT image showed multiple hypo-reflective cavities and atrophy of outer retinal layers. The patient underwent cataract surgery and PPV with fluid-air exchange in the right eye. Seven months after the initial surgery, the patient had a full-thickness MH in the right eye. The patient underwent a second surgery with PPV and ILM peeling with SF6 gas tamponade. The MH was closed at month 1 postoperatively. Twelve years after the surgery, the retinal atrophy temporal to the fovea had progressed, but the MH remained closed. The inner and outer retinal structures temporal to the fovea, where retinal atrophy was seen, were disrupted. The BCVA of the right eye was slightly recovered to 20/32 at 1 year and improved to 20/20 12 years after the surgery.\n\nSeven years after the initial visit, the patient experienced a decreased vision in the left eye. The BCVA of the left eye was 20/32. Fundus examination showed gray-colored retina temporal to the fovea. A scan using OCT revealed an inner retinal cavity within the macular area. Five years later (12 years after the initial visit), the patient complained of blurred vision in the left eye, and the BCVA was decreased to 20/50. The OCT image revealed a full-thickness MH. The patient underwent cataract surgery and PPV with an inverted ILM-flap technique and fluid-air exchange with SF6 gas tamponade. Following the procedure, the MH was almost closed at 1 month after the surgery, although there was tiny cavity in the outer retina, and the MH was fully closed at the 6-month postoperatively and the BCVA improved to 20/20. Twenty-two months after the surgery, the BCVA improved to 20/16, but the outer retina at the center had thinned, and disorganization of the inner and outer retinal layers and hyperreflective materials were seen temporal to the fovea.\n\nIn the patient, FAF and microperimetry were also evaluated. In both eyes, an increased FAF area was seen temporal to the fovea, possibly due to reduced blockage by macular pigment, and the retinal sensitivities were reduced in this area. As for the right eye, the center of the increased FAF was hypo-autofluorescence due to atrophy after longer than 12 years, and the retinal sensitivities in that area were particularly reduced. As for the left eye, longer than 2 years after the surgery, FAF showed hypo-autofluorescence at the center of the increased FAF area, where the retinal sensitivities were also reduced.",
    "summary": "Diagnoses: A 66-year-old woman was referred to our hospital for macular abnormalities in the right eye. The best-corrected visual acuity (BCVA) was 20/32 in the right eye and 20/16 in the left eye at the initial examination. Ophthalmic examination revealed decreased retinal transparency temporal to the fovea in both eyes, cystoid spaces at the macula of the right eye by optical coherence tomography, telangiectasia temporal to the fovea, and fluorescent leakage temporal to the fovea by fluorescein angiography in both eyes and the patient was diagnosed with MacTel type 2.\n\nInterventions: Since there was no tendency toward vision loss, the patient was followed up without any treatment. Four years later, the BCVA of the right eye had decreased to 20/50, and outer retinal layer atrophy at the macula had progressed, so the patient underwent cataract surgery, pars plana vitrectomy (PPV), and fluid-air exchange. Seven months after the initial surgery, an MH was formed in the right eye. Second surgery including PPV, ILM peeling, and sulfur hexafluoride gas tamponade were performed.\n\nOutcomes: Postoperatively, the MH was closed, and the BCVA improved to 20/32 at 1 year, and 20/20 at 12 years after the surgery, respectively. Twelve years after the initial visit, an MH appeared in the left eye, and the BCVA decreased to 20/50, so cataract surgery, PPV with inverted ILM-flap technique, and sulfur hexafluoride gas tamponade were performed in the left eye. Postoperatively, the MH was closed with no recurrence for longer than 2 years after surgery, and the BCVA improved to 20/16. Microperimetry performed after the surgery showed decreased retinal sensitivity consistent with areas of retinal atrophy in both eyes."
  },
  {
    "id": "multiclinsum_gs_en_514.txt",
    "fulltext": "An 86-year-old male patient presented to the emergency room for a 3-week nonpainful priapism. Our patient, a former cleaner agent, is only known for a transient ischemic incident. He has no previous surgical history. Physical examination showed a semierect nontender penis with a mild lateral deviation and a smooth glans. No superficial penile lesion was observed. The patient reported that he had lost normal erections almost 20 years ago. All clinical signs were in favor of a nonischemic priapism. The patient was a former smoker and reported mild upper respiratory tract symptoms as well. Lab work-ups and urine analyses were unremarkable; hence, the decision was to pursue investigations in an ambulatory setting using a penile ultrasound and a thoracoabdominal computed tomography (CT) scan looking for a malignancy.\n\nDoppler ultrasonography (US) of the penis was performed, revealing circumscribed hypoechogenic nodules infiltrating the albuginea of the corpus cavernosum, with a base and right-side predominance. No abnormalities were detected in the corpus spongiosum. A normal resistive index with a normal penile artery velocity was measured, in favor of a nonischemic situation.\n\nThoracoabdominal CT revealed a mass at the lung's left hilum surrounding the bronchovascular structures. Several bilateral nodules and micronodules were observed. The largest ones were located at the right apex and right lung base. Mediastinal enlarged lymph nodes were also seen at the lower paratracheal station. The liver was also affected by several lesions; the largest was located at Segment 7, which measured 96 mm. The left adrenal gland and pancreatic lesions were noted. Finally, two osteolytic lesions were observed on the first left rib and on the transverse process of fifth lumbar vertebra (L5). The patient was referred to the lung cancer specialist for further investigations. A pulmonary biopsy was performed, confirming adenocarcinoma of the lung. Molecular analysis of the cells showed a pGly12Cys (G12C) variant of the KRAS gene. PDL-1 was also noted as positive.\n\nAfter a multidisciplinary discussion, the decision was for the patient to pursue four-cycle chemotherapy and immunotherapy by cisplatin, pemetrexed, and pembrolizumab. The patient poorly tolerated the first cycle of chemotherapy and developed febrile pancytopenia. The decision was to halt the chemotherapy and pursue the immunotherapy by pembrolizumab.\n\nAs for the penile lesions, since the patient did not have any pain, surveillance was adopted.",
    "summary": "We hereby report the case of an 86-year-old male patient who presented with a 3-week-long nonpainful priapism. A penile Doppler ultrasound and a chest and abdominal CT scan were performed, showing a left hilar lung mass as well as lesions in the liver, the adrenal glands, the pancreas, bone structures, and the penis. Penile metastasis is associated with a poor prognosis because of the frequent disseminated malignant lesions in other sites."
  },
  {
    "id": "multiclinsum_gs_en_327.txt",
    "fulltext": "A 4-month-old male infant, after an uncomplicated pregnancy and delivery, weighed 3000 g at birth; there were no complications during pregnancy and no family history. The infant had symptoms of mild respiratory distress for 2 months, without fever or cough. He was diagnosed with patent foramen ovale by echocardiography at the primary hospital and received no treatments. Later, the symptoms were aggravated, and his parents sought care, again at the primary hospital, 9 days later. Ultrasonography of the abdomen showed features suggestive of hemangioendothelioma of liver. The hospital suggested that to the infant should be transferred to our hospital for treatment.\n\nExamination revealed an irritable infant with cough, fever, breathlessness and cyanosis; the infant weighed 6.8 kg and was in respiratory distress with a relative ratio of approximately 130/min. The infant had multiple skin hemangiomas of varying sizes on the head, neck, right index finger, and right shank. His physical examination was remarkable for bilateral wheezy phlegm in both lung bases. The physical examination showed enlarged cardiac dullness, but there were no significant heart murmurs. Abdominal distention was noted. The liver was soft and located 8 cm below the costal margin at the right mid-clavicular line.\n\nEchocardiography showed right atrial and right ventricular dilatation with a thickened right ventricular anterior wall and interventricular septum. The normal structure of the cardiac chamber and continuous atrioventricular septum were observed. The infant was diagnosed as having severe pulmonary artery hypertension with mild tricuspid regurgitation and trivial mitral regurgitation. Ultrasonography of the abdomen showed densely hypodense lesions, increased volume of liver lobes, with a clear boundary and a maximum diameter of 4.1 cm. The liver lobes had a heterogeneous internal echo and enhanced peripheral echo. Visible blood vessels were observed in the hypodense lesions. There were only a few normal liver parenchymas.\n\nA computed tomography (CT) scan of the abdomen showed an enlarged, irregularly shaped liver with multiple low-density intrahepatic masses, and its CT value was approximately 43 HU. Contrast-enhanced abdomen CT showed significant enhancement in the periphery of tumor, uneven enhancement in the center part of tumor during the arterial phase, centripetal enhancement in portal vein phase and even enhancement in late phase of tumor, which was more enhanced than normal liver. The lesions were more uniformly strengthened, and their degree of strengthening was higher than that of normal liver tissue in the delayed period.\n\nThe laboratory examinations showed normal values for creatine kinase, creatine kinase-MB, alanine aminotransferase, aspartate aminotransferase, unconjugated bilirubin, serum total bilirubin, conjugated bilirubin, creatinine, serum urea, and coagulant activity. However, thyroid-stimulating hormone (TSH) was 19.5 uIU/mL (NL = 1.36–8.8 uIU/mL), free triiodothyronine (fT3) was 3.21 pmol/L (NL = 4.5–10.5 pmol/L), and free thyroxine was normal. Meanwhile, alpha-fetoprotein was 15434.76 Ug/L (NL = 0–25 Ug/L).\n\nAfter we discussed the patient's condition, the infant was diagnosed with hepatomegaly, pulmonary artery hypertension, cardiac insufficiency, pneumonia, hepatic hemangioendothelioma, hypothyroidism, and multiple hemangiomas. Then, PAH and cardiac insufficiency were managed with fluid restriction, oxygen, diuretics, and inotropic support. In addition, the pneumonia was managed with antibiotics. Because fT3 was mildly decreased, we suggested that the infant should be regularly seen for endocrinology consultation. Meanwhile, propranolol was given at a dosage of 1 mg/kg every 12 hours.\n\nEight days after admission, the patient underwent transcatheter arterial embolization under general anesthesia. Unfortunately, because the diagnosis was relatively clear and the condition of the infant was worsening, his parents agreed to allow the patient to undergo TAE and refused a digital subtraction angiography-guided percutaneous biopsy after we informed them of the clinical risk. In addition, the TAE was approved by the ethics committee of Ji’nan Children's Hospital. The perineum was disinfected and draped with the patient in the supine position. The femoral artery was punctured by the Seldinger technique, and 100 IU/kg of heparin was administered to avoid thrombosis. The celiac artery was catheterized with a 4-F PIG angiographic catheter (Cordis, MI) under X-ray guidance. We observed that the blood supply to the IHH was derived from the proper hepatic artery branches, including the left hepatic artery and right hepatic artery, by digital subtraction angiography. The celiac artery was catheterized again with a 4-F Cobra guide catheter (Terumo, Tokyo, Japan) under X-ray guidance. Then, the 2.6 F microcatheter (Asahi, Nagoya, Japan) was used for superselective catheterization of the feeding artery. During the procedure, a pingyangmycin-lipiodol emulsion was injected slowly through the catheter until the periphery of the hemangioma was completely surrounded. Gelatin sponge particle (350–560 μm) embolization of the feeding artery was performed if the blood supply artery was faster, as shown by angiography. Selective celiac arteriography was performed once again if necessary to judge the degree of embolism of the supplying arteries. The injection was stopped when a small branch of the portal vein around the tumor was developed or the total volume was administered. At the conclusion of the embolization, the microcatheter was withdrawn, and the sheath was removed. Hemostasis of the femoral artery was then achieved by manual compression for 10 to 15 minutes.\n\nPostoperatively, meticulous nursing care was given to the patient, and symptomatic relief and supportive treatment were continued. Thirty-five days after admission, the PAH decreased, the symptoms of cardiac insufficiency were alleviated, and the severe pneumonia was cured. On the third month after the TAE, the abdominal distention was alleviated. The liver was soft and located 2 cm below the costal margin at the right mid-clavicular line. A CT scan of the abdomen still showed an irregularly shaped liver with multiple significantly strengthened intrahepatic masses, and the size of the largest mass was 1.6 cm. Echocardiography showed normal pulmonary artery pressure and EF. The patient underwent a second TAE under general anesthesia. There were no serious complications after the operation. At the 1-year follow-up, the infant had steadily gained weight, the liver volume and size of the mass decreased considerably, and the hypothyroidism returned to normal.",
    "summary": "Patient concerns:\nWe present a case with hepatomegaly, pulmonary artery hypertension, and cardiac insufficiency caused by infantile hepatic hemangioendothelioma.\n\nDiagnosis:\nInfantile hepatic hemangioendothelioma was diagnosed.\n\nInterventions:\nThe patient underwent transcatheter arterial embolization and was given propranolol.\n\nOutcomes:\nThe patient responded well to treatment with transcatheter arterial embolization and propranolol. The patient gained weight steadily, liver volume, and mass size have decreased considerably, echocardiography showed normal pulmonary artery pressure and ejection fraction, and we discovered no serious complications after 1 year of follow-up."
  },
  {
    "id": "multiclinsum_gs_en_39.txt",
    "fulltext": "A 52-year-old male patient with initial diagnosis of pulmonary arterial was admitted to the Department of Cardiology for medical assessment and decision on further treatment. The patient had a history of right-sided spontaneous pneumothorax, treated with thoracentesis and vacuum drainage 35 years earlier. The patient felt increasing dyspnea on exertion. He also complained about signs of right ventricle failure and cyanosis. Four years earlier the patient was hospitalized three times for paroxysmal atrial fibrillation that was converted to sinus rhythm by electric cardioversion besides electrocardiographic examination was normal.\n\nIn the same year coronary angiography indicated normal coronary arteries. Echocardiography revealed mild pulmonary hypertension with calculated right ventricle systolic pressure of 36 mmHg without right ventricle dilation.\n\nIn the following years, progressive heart failure with increasing pulmonary artery pressure in echocardiography has been observed. Angio-CT was performed on two occasions and chronic thromboembolic pulmonary hypertension was excluded each time. High-resolution computed tomography has excluded interstitial pulmonary pathology. Spirometry was normal. Screening for autoimmune diseases and HIV infection was negative.\n\n\nTimeline – history, course of the disease, diagnosis and treatment\n\n1976\tright-hand pneumothorax\n2007\tHospitalized three times for atrial fibrillation and heart failure echocardiography, cardioversion, coronarography were performed. Every time discharged from the departments with diagnosis: Atrial fibrillation, Heart failure, NYHA class II.\n2010–2011\tIncreasing growing shortness of breath and symptoms of heart failure. Patient was hospitalized 3 times. Indirect features of pulmonary hypertension in echocardiography were detected. Three times chest-CT examination was performed; pulmonary embolism or chronic thromboembolic pulmonary arterial hypertension (2 x angio-CT) or pulmonary fibrosis (high resolution computer tomography) was excluded.\nDiagnosis of pulmonary hypertension was established, WHO class III.\nDEC-2011\tAdmission to cardiology clinic – echocardiography (TTE, TEE), 6-min walking test, NT-proBNP, right heart catheterisation, pulmonary vasoreactivity test.\nDiagnosis of irreversible arterial pulmonary hypertension was established.\nTreatment with the illoprost and sildenafil has started\nJAN-2012\tcontrol visit – improvement in WHO class, decrease of NT-proBNP concentration and increase of 6-min test distance\nMAY-2012\tControl RHC. SaO2 of blood samples obtained during RHC from upper lobe artery of the right lung amounted 87%.\nAngiographic diagnostic of pulmonary arteries revealed PAH fistulas between subclavian and upper lobe of right lung arteries\nJUN 2012\tangio-CT of systemic arteries revealed additional presence of bronchial artery fistulas to upper lobe of right lung arteries\nIII-2013\tEmbolisation of fistulas\nVI-2013\tDeath as a result of worsening of heart failure combined with pneumonia.\n\n\n\nAt admission to our clinic functional class of patient was assessed as WHO III, In physical examination the second heart sound (S2) was accentuated with widened split S2. Moreover, heart auscultation indicated holosystolic murmur of tricuspid regurgitation. The auscultation of the chest did not show a vascular murmur. Peripheral and central cyanosis was marked. Hepatomegaly, peripheral edema and varicose veins bilaterally were examined.\n\nSaO2 obtained by pulse oximetry method was reduced to 88%. Electrocardiography revealed atrial fibrillation, right axis deviation and negative T wave in precordial leads v1-v3. Additional tests were as follows: NT-proBNP concentration – 3383 pg/ml, six-minute walking test distance - 373 m with 7/10 points in Borg dyspnea score.\n\nEchocardiography showed features of severe pulmonary hypertension: right ventricle enlargement to 44 mm (four chamber view), with depressed function of right ventricle TAPSE 9 mm, right atrium area enlargement to 40 cm2, severe tricuspid valve regurgitation (++++), increased calculated RVSP to 112 mmHg, shortened pulmonary artery acceleration time to 60 ms and mild pericardial effusion. There was no interventricular septum defect. Trans-esophageal echocardiography did not show a defect in the atrial septum too, which was confirmed later by angio-CT.\n\n\nSaO2 of blood obtained from radial artery was reduced to 87,8%. Right heart catheterization was performed. SaO2 of blood samples obtained during RHC from vena cava superior, vena cava inferior, right atrium, pulmonary trunk, middle lobe artery of the right lung and left pulmonary artery amounted respectively: 64,8%; 77,4%; 73,2%; 70,2%, 69,3%; 71,2% and did not indicate the presence of a left-to-right shunt.\n\nHemodynamic measurements showed severe precapillary pulmonary hypertension, irreversible in vasoreactivity testing with inhaled nitric oxide (80 ppm) and a combination of oral sildenafil (50 mg) and inhaled nitric oxide (80 ppm).\n\nBased on the whole clinical data and the results of RHC, a diagnosis of idiopathic irreversible pulmonary hypertension was established.\n\nTreatment with inhaled iloprost (Ventavis) 6 × 5 μg and sildenafil (Revatio) orally 3 × 20 mg was initiated. Moreover, digoxin (0,1 mg daily), warfarin (INR range: 2–3), furosemide (40 mg orally daily) and spironolactone (100 mg daily) were administered.\n\nNoninvasive follow up was performed one month later – the patient reported improved physical capacity, class II WHO, NT-proBNP concentration: 1014 pg/ml. Six-minute walking test distance - 471 m.\n\nInvasive assessment was done five months later. RHC showed higher than in initial measurements values of PAP [75,4/51,8 (59,7) mm Hg] and PVR (13,4 WU) (Table ​(Table22 – control RHC).\n\nOxygen saturation of blood samples obtained during RHC from upper lobe artery of the right lung was elevated and amounted 89.7%.\n\nIn the pulmonary angiography reduction of peripheral vascular drawing typical of pulmonary arterial hypertension and the lack of contrast of the right upper lobe artery were detected. Additionally the evidence of retrograde blood flow visible as a negative contrast in right pulmonary artery was found. Afterwards, right subclavian artery arteriography was performed and a huge vascular malformation communicating with right upper lobe artery was detected.\n\nAngio-CT of systemic arteries confirmed presence of previously described fistulas and revealed additional presence of bronchial artery fistulas to upper lobe of right lung arteries.\n\nSelective embolisation of fistulas was performed (50% mixture of Lipiodol and monomeric n-butyl-2-cyanoacrylate glue). Embolisation did not bring any clinical change in the patient’s condition.",
    "summary": "52-year-old male Caucasian patient with echocardiographically confirmed pulmonary hypertension (PH) was admitted to cardiology department due to exertional dyspnea and signs of right ventricle failure. Routine screening for causes of secondary PH was negative. Right heart catheterization (RHC) confirmed a high degree arterial PH [mean pulmonary artery pressure (mPAP); 50,6 mmHg, pulmonary wedge pressure (PWP); 11,3 mmHg, pulmonary vascular resistance (PVR); 11,9 Wood’s units (WU)] irreversible in the test with inhaled nitric oxide. Oxygen saturation (SaO2) of blood samples obtained during the first RHC ranged from 69.3 to 73.2%. Idiopathic pulmonary arterial hypertension was diagnosed. Treatment with inhaled iloprost and sildenafil was initiated.\n\nControl RHC, performed 5 months later showed values of mPAP (59,7 mmHg) and PVR (13,4 WU) higher in comparison to the initial measurement, SaO2 of blood obtained during RHC from upper lobe artery of the right lung was elevated and amounted 89.7%.\n\nThen, pulmonary arteriography was performed. Lack of contrast in the right upper lobe artery with the evidence of retrograde blood flow visible as a negative contrast in the right pulmonary artery was found. Afterwards, right subclavian artery arteriography detected a huge vascular malformation communicating with right upper lobe artery. Following computed tomography angiogram (angio-CT) additionally revealed the enlargement of bronchial arteries originated fistulas to pulmonary artery of right upper lobe.\n\nIn spite of intensive pharmacological treatment, including the therapy of pulmonary hypertension and percutaneous embolisation of the fistulas, the patient’s condition continued to deteriorate further. He died three months after embolisation due to severe heart failure complicated by pneumonia."
  },
  {
    "id": "multiclinsum_gs_en_503.txt",
    "fulltext": "A female infant was born at 34 weeks of completed gestational age with a birth weight of 2,820 g. A complete course of antenatal corticosteroids had been given and routine antenatal imaging showed polyhydramnios and a large for date fetus. There was history of maternal gestational diabetes and pre-eclampsia.\n\nThe infant was delivered by caesarean section in good condition with APGAR scores of 61, 95 and 1,010, but in view of respiratory distress she was given surfactant via less invasive administration 25 min after birth. She was then transferred to the neonatal intensive care unit on continuous positive airway pressure (CPAP) in 40% oxygen. At 4 h after birth in view of on-going respiratory distress and an increasing oxygen requirement up to 60% she was intubated and mechanically ventilated. A chest radiograph revealed evidence of possible bilateral eventration of the diaphragms. Diaphragm ultrasound examination confirmed this suspicion. An echocardiogram (ECHO) performed at that time revealed mild hypoplasia of the isthmus, but a repeat ECHO demonstrated a structurally normal heart. After undergoing a spontaneous breathing trial and a period of non-invasive assessment of the electrical activity of the diaphgram, she was successfully extubated after 36 h of invasive ventilatory support. Futhermore, she did not require post-extubation non-invasive respiratory support and remained self-ventilating in air until discharge. As she did not require prolonged periods of invasive respiratory support, she was felt not to be a candidate for surgical intervention in the acute neonatal period.\n\nDuring her neonatal course she was hypoglycaemic on admission to the neonatal unit with a blood glucose of 0.4 mmol/L and required a maximum glucose concentration of 20%. She was subsequently diagnosed with hyperinsulinism and commenced diazoxide. She had poor feeding despite normal videofluroscopy and ear, nose throat (ENT) examination and went on to require feeding support via a nasogastric tube. On neurological assessment she exhibited central hypotonia with brisk reflexes and was noted to have extensive melanocytic naevi over the lateral aspect of both arms with additional patches on the sacrum. Histopathological examination of a punch biopsy demonstrated results consistent with dermal melanocytosis. She was born with two neonatal teeth which were removed postnatally, however she subsequently developed two fibrous lesions on the anterior alveolar ridge which were pedunculated and mobile, these were later removed at 1 month of age. Extensive neurological investigation was performed and revealed normal brain magnetic resonance imaging scan, with normal upper and lower limb electromyography and nerve conduction studies. Considering the differential diagnosis of spinal muscular atrophy, immunohistochemistry analysis was performed, which showed normal results. Ophthalmological assessment and a renal ultrasound scan was performed, both were normal. Postnatal genetic testing revealed a KMT2D gene mutation, associated with Kabuki syndrome.\n\nShe was discharged home on day 64 after birth with nasogastric feeding support and continued on diazoxide medication. She continues to have extensive input from occupational therapists, speech and language therapists and physiotherapy teams.\n\nImaging and measurements\nThe chest radiographic thoracic area (CRTA) measured post extubation (day three after birth) was 1,654 mm2, equivalent to that of a term infant with severe congenital diaphragmatic hernia. Ultrasound imaging (USS) showed focal diaphragmatic eventration with bulging of the dome of the liver into the right and left hemithoraces. A spontaneous breathing trial (SBT) was conducted prior to exubation and electromyography of the diaphgram was measured during this period. The mean amplitude of diaphragmatic electrical activity was 2.47 μV, similar in magnitude to that of ventilated infants of the same gestational age with intact diaphragms. She successfully passed the SBT and subsequent extubation.\n\nThe parents gave informed written consent for this report and ethical approval was given for measuring the diaphragm EMG during the SBT prior to extubation (REC reference: 20/SW/0,062).",
    "summary": "A female infant born at 34 weeks gestation required intubation and ventilation at birth. Chest radiographical imaging revealed bilateral density to the bases of both lung fields with raised hemi-diaphragms. Ultrasound imaging showed focal diaphragmatic eventration with bulging of the dome of the liver into the right and left hemithoraces. Assessment of the electrical activity of the diaphragm during a spontaneous breathing trial demonstrated a mean amplitude consistent with that of ventilated infants of the same gestational age with intact diaphragms. Hence she was extubated which was successful. Chest radiographic thoracic area measured post extubation was 1,654 mm2, equivalent to that of a term infant with severe congenital diaphragmatic hernia. As the electrical activity of the diaphragm was normal this suggests replacement of the diaphragmatic muscle tissue with fibrous bands was likely to be only partial, and hence why extubation was successful. She had other abnormalities presenting in the neonatal period including dermal melancytosis, central hypotonia, hyperinsulinism and poor feeding. The infant underwent extensive investigation which revealed a KMT2D gene mutation associated with Kabuki syndrome."
  },
  {
    "id": "multiclinsum_gs_en_310.txt",
    "fulltext": "The patient is a 6-year-old girl from a farming family in a non-high-altitude area. She was presented with mild cyanosis of the lips at birth and was initially diagnosed with congenital heart disease. Because of progressive cyanosis and dyspnea, the patient came to our outpatient clinic for further diagnosis and treatment. She had normal growth and development without significant physical or intellectual delays. The family reported that she was prone to pneumonia and frequently coughed since birth. Physical examination revealed significant cardiac murmurs, clubbing of the fingers, and cyanosis of the lips. Electrocardiography showed sinus rhythm with biventricular hypertrophy and right axis deviation. Transthoracic echocardiography revealed significant hypertrophy of both ventricles and the left atrium, with an absent echo between the left wall of the ascending aorta and the right wall of the main pulmonary artery (MPA), which measured approximately 18 mm. There was a narrow segment in the isthmus of the aortic arch, measured approximately 4mm, and interruption of the aortic arch distal to the left subclavian artery (LSA). The right pulmonary artery (RPA) arose from the ascending aorta, while the left pulmonary artery (LPA) originated from the pulmonary trunk. Between the descending aorta and the left pulmonary artery, there was a prominent PDA with a diameter of approximately 6 mm. The atrial and ventricular septa were intact, valve function was normal, and the coronary artery origins were normal. The pulmonary hypertension was 50 mm Hg. The patient did not take pulmonary antihypertensive treatment before surgery. Subsequently, the patient underwent CT angiography, which confirmed the findings of the echocardiography. The 3-dimensional reconstruction clearly showed a type I APW, type A IAA, and PDA. Four branch vessels were also visualized, namely the right common carotid artery (RCCA), left common carotid artery (LCCA), anomalous right subclavian artery (ARSA), and LSA, which all arose from the proximal end of the interrupted aortic arch.\n\nBased on the patient’s medical history and examinations, a definitive diagnosis of Berry syndrome was established, and surgical intervention was indicated. The patient’s family requested surgery. A standard mid-sternotomy approach was performed, revealing abundant collateral vessels from the main pulmonary artery. During the repair of interrupted aortic arch, conventional deep hypothermic circulatory arrest and selective cerebral perfusion were employed. Firstly, the ductus arteriosus was dissected distally and ligated, followed by excision of the ductal tissue. The aortic arch and descending aorta were carefully mobilized, and an end-to-side anastomosis was performed between the descending aorta and the aortic arch. The anterior wall was reinforced using a pericardial patch. After the correction of IAA, the RPA was disconnected. The APW was observed, and the defect was approximately 1cm from the aortic valve annulus. The origin of the coronary arteries was normal. Along the edge of the APW, aorta and MPA were separated, while the RPA was end-to-side anastomosed to the MPA. A bovine pericardial patch was used, and the incision in the aorta was closed with 6-0 prolene sutures in a continuous manner. Intraoperative transesophageal echocardiography confirmed continuous flow through the aortic arch and no shunting between the MPA and the aorta. The patient received further treatment in the ICU postoperatively and was transferred to a regular ward after 5 days. The pulmonary hypertension reduced to 26 mm Hg after surgery and no pulmonary hypertension medication was needed. The patient did not need hemodynamic support after the surgery. A successful evaluation was conducted, and the patient was discharged 7 days later.",
    "summary": "Patient concerns: In this article, we report a case of a 6-year-old girl with Berry syndrome who presented with significant ischemic and hypoxic symptoms.\n\nDiagnoses: Based on the patient's medical history and examinations, a definitive diagnosis of Berry syndrome was established.\n\nInterventions: She underwent a 1-stage surgical treatment and had a successful discharge. The surgical process was aimed to preserve the growth potential of the aorta and pulmonary arteries while achieving unobstructed left ventricular outflow and continuity of the aortic arch, ensuring no shunting between the main pulmonary arteries.\n\nOutcomes: Intraoperative transesophageal echocardiography confirmed continuous flow through the aortic arch and no shunting between the MPA and the aorta."
  },
  {
    "id": "multiclinsum_gs_en_148.txt",
    "fulltext": "Clinical Presentation\nA 68-year-old-woman presented to the emergency department with a 2-day history of acute confusion and behavioural changes (delirium), against the background of known severe cerebral palsy. She was known to have recurrent UTIs well-managed at home with oral antibiotics. The rest of her past medical history included bilateral staghorn calculi, which had been previously treated by PCNL. On presentation, her blood results showed a marked increase in C-reactive protein (CRP = 260.9 mg/L), a decline in renal function (estimated glomerular filtration rate (eGFR) = 38 mL/min/1.73m2, urea = 11.7 mmol/L, and creatinine = 124), and microcytic hypochromic anemia with thrombocytopenia. The blood cultures that were taken returned as negative, and the urine cultures revealed mixed growth.\n\nDiagnostic Approach\nThe initial diagnosis included a UTI, acute kidney injury (AKI), and microcytic anemia with thrombocytopenia, all in the context of urosepsis. As she was severely constipated, an abdominal X-ray was ordered, which first revealed left radiopaque renal calculi. A subsequent computed tomography (CT) KUB (kidneys−ureters−bladder) scan identified large left renal calculi, including a left staghorn calculus measuring 4.5 cm. The presence of a second displaced left-sided staghorn (measuring 4 cm) within a renocolic fistula was initially missed. The migrated staghorn was described as “calcification arising from the large bowel.” The presence of a renocolic fistula was suggested as there were pockets of air seen inside the renal pelvis.\n\nDue to worsening renal function during hospitalization, repeat imaging (CT KUB) revealed a 4.4-cm staghorn calculus within the rectum. The CT report highlighted a strong suspicion of a renocolic fistula, facilitating the migration of the stone into the rectum. The stone was subsequently expelled spontaneously through the rectum.\n\nManagement and Outcomes\nGiven her significant comorbidities, the patient's condition was managed conservatively. She was deemed unsuitable for general anesthesia due to the high risk of intubation and was not a candidate for local anesthetic JJ-stent insertion due to her cerebral palsy. Nephrostomy was also ruled out as an option since the in situ staghorn calculus occupied the entire left renal pelvis. Ultimately, after an extended hospital stay, she responded well to conservative treatment with antibiotics. She was given a one-off (STAT) dose of amikacin at presentation and clarithromycin−amoxicillin (1.2 g intravenously three times a day) for 6 days, which was then escalated to ceftriaxone (2 g intravenously once a day) for another 8 days. Her case was also discussed at the Stone Urology Multidisciplinary Team Meeting (MDTM), and it was decided to provide symptomatic treatment only, with no further interventions, as there was a high mortality risk. After improving clinically, she was discharged to her usual place of residence.\n\nComplication: Psoas Abscess\nSeveral months later, she represented to the emergency department with signs of urinary infection (low oral intake, foul-smelling urine, and fevers). A CT KUB scan revealed a large left iliopsoas abscess, measuring 87 × 54 mm, with gas bubbles, alongside bilateral staghorn stones. Conservative management with antibiotics was again recommended due to her extensive comorbidities and high mortality risk. This approach was agreed upon by the Urology Team, the Medical Team, and the Interventional Radiologists. After an extensive course of antibiotics (clarithromycin−amoxicillin 1.2 g three times daily, for 4 weeks), she responded well and was discharged to her usual place of residence. A few weeks later, she attended the emergency department with aspiration pneumonia and sepsis and unfortunately passed away.",
    "summary": "A 68-year-old female presented to the emergency department with signs of urosepsis. Computed tomography (CT) imaging revealed a left-sided staghorn calculus with concurrent smaller renal calculi. Due to worsening kidney function during hospitalization, repeat imaging was done, which revealed a staghorn calculus in the rectum. The staghorn calculus migrated to the colon through a renocolic fistula, and the patient subsequently passed the large staghorn through the rectum spontaneously. Conservative management was pursued due to her high surgical risk. Several months after discharge, she represented with signs of infection, and a large left-sided psoas abscess was identified."
  },
  {
    "id": "multiclinsum_gs_en_106.txt",
    "fulltext": "This 53-year-old man initially presented with acute-onset chest discomfort as an isolated symptom. He was previously an active, fit and well non-smoker with no medical nor family history.\n\nOn examination, he had normal heart sounds with no murmurs. His jugular venous pressure was not elevated. His chest was clear and there was no ankle oedema.\n\nHis blood pressure was 98/78 mm Hg and his heart rate was 62 beats per minute. His oxygen saturations were 100% on room air and his respiratory rate was 16 breaths per minute. He was apyrexial with a temperature of 37.1°C.\n\n\nInvestigations\n\nECG showed LVH and widespread T wave inversions. Serum high-sensitivity cardiac troponin I (hs-cTnI) levels rose from 28 ng/L (0 hour) to 77 ng/L (6 hours) (male upper reference limit for this assay: 34 ng/L). He was managed with dual antiplatelet therapy for a working diagnosis of non-ST elevation myocardial infarction.\n\nCT coronary angiography showed calcific plaque in two coronary arteries. Conventional angiography confirmed no flow limitation. Transthoracic echocardiography showed moderate LVH with significant outflow tract obstruction. There was a mild systolic impairment with localised inferior wall akinesia. A cardiac MRI was requested as an outpatient investigation.\n\nOne month later, the patient was readmitted with further chest discomfort. Four days of telemetry revealed no dysrhythmia during these episodes of discomfort. ECG showed no dynamic changes. There was a static low-level hs-cTnI rise at 37 ng/L, 30 ng/L and 33 ng/L, respectively, taken daily due to multiple intermittent episodes of chest pain over several days. C reactive protein level was less than 3 mg/L and he was afebrile.\n\nCardiac MRI showed concentric LVH, an area of basal inferolateral probable oedema and an unusual pattern of predominantly endocardial late gadolinium enhancement (LGE) with patchy septal mid-wall enhancement and diffuse subendocardial enhancement. He had normal LV volumes and ejection fraction (61%) but an elevated mass at 221 g (101 g/m2) consistent with hypertrophy. As his blood pressure remained normal, we were reluctant to put the LVH down to hypertensive heart disease.\n\n\nDifferential diagnosis\n\nDue to the unusual nature of the case, it was discussed at the regional multidisciplinary team meeting. The MRI was not felt to be classical of either myocarditis or amyloid, but the outcome of the meeting had suggested to screen for amyloid cardiomyopathy and Anderson-Fabry disease.\n\nAlpha galactosidase level was normal, effectively excluding Fabry disease.\n\nSerum free (SF) light chain showed raised SF Kappa at 253.20 mg/L (reference range: 3.3–19.4) with normal SF Lambda 9.6 mg/L (reference range: 5.7–26.3). The kappa/lambda ratio was 26.375 (reference range: 0.26–1.65).\n\nBone marrow aspirate showed particles largely obscured by amorphous cloudy blue extracellular proteinaceous deposits. These deposits stained salmon-pink on Congo red staining. When visualised under polarised-light microscopy, they gave a characteristic apple green birefringence—consistent with amyloid deposition. There was a slight excess of plasma cells, which was insufficient to diagnose a plasma cell dyscrasia.\n\nStaining of fat pad aspirate with Congo red did not demonstrate convincing evidence of amyloid deposition.\n\nA CT abdomen and pelvis showed nothing else to account for his amyloidosis. Hepatitis B, hepatitis C and HIV screen were negative. Serum electrophoresis showed no abnormal monoclonal band detected and immunoglobulins were normal.\n\n\nTreatment\n\nThe patient was referred to the National Amyloidosis Centre in London where the diagnosis was confirmed. At their recommendation, the local haematology team oversaw administration of chemotherapy for primary AL amyloidosis with cardiac involvement. He received a 21-day cycle of VCD (bortezomib, cyclophosphamide and dexamethasone).\n\nAdditional supportive medications were provided, including doxycycline, aciclovir and allopurinol for the first 2 cycles of chemotherapy.\n\n\nOutcome and follow-up\n\nFollow-up at 1 year from diagnosis showed that the patient remained stable, his chest pain had completely resolved, and he still did not exhibit any symptoms of heart failure.\n\nHowever, when the COVID-19 pandemic hit the country, his chemotherapy was stopped by his clinicians at the National Amyloidosis Centre, given his good progress with treatment and the associated risks of COVID-19.\n\nTwo months following this, he represented with a further episode of chest pain and low-level hs-cTnI rise. His chemotherapy was, therefore, reintroduced, and his chest pain had subsequently resolved.",
    "summary": "A 53-year-old man presented to a district general hospital with chest pain, ECG changes and a small high-sensitivity cardiac troponin I rise. There were no symptoms of heart failure. CT coronary angiography revealed moderate calcific disease and conventional angiography confirmed no flow limitation. Echocardiography showed left ventricular hypertrophy (LVH). His blood pressure remained normal throughout his admission. The tertiary centre labelled this as a ‘plaque rupture’ event but the LVH remained unexplained. Cardiac MRI displayed an unusual pattern of late gadolinium enhancement, which was not classical of amyloid. However, a raised serum free kappa light chain along with the deposition of amyloid on his bone marrow aspirate confirmed the diagnosis of primary AL amyloidosis with cardiac involvement. The patient went on to have chemotherapy and remained stable at 1-year follow-up."
  },
  {
    "id": "multiclinsum_gs_en_100.txt",
    "fulltext": "A six-month-old male infant was observed in the emergency department for fever (maximum temperature 40ºC every 6 hours), rhinorrhea, cough and refusal of food with three days of evolution. The pregnancy was full term, monitored and without complications. In the neonatal period he was admitted for congenital pneumonia complicated with pneumothorax and recovered with drainage, antibiotic therapy and invasive mechanical ventilation. He had vaccinations up to date according to the National Vaccination Calendar and including three doses of the Hib vaccine, two doses of the MenB vaccine, two doses of the MenACWY vaccine and two doses of the rotavirus vaccine. He attended a day care center and his family history was not relevant.\n",
    "summary": "A six-month old infant presented to the emergency department with a fever, cough and runny nose. He was alert and hemodynamically stable at admission, but became progressively lethargic and had a bulging fontanelle. Blood tests showed a normal white blood cell count and elevated C-reactive protein. A cerebrospinal fluid cytology and biochemistry were consistent with bacterial meningitis, and ceftriaxone was initiated. A blood culture and a cerebrospinal fluid culture were positive for Haemophilus influenzae. Serotyping of the strain identified a Haemophilus influenzae serotype A. Viral testing of the cerebrospinal fluid and nasopharyngeal aspirate was positive for adenovirus. He was discharged after 10 days of antibiotics and full clinical recovery.\n"
  },
  {
    "id": "multiclinsum_gs_en_471.txt",
    "fulltext": "A 7-year-old boy was brought to the Emergency Department by his mother. The mother complained that the child’s left eye had deviated upward. Five days before the deviation, the boy had blunt trauma from a football striking to the left orbit and face. The mother noticed an upward deviation but did not seek immediate medical consultation. The child did not have any pain, blurring of vision, diplopia, loss of consciousness, nausea or vomiting, seizures, or abnormal behavior at presentation.\n\nThe child was playful during the ophthalmological examination and had no abnormal head position. His vision was 20/20 in both eyes. He had mild limitation of depression in the left eye but had full extraocular motility in other cardinal directions. In the primary position, hypertropia was noted in the left eye, and it increased in the left gaze with a right-side head tilt, consistent with inferior rectus muscle palsy. He had normal intraocular pressure (IOP) in RE (17mmHg) and LE (16mmHg) as measured by a tonometer (iCare, Vantaa, Finland). No mass was felt around his orbit on palpation, nor was any optic nerve function deterioration noted. Fundus examination showed a healthy optic nerve head and normal retina without brakes. The exophthalmometer measurements at the base (91mm), RE (14 mm), and LE (15 mm) were of normal size.\n\nComputed tomography (CT) of the head revealed soft tissue density involving the left maxillary sinus extending into the left nasal cavity and left extraconal orbit. This mass could be attributed to an organizing hematoma and was reported to correlate with the clinical findings. The ear, nose, and throat (ENT) review revealed no nasal discharge or obstruction. The left middle turbinate was congested with purulent discharge adherent to the mucous membrane. The maxillary opacification was attributed secondary to trauma, but an urgent Magnetic resonance imaging (MRI) sinus with contrast was recommended to rule out other causes.\n\nThe Magnetic Resonance Imaging (MRI) showed a 37.6×38.4 mm lesion within the left maxillary sinus, extending to the orbit, nasal cavity, premaxillary, and retro-maxillary areas with a heterogeneous signal and mild heterogeneous enhancement. There was also an underlying abnormal marrow signal in the left posterior maxillary alveolus with abnormal thickening and signal in the gingiva, which was suspected to be a neoplastic process.\n\nA biopsy of the left maxillary sinus and left nasal cavity showed malignant round cell neoplasm positive for desmin, myogenin, and myogenic differentiation 1. Fluorescence in situ hybridization was positive for FOXO1.\n\nBased on these clinical and imaging findings, the patient was diagnosed to suffer from alveolar fusion-positive RMS. A full metastatic workup included cerebrospinal fluid analysis, bone marrow aspiration and biopsy, chest CT, brain MRI, bone scan, and positron emission tomography. It did not reveal any metastatic lesions.\n\nOne month after the presentation, the child developed severe conjunctival chemosis, high IOP, and lagophthalmos. He was given thrice daily dorzolamide 2% eye drops to lower the IOP.\n\nThe Tumor Board labeled this child to have PM-RMS stage III. According to the TNM classification, the tumor was classified as T2bNxM0, representing intermediate risk based on Children’s Oncology Group Rhabdomyosarcoma Risk Stratification.11 The treatment plan included radiotherapy and chemotherapy. The chemotherapy included vincristine, actinomycin D, and cyclophosphamide (VAC) in high doses. The child received 45 Gy/25 fx using rapidArc technique. Five cycles were given, and treatment is still ongoing. Three months after the start of treatment, there was a marked decrease in the size and extension of the tumor, with the 3 months later image showing the orbits and optic nerve sheath free of tumor. Six months after initiating the therapy, the patient’s appearance improved, and his IOP normalized. Therefore, 2% of dorzolamide eye drops were discontinued. The child continues to be under the care of a multidisciplinary team.",
    "summary": "A child presented with an upward deviation of the left eye. He had a history of blunt trauma to the face before 5 days. Computed tomography (CT) of the head revealed a soft tissue density involving the left maxillary sinus. The magnetic resonance imaging (MRI) showed a 37.6 mm x 38.4 mm lesion within the left maxillary sinus extending to the orbit, nasal cavity, and premaxillary and retro maxillary areas with a heterogeneous signal and mild heterogeneous enhancements. A biopsy and histopathology confirmed alveolar RMS. The child was treated with chemotherapy and radiotherapy."
  },
  {
    "id": "multiclinsum_gs_en_246.txt",
    "fulltext": "A 29-year-old man (height = 180 cm, weight = 60 kg) was admitted to our hospital due to sudden onset of palpitation, chest tightness, mild fever, and night sweats, accompanied with bilateral double lower extremities adynamia and paralysis for 5 days, but no obvious syncope and edema. Examination on admission revealed a normal heart rate of 96 beats/minute (bpm) and blood pressure of 120/80 mmHg. On cardiac auscultation, 3/6 grade systolic murmur (Levine Scale) was heard between the third and fourth ribs at the left margin of sternum. The sensory below the sternum was dysfunctional. Muscle strength on both legs was at 1/6 levels (Lovett Scale), and tendon reflex diminished. Electrocardiography showed a sinus rhythm with pulmonary P-wave. An X-ray image of the chest showed discrete and scattered miliary nodules over both lungs, and cardiac silhouette was enlarged. Magnetic resonance imaging (MRI) showed an erosive space-occupying lesion located between the first and third thoracic vertebrae, which resulted in stenosis of the spinal canal and thinning of the spinal cord. Transthoracic echocardiography (TTE) showed a huge mobile mass (72 × 58 mm) in the RA and myxoma was considered. The left ventricular ejection fraction was 60%. The remaining physical examination findings were unremarkable, and laboratory tests were normal, except for the accelerating erythrocyte sedimentation rate. There was no family history of heart disease, including tumors and other cardiovascular problems. The preliminary diagnosis was thoracic vertebra tumor and cardiac myxoma. To treat the incomplete paraplegia caused by thoracic vertebra tumor erosion, the operation including resection of thoracic vertebral lesions, decompression, and internal fixation with nail-rod must be carried out immediately. A multiple disciplinary team consisting of cardiologist, orthopedist, sonologist, and anesthesiologists, was created. Fatal complications of cardiac myxoma, such as intracardiac obstruction and pulmonary embolism, were assessed. Informed consent of critical illness was signed by the patient's legal representative.\n\nThe patient did not receive premedication before anesthesia. On arrival in the operating room, peripheral venous access was established on the dorsum of the hand, and continuous electrocardiogram and pulse oximetry monitoring were instituted. Invasive arterial blood pressure (IBP) was measured in the left radial artery, and the central venous pressure (CVP) was measured in the right femoral vein. Anesthesia induction was carried out with intravenous injection of midazolam 4 mg, penehyclidine hydrochloride 1 mg, etomidate 16 mg, and sufentanil 50 μg. Cisatracurium 12 mg was used to facilitate tracheal intubation. Maintenance of compound anesthesia consisted of 2% sevoflurane in an air–oxygen mixture, and remifentanil was continuously injected intravenously at 0.2 μg/kg/min. Intermittent bolus dose of 5 mg cisatracurium was administered for muscle relaxation. After anesthesia induction, hemodynamic parameters were stable at the supine position: heart rate of 80 bpm, IBP of 110/65 mmHg, and CVP of 8 mmHg. However, after the patient was turned to the prone position on the level of the standard operating table (lying on a pair of bolsters, unpressurized abdomen), the patient's heart rate increased gradually to 130 bpm, IBP dropped to 70/45 mmHg, and CVP increased to 22 mmHg. Moreover, the jugular vein was filled observably. Emergency treatment was carried out immediately against the symptoms of right heart failure. Fluid infusion was restricted and vasoactive drugs were used to maintain appropriate arterial blood pressure. Dopamine at 5 to 10 μg/kg/min and norepinephrine at 0.03 to 0.05 μg/kg/min were continuously injected intravenously, keeping the mean arterial pressure above 70 mmHg during the operation. During the 3 hours of surgery, blood volume supplementation totally consisted of sodium chloride 500 mL, hydroxyethyl starch 500 mL, fresh-frozen plasma 600 mL, and suspended red blood cells 2 U. Total blood volume loss was 600 mL, and urine output was 500 mL. After the operation, anesthetic drugs were stopped, and the patient was returned to the supine position. At this moment, his hemodynamic status was stabilized gradually with a heart rate of 84 bpm, IBP of 130/88 mmHg, and CVP of 10 mmHg. Dopamine and norepinephrine intravenous titration was suspended. When the patient recovered spontaneous respiration and responded to verbal commands, tracheal extubation was performed. After ventilated with 100% oxygen via a facemask in 5 min, the patient was transferred to the post-anesthesia care unit. Evaluation of spinal function was performed on the second postoperative. The muscle strength of the left leg was 4/6 levels, and the right leg was 3/6 levels; meanwhile, the superficial sensibility was considered dysesthesia. Furthermore, hemodynamic parameters were stable at the ward.",
    "summary": "Patient concerns:\nThe patient was admitted to our hospital due to sudden onset of palpitation, chest tightness, mild fever, night sweats, accompanied with bilateral lower extremities adynamia, and paralysis for 5 days, but no obvious syncope and edema.\n\nDiagnoses:\nTransthoracic echocardiography showed a giant mobile myxoma (72 × 58 mm) in the right atrium (RA). Magnetic resonance imaging revealed an erosive space-occupying lesion located between the first and third thoracic vertebrae.\n\nInterventions:\nThoracic vertebral lesions were resected immediately to rescue the incomplete paraplegia. After the patient was placed in the prone position, significant hemodynamics changes were observed due to the displacement of the huge RA myxoma.\n\nOutcomes:\nStable hemodynamics was maintained during the operation through control of fluid infusion combined with vasoactive drugs."
  },
  {
    "id": "multiclinsum_gs_en_215.txt",
    "fulltext": "We present the case of a 39 year-old healthy patient with a history of infertility and no consanguinity. The patient was overweight (BMI 28.9) and this was her second pregnancy after a previous miscarriage. This pregnancy was achieved by embryo transfer after two failed in vitro fertilizations.\n\nThe first trimester aneuploidy screening ultrasound at week 12 + 3 was normal with CRL 55.6 mm and nuchal translucency 1.6 mm (59 centile). The results of the first trimester combined screening were: MoM PaPP-A 1.42, MoM HCG-Beta 1.46, trisomy 21 risk 1/1544.\n\nRoutine ultrasound scan at 22 week gestation showed small cavum septum pellucidum (2.3 mm; −2 SD for gestational age), as well as parallel anterior frontal ventricular horns. Hypoplasia of corpus callosum was suspected and reevaluation took place in a week. At 22 weeks gestation corpus callosum was 15 mm and posterior ventricular horns measurement was 8 mm. Once informed, the couple opted for invasive testing and molecular karyotype.\n\nAt 26 weeks fetal growth was within normal percentiles, corpus callosum was normal and posterior ventricular horns measured 12.8 mm. Array could not be assessed due to contamination but conventional karyotype was normal. New array and maternal serologic TORCH analyses were offered and performed.\n\nAt 30–32 weeks fetal growth remained normal and asymmetric ventriculomegaly developed, the right ventricle posterior horn reached 14 mm and there were signs of germinal matrix hemorrhage along with a secondary periventricular cyst. There was periventricular echogenicity and a complicated periventricular cyst. Medium cerebral artery Doppler showed no signs of anemia. Thrombophilia, infectious diseases screening (toxoplasmosis, parvovirus, cytomegalovirus, listeria), and antiplatelet antibodies studies were negative. CGH Array demonstrated a microdeletion in the short arm of chromosome 16, 16p11.2 (28682192_29076269)x1.\n\nMagnetic resonance imaging at week 32 showed severe dilatation of the left cerebral ventricle up to 20 mm and altered subcortical sign in the left hemisphere suggestive of ischemical, toxic vs. infectious insult.\n\nParents underwent counseling by a multidisciplinary team including ann a neurology pediatrician and a geneticist. The patient opted for pregnancy termination and refused necropsy. Fetal specimen showed normal phenotype. Severe postpartum hemorrhage occurred due to uterine atony and resolved after medical treatment and uterine tamponade.\n\nCarrier status study was offered to the couple and the mother was found to be a carrier of the same deletion. This copy number variant implies a 50% risk of recurrence.\n\nThe patient opted for embryo donation and two years later gave birth to a healthy newborn after an uneventful pregnancy which ended in labor induction for prolonged pregnancy. Severe postpartum hemorrhage recurred again in absence of placental abnormalities and was controlled with conservative management.",
    "summary": "We present the diagnosis, evolution and management of a fetal hemorrhagic accident associated with an inherited maternal microdeletion of the chromosome 16 short arm. Abnormal neurosonography in routine second trimester ultrasound led to follow up. Fetal germinal matrix hemorrhage along with severe asymmetric ventriculomegaly and a secondary periventricular cyst developed in the early third trimester. Array CGH showed microdeletion 16p11.2."
  },
  {
    "id": "multiclinsum_gs_en_359.txt",
    "fulltext": "Neonate born at 920 grams in the 29th week of pregnancy by emergency cesarean due to risk of loss of fetal well-being and suspicion of maternal chorioamnionitis. She is the first daughter of non-consanguineous parents, without known diseases to date, or history of previous abortions. However, the mother's infertility stands out, requiring up to 4 cycles of in vitro fertilization to achieve pregnancy. The pregnancy was monitored and moderate polyhydramnios was observed. After premature rupture of membranes and initiation of uterine dynamics, two doses of prenatal corticotherapy were administered for pulmonary maturation and neuroprotection with magnesium sulphate prior to delivery. The patient presented hyaline membrane disease, which was managed with administration of surfactant and invasive mechanical ventilation until 7 days of life. Subsequently, she was kept on non-invasive mechanical ventilation until 85 days of life, after 41 weeks of postmenstrual age, presenting a striking difficulty in withdrawing respiratory assistance. In addition, she presented frequent and severe mixed-character apneas (obstructive and central), some of which required resuscitation with self-inflating bag and cardiac massage.\n\nThe physical examination revealed severe hypotonia and muscular weakness, with lower limbs in a frog position, hyporreflexia and bilateral Achilles tendon retraction, as well as facial diplegia with an inverted “V” shape of the upper lip, characteristics that initially could go unnoticed due to the gestational age and the difficulty of exploration due to the clinical instability of the patient, but that nevertheless later became evident in the various physical examinations. In addition, at 35 weeks of corrected gestational age, difficulty in oral feeding was observed, not attributable to prematurity, with difficulty in removing the nasogastric tube.\n\nGiven the maternal history of infertility, the history of polyhydramnios during pregnancy, and the physical examination findings of hypotonia, facial diplegia, and arthrogryposis, the possibility of neuromuscular disease was considered.\n\nA full neurological examination was then performed on the parents, and the mother was found to have clinical signs of myotonia (showing slow relaxation of fingers and hand after normal muscle contraction), which she did not perceive as symptomatic, as it allowed her to lead a normal life.\n\nFollowing this finding, the mother underwent an electromyogram, which showed a pattern of myotonic discharges that, in the clinical context of the patient, suggested DM1. In view of these results, a directed genetic study was requested, which found 2,000 CTG copies in the newborn, and 833 copies in her mother, confirming the definitive diagnosis of DM1 in both, as well as explaining the different clinical expressivity according to the genetic anticipation phenomenon.\n",
    "summary": "A 29-week pre-term newborn required non-invasive mechanical ventilation until the 41st week of postmenstrual age, presenting apneas that were managed with manual ventilation with self-inflating bag and cardiac massage. Initially, they were attributed to prematurity. However, the patient presented hypotonia, hyporeflexia, bilateral Achilles' retraction, facial diplegia and weak suction, characteristics that, together with respiratory compromise, indicated a neuromuscular disease. As a background, the mother's infertility and polyhydramnios during pregnancy were highlighted. In the exploration directed to the mother, clinical myotonia was presented, confirmed later in the electromyogram, which indicated a congenital myotonic dystrophy. It was confirmed genetically, with 2000 CTG copies in the newborn and 833 in her mother.\n"
  },
  {
    "id": "multiclinsum_gs_en_284.txt",
    "fulltext": "A 67-year-old Lebanese male patient presented to the emergency department at the American University of Beirut Medical Center, Lebanon, with a 10-day history of dysuria, urinary frequency, and urgency. The patient’s medical history was notable for hypertension, benign prostate hypertrophy, hyperuricemia, and dyslipidemia. The patient was not on immunosuppressive treatment and did not have a history suggestive of immunologic problem. He was on amlodipine, valsartan, and bisoprolol for hypertension, as well as a statin for hyperlipidemia, and allopurinol. The patient did not have a significant surgical history. He does not smoke or consume alcohol. His father had coronary heart disease, and his mother had Parkinson disease. Personal and family histories were otherwise unremarkable, without testicular torsion or trauma. He has an administrative job and is married with children.\n\nTimeline showing pertinent procedures and findings\n\nJuly 03, 2012: US of the kidneys and pelvis revealed left kidney heterogeneous hyperechoic lesion. Further evaluation (18 July 2012) by triphasic CT showed a Bosniak type 2 renal cyst.\n10 May 2014: Admitted for urinary symptoms, enlarged scrotal sac.\n12 May 2014: US of the testicles revealed right epididymo-orchitis with reactive inflammatory hydrocele. Lesion containing calcifications within the tail of the right epididymis possibly representing an adenomatoid tumor.\n14 May 2014: US of the abdomen and pelvis revealed hyperechoic lesion within the superior aspect of the left kidney slightly increased in size. Further evaluation via a dedicated MRI examination recommended.\n17 May 2014: MRI of the abdomen showed multiloculated cystic mass within the midpole of the left kidney. Cystic renal cell carcinoma was the most likely diagnosis.\n6 June 2014: PET scan showed a well-defined hypodense lesion involving the anterior aspect of the left kidney measuring 4.3 × 3.3 cm and showing diffusely low activity (SUVmax 2.2) with a focus of increased activity along its superior anterior aspect with an SUVmax of 2.9 on the early phase and an SUVmax of 3.2 on the delayed phase.\n19 November 2014: MRI the abdomen with gadolinium showed an interval increase in the size of the left kidney lesion measuring 4.7 × 5.2 cm (previously 3.9 × 4.7 cm). The mass again showed extension to the renal hilum.\n21 November 2014: US of the testicles showed a decrease in the lesion in the right epididymal tail, showing some calcifications. This lesion can represent an adenomatoid tumor\nReactive right hydrocele and right small spermatocele or epididymal head cyst were noted.\n2 April 2015: Partial left nephrectomy.\n16 April 2015: Immunohistochemistry and microscopic findings revealed tubulo-cystic renal carcinoma with free surgical margins.\n15 October 2024: Patient functional, assuming an advisorship position in a university.\n\n\nOn physical examination, the right scrotum was found to be three times larger than the left one, and the scrotal sac was erythematous. The exam also revealed a firm, non-tender intrascrotal mass, distinct from the testis. The mass looked to be arising directly from the right epididymis. The exam was otherwise normal.\n\nGiven his dysuria and other urinary symptoms, a urine culture was obtained. The culture revealed extended-spectrum beta-lactamase Escherichia coli. Ultrasonography showed a slightly disturbed echotexture of the right testicle with increased blood flow, and an associated septate reactive hydrocele with inflammatory changes. The US also revealed a 1.6 cm lesion within the right epididymal tail with some calcifications; this was reported as a possible adenomatoid tumor by the radiologist and the urology team. Since adenomatoid tumor is a benign neoplasm with no malignant potential, no surgical intervention was taken.\n\n\nUltrasound of the abdomen revealed a hyperechoic mass within the superior aspect of the left kidney. This mass was seen on a CT 2 years prior to presentation and was reported by the radiologist to be consistent with a Bosniak type 2 cyst. MRI of the abdomen in May 2014 showed a multiloculated cystic mass within the midpole of the left kidney that may represent RCC.\n\nThe patient was diagnosed with prostatitis and epididymo-orchitis. He was treated with piperacillin/tazobactam 4.5 g three times daily for 5 days and was discharged on trimethoprim/sulfamethoxazole double strength two tablets twice daily for 3 weeks.\n\nPositron emission tomography (PET) scan, done 3 weeks after the MRI on an outside basis did not report an epididymal lesion; however, a hypodense solid left kidney mass with a worrisome focal area of increased activity was noted.\n\nMRI was repeated 6 months after discharge (November 2014) revealing an interval increase in the size of the left kidney lesion from 3.9 × 4.7 cm to 4.7 × 5.2 cm. A decision for surgery was made, and the patient underwent left partial nephrectomy in April 2015. Histology confirmed the diagnosis of TRCC. Laboratory studies including a complete blood count (CBC) and prostate-specific antigen (PSA) were repeated and were normal. Repeat testicular US (November 2014) showed complete regression of the right orchitis with partial regression of the epididymitis and a decrease in the right epididymal tail lesion with some calcifications. A total of 9 years after the surgery (October 2024), the patient is functional, with good health.\n\n",
    "summary": "We aim to present the first case in literature, according to our knowledge, of both tubulocystic renal cell carcinoma and probable adenomatoid tumor existing at the same time in a 67-year-old Lebanese male presenting with epididymo-orchitis, who on ultrasound was found to have an incidental finding of probable adenomatoid tumor located in the tail of the right epididymis, as suggested by the radiologist and the urology team. The patient was also found to have a renal mass that was described earlier to be a Bosniak type 2 renal cyst. The patient underwent left partial nephrectomy. A pathological examination revealed tubulocystic renal cell carcinoma."
  },
  {
    "id": "multiclinsum_gs_en_330.txt",
    "fulltext": "We present the case of a 77-year-old man with a history of type 2 diabetes mellitus and hypertension who presented with a recent diagnosis of mycosis fungoides (MF). On physical examination, he had a pruritic dermatosis characterized by multiple erythematous-descamative macules and plaques distributed generalized on the face, trunk, and extremities. Skin biopsies were performed on the right arm and left arm, where atypical epidermotropic dermal lymphoid infiltration was observed. In addition, areas of subepidermal detachment, spongiosis, and occasional eosinophils in the superficial dermis were evident. In immunostaining, CD3 (70%), CD7 (30%), CD4 (90%), CD8 (10%), CD4/CD8 90:10, and CD20 were observed in single cells. The histopathologic and immunophenotypic findings were consistent with MF. He was referred to the hematology department. His blood counts were normal, as was lactate dehydrogenase. Positron emission tomography showed no pathologic findings, and both peripheral blood smear and flow cytometry reported the absence of circulating atypical lymphocytes.\n\nT cell clonality by reverse transcriptase polymerase chain reaction (RT-PCR) of the T cell receptor (TCR) in peripheral blood was negative. He was classified as stage IIIA (T4N0M0B0). Two weeks after diagnosis, he consulted due to the appearance of blisters after sun exposure. On physical examination, generalized dermatosis was observed, characterized by erythema associated with multiple erythro-crosslinked lesions, tight blisters and other de-tents. Two blisters were found in the oral mucosa, without ocular and genital mucosal involvement. With the suspicion of a bullous PA versus a MF, new skin biopsies for histopathology and direct immunofluorescence were taken from the edge of a blister and perilesional skin, respectively. The histology showed a dermo-epidermal detachment with linear immunoglobulin G (IgG) and C3 positivity in the basement membrane, confirming the diagnosis of PA. Treatment with meprednisone 40 mg daily associated with methotrexate as a corticosteroid sparing agent was indicated. The patient progressed favorably, without the appearance of new blisters despite the reduction of the corticosteroid dose or recurrence of MF. He is currently being treated with methotrexate 10 mg weekly combined with folic acid.\n",
    "summary": "A 77-year-old man with a history of type 2 diabetes mellitus and hypertension was diagnosed with MF. Subsequently, he developed blisters after sun exposure and was diagnosed with PA by histopathology and direct immunofluorescence. The patient was treated with meprednisone and methotrexate and recovered without recurrence of MF or new blisters.\n"
  },
  {
    "id": "multiclinsum_gs_en_541.txt",
    "fulltext": "The patient is a 66-year-old female in good health. During the mid-1980s, she received repeated series of grenz ray treatment on her scalp to relieve itch associated with scalp psoriasis. With regular treatment of approximately one session per month over a 5-year period now and then supplemented with coal tar, salicylic acid, and prednisone, there was some relief of her condition. Over time, her hair thinned; the skin in the entire scalp area became pain-sensitive with scarring. Treatments with grenz rays had been given in a private clinic; treatment details such as single and accumulated dose were not available. She had suffered no radiodermatitis.\n\nWithin a very short period in 2020, some 35 years since the radiation treatment stopped, numerous BCCs and premalignant actinic keratoses (AKs) appeared in her scalp. A treatment regimen of surgical removal of BCCs verified by preoperative histology and cryotherapy of AKs by clinician’s assessment was initiated. Photodynamic therapy or topical treatments were not applicable due to pain sensitivity and sequelae from surgery. From 2020 to 2022, she received several cryo- and curettage treatments and a total of 13 surgical excisions of BCC by Mohs surgery. Her total number of excisions over time is estimated to about 30. Recalcitrant and de novo BCC in the increasingly damaged scalp, obviously, is an everlasting challenge; plastic surgeons and dermatologists were therefore searching another treatment modality of better therapeutic index.\n\nIn September 2022, she came with new histologically confirmed BCCs in the scalp. Ultrasound scanning (DermaScan C, Cortex Technology ApS, Aalborg, Denmark) showed echo-lucent tumors of thickness 0.5–1.3 mm in both the histologically analyzed sites as well as in a few additional lesions that could be identified based on clinical and dermoscopic examination. The patient after information granted her written consent to HIFU treatment made with or without pretreatment biopsy of suspected lesions.\n\nEligible lesions for treatment were outlined with a waterproof pen including a perilesional margin of 2 mm. Each selected lesion was mapped on a transparent foil to help the precise location on follow-up. The 20 MHz ultrasound scanning was used to confirm the depth of identified lesions at baseline and at subsequent follow-up visits. Due to the state of known pain-sensitive scalp, local anesthesia (25 mg/mL lidocaine + 5 mg/mL adrenaline, Amgros I/S, Copenhagen, Denmark) was administered to all lesions 10–15 min before treatment.\n\nLesions were treated with HIFU using the 1.3 mm probe; settings 150 ms/dose duration and acoustic energy 0.9 J/dose. 20–200 doses were applied to lesions depending on lesion extension. Treated lesions healed spontaneously with no complication or need of special treatment. Follow-up visits had been scheduled every 3–6 months to monitor cure rate/relapse, local tolerance, and newcomer lesions not identified before.\n\nDuring the 15 months after the above-described initial clearing by HIFU, a total of 10 lesions that following routines would require biopsy followed by excisional surgery were treated with HIFU in sessions of about 30 min. Lesions healed in a few days with no complication or need of intervention. Full clearing was noted in 7 of 8 treated BCC lesions and both AK lesions. The single recurrent BCC of small size was observed after 15 months among the first six treated lesions; the lesion was retreated with HIFU. Examples of healed lesions 15 months after HIFU treatment; the tumor with recurrence.",
    "summary": "A 66-year-old female, who in the 1980s had received several grenz ray treatments of the scalp, developed multiple basal cell carcinomas in the field. She had over 30 excisional surgeries including Mohs surgery in the past with many local complications but, nevertheless, recurrent cancers. HIFU treatments applied to eight basal cell carcinomas and two precancerous lesions resulted in complete clearing at 12-month control, but one recurrence after 15 months."
  },
  {
    "id": "multiclinsum_gs_en_163.txt",
    "fulltext": "We report a case of a male newborn, second child of a healthy mother. The pregnancy was uneventful and he was born at 39 weeks’ gestation by a vacuum extraction after a 19 h spontaneous membrane rupture. During labor the mother presented with fever (38.1 °C), leukocytosis with neutrophilia and elevation of C-Reactive protein. Antibiotics were started. Apgar scores were 8, 8 and 9 at 1, 5 and 10 min, respectively. After birth, the 4.1 kg newborn was transferred to the neonatal special care unit with respiratory distress. He needed supplemental oxygen for the first 8 h, after which he showed significant clinical improvement. Despite clinical improvement the blood panel at 24 h of life showed elevated inflammatory markers (C-Reactive Protein 4.6 mg/dL and procalcitonin 10.79 ng/mL) and treatment with ampicillin and gentamicin was initiated. Blood cultures (day 1 and 7) were sterile.\n\nAt day 7 he presented with gross hematuria (bright red urine) with a normal clinical exam. He had no hypertension, oliguria or edema. Urine microscopy showed a high number of red and white blood cells and trace proteins (25 mg/dL). Serum creatinine and coagulation were normal. Although there was no leukocytosis or elevation of C-Reactive Protein, hematogenous bacterial pyelonephritis was suspected and cefotaxime was added. Urine and blood cultures were sterile. Renal ultrasound (day 10) showed an enlarged left kidney, with a slight hyperechogenicity of renal sinus fat, and an echogenic content inside the bladder, suggesting an infectious process (cystitis and possibly pyelonephritis). The Doppler ultrasound (only possible at day 15) did not have indirect signs of renal venous or arterial thrombosis. He completed 8 days of gentamicin, 14 days of ampicillin and 9 days of cefotaxime.\n\nGross hematuria persisted until day 16 and urine microscopy on day 15 still showed an elevated number of red (250/µL) and white blood cells (positive leukocyte esterase test +++), as well as a low level of proteinuria (25 mg/dL) and occasional granular casts. Nitrite test was negative. A new urine culture was also sterile. Urine DNA by polymerase chain reaction (PCR) for adenovirus was positive, cytomegalovirus and human polyomavirus were negative. The newborn remained clinically stable and was discharged on day 18 with a normal urinalysis.\n\nOn 1 month follow-up visit he remained asymptomatic, with normal urine microscopy. He had positive anti-adenovirus antibodies (IgG) and normal renal ultrasound. After one month he remained asymptomatic, with normal urine microscopy and normal renal ultrasound.",
    "summary": "We present the case of a newborn admitted to the neonatal unit after birth with respiratory distress. Empiric treatment with ampicillin and gentamicin was initiated. He presented a favorable clinical and laboratory course with decreasing inflammatory parameters. On day 7 gross hematuria was detected and the urinalysis revealed red blood cells, trace of proteins and leukocytes. Cefotaxime was added after urine and blood cultures. Doppler ultrasound showed bladder sediment with no signs of renal venous thrombosis and the cultures were negative. There was a progressive improvement of gross hematuria with resolution on day 16. Urine adenovirus PCR was positive and the diagnosis of adenovirus hemorrhagic cystitis was made."
  },
  {
    "id": "multiclinsum_gs_en_248.txt",
    "fulltext": "Our patient is a healthy 37-year-old Hispanic male who sustained a simultaneous rupture of his bilateral patellar tendons after jumping attempting to make a “lay-up basket” while playing basketball. Pertinent history includes anterior cruciate ligament (ACL) reconstruction of the right knee using an ipsilateral bone-patellar tendon bone (BPTB) autograft in 2002. The patient was unable to ambulate and presented to our clinic in wheelchair. The patient was unable to perform a straight leg raise and had a tender defect at the inferior pole of the patella bilaterally. Plane radiographs demonstrated bilateral patella alta and MRI studies demonstrated bilateral proximal patellar tendon ruptures. The recommendation for acute simultaneous surgical repair of both knees was given to the patient.\n\nOperative technique\nIntraoperative exam showed significant swelling of both knees, with full extension and flexion to 140 degrees bilaterally. There was palpable defect and patella alta bilaterally associated with patellar tendon rupture.\n\nThe knee was approached through the standard anterior midline approach. The extent of the tear was elucidated, involving both the medial and lateral retinaculum. A hematoma was evacuated, and the deep and subcutaneous tissues were irrigated. Traction sutures were placed in the quadricep tendon to help mobilize the patella distally. The proximal patellar tendon and the distal stump of the patellar tendon were elucidated.\n\nTwo 4.75 mm bio-composite SwiveLock suture anchors (SpeedBridge Implant System with Scorpion-Multifire Needle, Arthrex, Inc., No. AR-2600SBS-8) were placed within the inferior pole of the patella at the origin of the patellar tendon. A Krackow locking stitch was performed with each of the SwiveLock suture anchors with a pull through suture. This was brought up and down the patellar tendon in a locking stitch configuration. The knee was placed in 30 degrees of flexion, and the patellar length was made to be 4.5 cm. As the patient did not have an intact contra-lateral patellar tendon to base our patella tendon length, 4.5 cm was chosen as this has been an average male patella length recently described in the literature. Intraoperative C-arm fluoroscopy was utilized to confirm appropriate patellar height. This was double checked by attempting to obtain a Caton-Deschamps index of approximately 1:1. The knots were then tied down from the locking stitch configuration in the upper repair back onto the suture anchors in the patella.\n\nThe same anchors had #2 FiberTape sutures (Arthrex, Inc) loaded. These were crisscrossed in a suture bridge configuration and placed in separate SwiveLock anchors in the tibial tubercle with the knee at 30 degrees of flexion. The remaining paratenon and soft tissue was imbricated to help reinforce the repair. The medial and lateral retinaculum were then repaired with a running locking #2 FiberWire suture (Arthrex, Inc). After an extensive irrigation of the deep and subcutaneous tissues, a standard layered closure was then performed.\n\nThe left knee was addressed next in an identical fashion. At the end of this case, each knee was able to obtain 0 to 30 degrees of flexion without any undue tension on the repairs.\n\nPatient follow-up\nThe patient remained non-weight bearing except for transfers for 6 weeks post-operatively. Both knees were initially locked in full extension with a brace. Two days after surgery, the patient started physical therapy with Continuous Passive Motion machine, increasing ∼15° per week. After 6 weeks, the patient started full weight bearing with braces locked in extension with a walker. His ROM was approximately 0–110° on both legs, and he could perform straight leg raises without difficulty.\n\nAt 10 months he demonstrated 5/5 quadriceps strength, −10° of extension, and 140° of flexion bilaterally. Knee Documentation Committee (IKDC) score was 57 bilaterally.\n\nAt 12 months the patient had normal alignment with symmetric quadriceps strength bilaterally. His ROM remained at −10 degrees of uncorrectable passive extension and 140 degrees of flexion bilaterally. The patient's right and left knee IKDC score improved to 69 and 72, respectively. His recorded Lysholm score at 12 months for his right and left knee was 94 and 99, respectively.",
    "summary": "We describe the case of a 37-year-old male who presented with simultaneous bilateral patellar tendon rupture without any associated risk factors. Additionally, this is the first reported use of the suture bridge technique with patellar and tibial suture anchors in repairing bilateral proximal patellar tendon rupture. At 12-month follow-up, the patient had normal alignment, no effusion, and symmetric quadriceps strength."
  },
  {
    "id": "multiclinsum_gs_en_456.txt",
    "fulltext": "Patient information\nA 27 years old female patient with no relevant medical history visited the Department of Periodontics and Community Dentistry in the month of August 2023, presented with thin gingival phenotype and root prominence at lower anterior teeth. No past relevant interventions reported by the patient. The patient’s overall appearance, vital signs were normal. Findings from the head, neck, chest, lungs, and abdomen, heart sounds, and pulse were also.\n\nClinical examination\nThe clinical examination reveals a case of generalized chronic periodontitis characterized by deep periodontal pocket 7 mm distal to #41 with bleeding on probing and grade 1 mobility, recession type-2 recession was detected at #41, 42. A notable intra-bony defect, measuring 10 mm, is observed in the mandibular anteriors, indicating advanced periodontal destruction. The patient’s periodontal phenotype is marked by thin gingiva, high frenum attachment, and inadequate keratinized tissue, which may contribute to the complexity of periodontal management and the overall stability of the periodontal tissues.\n\nRadiographic examination\nThe radiographic examination, including periapical radiographic examination, intra-bony defect distal to #41 was detected demonstrating significant bone loss around the mandibular anterior region, highlighting the extent of periodontal destruction in this area. Further evaluation with a cone beam computed tomography (CBCT) scan provided a detailed assessment, confirming the presence of a deep intra-bony defect. The CBCT imaging offered a comprehensive view of the defect’s depth and extent, aiding in the accurate diagnosis and planning of appropriate periodontal treatment strategies.\n\nDiagnosis\nBy summarizing the thorough gingival and periodontal examination clinical findings, the case was diagnosed as periodontitis stage 3 grade B.\n\n\nTreatment\n\nTreatment plan\nEthical approval was waived, as it is the case report and good clinical practice guidelines followed and the patient informed consent was taken before the treatment procedure. In order to properly address the patient’s periodontal problems, the suggested treatment plan includes a number of essential elements. Scaling and root planning are examples of nonsurgical periodontal therapy procedures used to eliminate plaque and tartar from tooth surfaces and lessen inflammation caused by the disease. In order to promote healing and improve bone regeneration, bone grafting using an allograft material was carried out to correct the profound intra-bony defect. Furthermore, it was advised to have orthodontic treatment to realign teeth, which can improve the stability and general health of the periodontal tissues. PhMT was used to enhance the gingival thickness and augment keratinized tissue in order to further improve the periodontal phenotype. This reduced vulnerability to future periodontal breakdown and supported long-term periodontal health.\n\nTreatment procedure\nTo ensure patient comfort and successfully address the deposition of calculus and plaque, nonsurgical periodontal therapy was performed under local anesthesia as the first step in the treatment procedures. Six weeks after the healing period, bone grafting with guided tissue regeneration was performed to assist the periodontal tissue restoration and restore the intra-bony defect. In this case study, orthodontic therapy was started 3 months before bone grafting in order to improve the periodontal environment and straighten the teeth. In addition, during the course of the treatment, PhMT was carried out to promote gingival thickness and increase keratinized tissue, which in turn improved overall periodontal health and stability.\n\n\nFollow-up\nIn order to track progress and make sure the interventions were working, the patient was scheduled for follow-up appointments 3, 6, and 12 months after starting therapy. Clinical and radiographic assessments were performed at every follow-up appointment to evaluate the stability of orthodontic corrections overall, the success of bone graft integration, and improvements in periodontal health. These assessments yielded vital information on the healing process, enabling prompt modifications to the treatment regimen and guaranteeing the best possible long-term results.\n\nClinical outcome\nThere was a noticeable improvement in the clinical outcomes at the 12-month follow-up. The more advantageous 2 to 3 mm range of probing depths was observed after the initial 6 to 10 mm range, suggesting that periodontal pockets had been effectively resolved. Significant improvement in attachment levels was seen, resulting in an increase of 4 to 6 mm, which is indicative of improved periodontal support. The gingival thickness increased significantly from 0.5 to 2.5 mm, which strengthened the periodontal environment. Furthermore, the gingival tissues’ stability and vitality are further supported by the growth in keratinized tissue from 1 to 4 mm. These results highlight how well the all-encompassing treatment approach worked to improve overall tissue quality and restore periodontal health.\n\nRadiographic outcomes\nBased on a CBCT scan, the radiographic results at 12 months showed notable improvements. Effective bone regeneration and repair was demonstrated by the successful reduction of the deep intra-bony defect, which measured 10 mm originally, to 3 mm. Furthermore, there was a significant 25% increase in bone density in the afflicted area as compared to baseline values. The success of the bone grafting process and the general improvement in bone structure and density are reflected in these radiography results, which support the stability and long-term prognosis of the periodontal therapy.\n\nPeriodontal phenotype modification\nBy the 12-month mark, the periodontal phenotypic modification had produced noticeable improvements. The gingival thickness grew from 0.5 to 2.5 mm, a 400% increase that markedly improved tissue support and resilience. Additionally, there was a noticeable 300% increase in keratinized tissue, from 1 to 4 mm, which helped to create a gingival environment that was more stable and protective. Furthermore, a 2 mm reduction in the high frenum attachment was accomplished, which lessened its influence on the periodontal tissues and enhanced the overall periodontal phenotype. Together, these changes strengthened the gingival structure and improved periodontal health.\n\nOrthodontic outcomes\nSignificant improvements were observed in the orthodontic outcomes during the 12-month follow-up. Significant progress was made in tooth location, leading to better alignment and spacing and a more aesthetically acceptable and practical dental arrangement. Significant progress was also shown in the bite connection, where a more ideal occlusal relationship was formed, improving comfort and function. In addition to complementing the overall periodontal therapy, these beneficial improvements in orthodontic alignment and occlusion also help to create a more balanced and healthy dental environment.\n\nPatient-reported outcomes\nPatient-reported outcomes at the 12-month point show a significant improvement in oral health-related quality of life, with a 50% improvement reported. This notable improvement shows how the patient’s everyday functioning and general well-being have improved as a result of the thorough treatment. The patient also showed a great deal of satisfaction with the results of the treatment, demonstrating how well the therapeutic approaches addressed both functional and aesthetic concerns. These outcomes highlight how well the treatment plan worked to improve the patient’s quality of life and happiness with their dental health in addition to meeting clinical and radiographic goals.",
    "summary": "Patient concerns: A 27-year-old male patient arrived with a severe intrabony defect and a poor periodontal phenotype. The patient received PhMT, which includes nonsurgical periodontal therapy, bone grafting, and orthodontic treatment. After 1 year, there were considerable changes in the intrabony defect, periodontal phenotype, and general oral health.\n\nDiagnoses: A 27-year-old male patient had a profound intrabony defect (10 mm) and a poor periodontal phenotype (thin gingiva, high frenum attachment).\n\nInterventions: The patient received PhMT, which includes nonsurgical periodontal therapy (scaling and root planing), bone grafting (allograft), and orthodontic treatment (correcting tooth placement). After 1 year, there were considerable improvements: Intrabony defect reduction (from 10 to 3 mm), improved periodontal phenotype (thickened gingiva, decreased frenum attachment), and improved dental health (lower pocket depths, increased attachment levels). PhMT successfully repaired the intrabony deficiency and altered the patient's periodontal phenotype.\n\nOutcomes: Improved dental health and aesthetics were the result of the comprehensive treatment, which addressed the problem as well as the patient's underlying periodontal features."
  },
  {
    "id": "multiclinsum_gs_en_349.txt",
    "fulltext": "30-year-old male patient with no previous chronic or traumatic history. He presented a few hours prior to admission with intense oppressive chest pain, irradiating to the left scapula, without attenuation, exacerbated by physical activity. He also presented nausea, diaphoresis, and dyspnea with small efforts. Electrocardiogram and cardiac enzymes ruled out acute myocardial infarction. After 24 hours of observation, he presented sudden generalized abdominal pain of moderate intensity, with a positive Kehr sign and diaphoresis. A computed tomography of the abdomen with intravenous contrast was performed, revealing the presence of free liquid in the abdominal cavity. The spleen was observed with loss of its normal anatomy. An exploratory laparotomy was performed, revealing rupture of the spleen and 2000 ml of haemoperitoneum. During evacuation of the haemoperitoneum, active bleeding and devascularisation of more than 25% of the spleen was observed, so a splenectomy was performed.\n\nFollowing the surgical event, a decrease in the level of hemoglobin from 13.0 g/dL to 9.1 g/dL was observed, so two erythrocyte concentrates were transfused, with the last hemoglobin of 11.0 g/dL. The evolution was favorable, with discharge six days post-surgical after application of anti-pneumococcal, anti-meningococcal and anti-haemophylus influenzae B vaccines. The histological examination showed the presence of a spleen with hyperplastic vascular tissue around the rupture zone of the spleen. The patient's viral panel (human immunodeficiency virus [HIV], hepatitis B and hepatitis C) was negative.\n\nFollowing discharge, the patient's family was contacted and informed of the patient's death three weeks later. The direct cause of death is unknown.\n",
    "summary": "30-year-old male patient with no medical history, with generalized abdominal pain accompanied by Kehr's sign. He is diagnosed with rupture of the spleen by contrasted computed tomography and successfully treated with splenectomy. He is discharged 6 days postoperatively.\n"
  },
  {
    "id": "multiclinsum_gs_en_107.txt",
    "fulltext": "We present the case of an 82-year-old man with a diagnosis of adenocarcinoma of the ascending colon, confirmed by endoscopic biopsy. In the preoperative staging studies, there were no signs of distant disease and he had a CEA of 2.8 ng/mL. He underwent a laparoscopic right hemicolectomy and had a favorable postoperative course. The pathology report showed a moderately differentiated adenocarcinoma, stage 1, T1 N0, and did not require adjuvant treatment.\n\nIn the oncological follow-up, a nodular image in the left iliac chain measuring 22 mm in its minor axis was identified by tomography. Due to this finding, a PET-CT with 18F-FDG was performed in which a single ovoid lesion was evidenced at the retroperitoneal level, adjacent to the aortic bifurcation of approximately 34 mm in major diameter with scarce enhancement after administration of iodinated contrast.\n\nThis image proved to be hypermetabolic (SUV: 6.7). No other images linked to the pathology under study were found. Given the patient's background, a percutaneous biopsy guided by images was scheduled with local anaesthesia. The procedure was well tolerated and was not associated with complications. This study demonstrated that the finding was a schwannoma. After a year of follow-up, the size of the biopsy lesion increased (44 mm in major diameter), however, without clinical manifestations. In turn, there was no evidence of progression of oncological disease.\n",
    "summary": "We present the case of an 82-year-old male patient with a newly diagnosed moderately differentiated colon adenocarcinoma and a hypermetabolic periaortic nodule as an incidental finding.\n\nResults: Percutaneous biopsy of the periaortic node confirmed the diagnosis of schwannoma. At one year follow-up, the schwannoma has demonstrated growth. There is no evidence of progression of his cancer disease.\n"
  },
  {
    "id": "multiclinsum_gs_en_87.txt",
    "fulltext": "A 44-year-old woman with no known cardiovascular risk factors or other relevant medical history and not under medication presented at our emergency department after experiencing six hours of chest tightness radiating to the shoulder, following emotional stress, with no relieving or aggravating factors. There were no other associated symptoms or clinical context (e.g. infection).\n\nAt admission, she still had chest pain, and blood pressure of 140/74 mmHg, tachycardia (140 ppm), slight polypnea but with no need for supplementary oxygen, and bibasilar rales; there was no peripheral edema. Laboratory findings were leukocytosis, normal C-reactive protein, mild elevation of troponin T (112 ng/ml; cut-off <14 ng/l), N-terminal pro-brain natriuretic peptide 950 pg/ml and dyslipidemia. The electrocardiogram (ECG) revealed sinus tachycardia, QS pattern from V1-V4, and first-degree atrioventricular block following one premature ventricular contraction. Arterial blood gas analysis showed hyperlactacidemia (maximum 3 mmol/l). The chest X-ray showed signs of pulmonary congestion. Transthoracic echocardiography (TTE) revealed akinesia of the mid-distal walls, hyperkinesia of the basal segments, severe left ventricular (LV) dysfunction and no LV outflow tract obstruction.\n\nShe was admitted to the coronary care unit with a provisional diagnosis of Takotsubo (stress) cardiomyopathy.\n\nWithin three hours she progressed to cardiogenic shock with need for mechanical ventilation, and inotropic and vasopressor support with dobutamine and noradrenaline was begun. Sinus tachycardia continued but there were no changes on the ECG.\n\nShe underwent coronary angiography (CA) during which selective cannulation of the left coronary artery (LCA) was not possible, and a non-selective injection disclosed no coronary artery arising from the left coronary sinus. On selective injection of the right coronary sinus, a single ostium was visualized. The right coronary artery (RCA) was a great vessel, with no stenosis. A hypoplastic left anterior descending artery (LAD) and left circumflex artery (LCx) were perfused from RCA collateral vessels, both without lesions. Left ventriculography revealed apical ballooning akinesis, basal hyperkinesis and severe LV dysfunction.\n\nThe most likely hypothesis was anomalous coronary artery origin, but an ostial left main lesion could not be excluded.\n\nCoronary computed tomography angiography (CCTA) revealed a single coronary artery with its ostium in the right sinus of Valsalva (RSV), agenesis of the left main artery and a hypoplastic LAD, the RCA with a normal course, antegrade flow through a posterior lateral branch (PLB) to the LCx and LAD, and collaterals originating from the posterior descending artery (PDA) to the distal segment of the LAD. All coronary arteries were patent and with no evidence of atherosclerotic plaque.\n\nThe patient's clinical course was favorable, with spontaneous ventilation and withdrawal of inotropic and vasopressor support at 48 hours, optimal diuretic response, and gradual recovery of global and segmental LV function.\n\nCardiac magnetic resonance imaging (MRI), performed six days after admission, showed mild hypokinesia of the mid segments of both anterior and anteroseptal walls, preserved global LV systolic function, and diffuse myocardial edema, with no significant late enhancement and no perfusion defects, which was a clue to the diagnosis of Takotsubo cardiomyopathy.\n\nA diagnosis of Takotsubo syndrome was made with an incidental finding of a right single coronary artery.\n\nThe patient's clinical course was uneventful and she was discharged on day 7, medicated with low-dose beta-blockers and angiotensin-converting enzyme inhibitors.\n\nAt two-month follow-up she was in New York Heart Association class I. TTE revealed normal global and segmental LV function and the ECG was normal.",
    "summary": "A 44-year-old woman presented with Takotsubo cardiomyopathy and cardiogenic shock. Selective cannulation of the left coronary artery (LCA) was not possible on coronary angiography (CA); an SCA was revealed arising from the right sinus, continuing distally as the circumflex artery and thereafter as the left anterior descending artery. Coronary computed tomography angiography (CCTA) confirmed left main atresia and no coronary stenosis. Cardiac magnetic resonance imaging (MRI) showed diffuse myocardial edema and no perfusion defects. The patient's clinical course was favorable under conservative management."
  },
  {
    "id": "multiclinsum_gs_en_157.txt",
    "fulltext": "A 57-year-old man was referred to our hospital for New York Heart Association functional class 4 HF and extremely elevated liver enzymes. He had palpitation from 2 weeks ago which was accompanied with orthopnoea and serious fatigue on admission, despite being healthy without any history of AF. The electrocardiography showed AF tachycardia of approximately 180 beats per minute, and the bedside echocardiography showed low LVEF of 20%. In addition to fatigue, coexisting hypotension and elevated lactate of 13 mmol/L indicated LOS. Electrical cardioversion was conducted, barely terminated AF successfully on day 1, and restored blood pressure and urinalysis response to intravenous furosemide. Intravenous landiolol hydrochloride was administered for AF tachycardia. HF and LOS were treated with intravenous dobutamine, intravenous furosemide and oral tolvaptan, and non-invasive positive pressure ventilation under mild sedation using intravenous dexmedetomidine hydrochloride. On day 2, torsade de pointes suddenly occurred subsequent to a premature atrial beat in a long-short manner of coupling interval with QT prolongation. Cardiopulmonary resuscitation with electric cardioversions, intratracheal intubation, and establishment of mechanical ventilation were carried out, which achieved return of spontaneous circulation. Temporary atrium-atrium inhibited pacing was emergently established to shorten prolonged QT and maintain regular heart rate. However, AF tachycardia recurred repetitively. Repeated electrical cardioversions failed to terminate AF. Hypotension continued along with oliguria. The liver dysfunction was further exacerbated with aspartate aminotransferase of 11,708 U/L. The intravenous amiodarone was started. On day 3, AF tachycardia with hypotension still occurred despite intravenous amiodarone and gradually became resistant to electrical cardioversions. The atrial tachycardia (AT) and common-type atrial flutter (AFL) appeared in addition to AF. On day 4, disseminated intravascular coagulation (DIC) was diagnosed according to the Japanese Society on Thrombosis and Hemostasis criteria, with DIC score of 6 points. Acute kidney injury was diagnosed according to the Kidney Disease Improving Global Outcomes criteria, fulfilling both serum creatine and urine output criteria. At this time, because the patient’s general condition was becoming worse and more resistant to treatment, we decided to perform semi-urgent rescue ablation to AF and common-type AFL for acute-phase rhythm control to treat HF and MOF.\n\nThe patient’s family agreed with our treatment policy and signed informed consent for the semi-urgent rescue ablation procedure.\n\nOn the same day, prior to the procedure, trans-oesophageal echocardiography was performed and found no detectable thrombus in the left atrium (LA). PVI to the AF and cavotricuspid isthmus ablation to common-type AFL were planned. Fortunately, the patient’s haemodynamics did not collapse at the time of ablation, we performed our institutional standard procedure including 3-D mapping. The cryoballoon was chosen as a PVI catheter because cryoballoon ablation was expected to have a shorter procedure time and lesser thrombogenic effect than other catheter types. A 20-polar catheter (Response™; Abbott, St. Paul, MN, USA) was placed in the coronary sinus. A three-dimensional electroanatomical mapping was constituted by a cardiac mapping system (EnSite velocity™; Abbott). Transseptal access was obtained using the standard Brockenbrough needle technique with intracardiac ultrasound and fluoroscopic guidance, and an 8-Fr SL0 sheath (Swartz™; Abbott) was inserted into the LA. The cardiac geometry including all pulmonary veins (PV) was established using a 20-pole circular mapping catheter (Reflexion Spiral™; Abbott). No left atriography was conducted because of acute kidney injury. Then, we changed the SL0 sheath to a steerable sheath (FlexCath Advance™; Medtronic Inc., Minneapolis, MN, USA) and inserted a 28-mm second-generation cryoballoon catheter (Arctic Front Advance™; Medtronic Inc.). In each PV, the cryoballoon was placed at the ostium of each PV in turns, and cryoballoon ablation was performed after complete occlusion of each PV as confirmed by the minimum amount of contrast agent. During cryoenergy deliveries, the oesophageal temperature and diaphragmatic compound motor action potential were monitored to avoid LA-oesophageal fistula and phrenic nerve injury. Additional touch-up radiofrequency ablation using FlexAbility™ (Abbott) to the residual LA-PV conduction gap at the bottom of the right inferior PV after cryoballoon ablation was conducted, and complete PVI was achieved (detailed PVI procedural data). Subsequently, a 20-polar catheter (Livewire™; Abbott) was placed around the tricuspid annulus, confirming that the AFL was cavotricuspid-isthmus dependent. The cavotricuspid isthmus ablation for common-type AFL was performed by standard procedure using radiofrequency ablation catheter and successfully achieved bidirectional block. The whole procedure was finished uneventfully and restored sinus rhythm and blood pressure of approximately 110 mmHg.\n\nThereafter, AF and other atrial arrhythmias seldom occurred and was terminated by single electrical cardioversion. Normal blood pressure and urine output were restored. The hepatic and renal functions were improved gradually as well. On day 7, intravenous amiodarone was discontinued. On day 11, the patient was weaned from the ventilator support. The DIC was restored eventually. On day 18, pulmonary abscess that required long-term antimicrobial treatment was cured. On day 22, AF recurred, but oral amiodarone was restarted and suppressed the AF. Although the patient had a pulmonary abscess that required approximately one-month antimicrobial treatment after ventilator withdrawal, he was discharged alive on day 72. The elective coronary angiography and left ventriculography revealed no significant coronary stenosis and LVEF normalisation, diagnosing that the tachycardia-induced cardiomyopathy due to AF tachycardia was the cause of reduced left ventricular function. For 2 years, albeit the discontinuation of HF drugs and amiodarone, the patient has been free from HF symptoms and atrial arrhythmias including AF and AFL.",
    "summary": "A 57-year-old man was hospitalised for New York Heart Association functional class 4 heart failure with atrial fibrillation tachycardia and reduced left ventricular ejection fraction of 20% accompanied with low cardiac output syndrome-induced liver damage. The haemodynamics collapsed during atrial fibrillation tachycardia, which had become resistant to intravenous amiodarone and repeated electrical cardioversions. In addition to atrial fibrillation, atrial tachycardia and common-type atrial flutter appeared on day 3. Multiple organ failure progressed gradually due to haemodynamically unstable atrial fibrillation tachycardia storm accompanied with low cardiac output syndrome. On day 4, to focus on treatment of heart failure and multiple organ failure, semi-urgent rescue pulmonary vein isolation using cryoballoon to atrial fibrillation and cavotricuspid isthmus ablation to common-type atrial flutter were performed for acute-phase rhythm control. Soon after the ablation procedure, atrial fibrillation and common-type atrial flutter were lessened, and sinus rhythm was restored. A stable haemodynamics was successfully achieved with the improvement of hepatorenal function. The patient was discharged on day 77 without complications."
  },
  {
    "id": "multiclinsum_gs_en_178.txt",
    "fulltext": "A 56-year-old male presented to the emergency department of our hospital due to sudden onset shortness of breath and an episode of syncope while walking around inside his house. He underwent robotic assisted laparoscopic prostatectomy for prostate carcinoma, 5 days prior to his presentation to the Emergency Department. His post-operative course in the hospital was uneventful. In the emergency department, his blood pressure was 94/54 mmHg, heart rate 121 beats per minute, respiratory rate 20 breathes per minute, he was afebrile, and his oxygen saturation was 92% on 6 L per minute of oxygen via nasal cannula. Cardiac examination revealed S1S2, regular, tachycardic, no murmur/gallops/rubs. Respiratory examination revealed normal vesicular breath sounds bilaterally. He was noted to have asymmetrical left lower extremity edema. Electrocardiogram (ECG) revealed sinus tachycardia, no ST-T wave changes. Troponin was mildly elevated at 0.120 ng/mL (reference range: 0 to 0.020). Computed tomography angiography (CTA) of chest showed extensive bilateral pulmonary emboli, with a large clot burden in both main pulmonary arteries, evidence of acute right ventricular failure. Duplex venous scan showed acute left infra-popliteal deep vein thrombosis. Echocardiogram showed normal left ventricular ejection fraction of 60% to 65%, abnormal septal motion and flattening of interventricular septum, right ventricular systolic pressure of 49.7 mmHg, moderately dilated right ventricle, decreased right ventricle function, Tricuspid annular plane systolic excursion of 12.1 mm (normal 15 to 20 mm). As the majority of the clot burden was distal, it was not deemed amenable to surgical extraction as recent surgery was a major contraindication for thrombolysis. The patient was started on a heparin drip and inhaled nitric oxide at 20 ppm along with oral sildenafil 40 mg every 8 hours. The next day, the patient was stable hemodynamically and his inhaled nitric oxide was tapered off. Repeat echocardiogram 48 hours from initial presentation showed improved right ventricle size and function. His right ventricular systolic pressure decreased to 22.4 mmHg and his tricuspid annular plane systolic excursion improved to 17.8 mm. We recommended that he continue sildenafil for the next month after discharge along with oral anticoagulation with a plan to follow-up as an outpatient. The patient gave written consent to treatment during his hospitalization. The patient and his family members were well-informed regarding the entire plan of care, and they were in agreement with the care plan.",
    "summary": "Patient: Male, 56\n\nFinal Diagnosis: Right heart failure due to pulmonary embolism\n\nSymptoms: Syncope\n\nMedication: —\n\nClinical Procedure: —\n\nSpecialty: Cardiology\n\nThis is a case report where sildenafil was used as a rescue agent to achieve improvement in the right ventricle size and function in a case of acute onset massive pulmonary embolism with acute right ventricle failure in the scenario where systemic thrombolytic therapy was contraindicated."
  },
  {
    "id": "multiclinsum_gs_en_52.txt",
    "fulltext": "A 91-year-old man with recurring episodes of heart failure (HF) was admitted to our hospital presenting with dyspnoea and leg swelling accompanied by pitting oedema. A physical exam revealed respiratory distress, crackles, and a 4/6 Levine diastolic murmur upon heart auscultation. His medical history included an aortic valve replacement for severe aortic regurgitation with a 3F Enable 25 mm SBV via an anterior right thoracotomy in 2015, which was complicated by an advanced atrio-ventricular block requiring permanent pacemaker implantation. Other comorbidities included liver cancer (with an estimated survival of over 12 months), chronic kidney disease (CKD), hypertension, and a smoking history. Transthoracic echocardiography (TTE) revealed a mildly reduced ejection fraction (EF) and structural bioprosthetic valve deterioration (SVD) leading to severe intravalvular aortic regurgitation (Doppler aortic PHT of 201 ms with holodiastolic reverse flow in the descending aorta). In preparation for a potential transcatheter heart valve (THV) treatment, a multi-detector computed tomography (MDCT) was performed, confirming severe deterioration of the aortic prosthesis leaflets. The effective inner diameter (ID), measured at the level of the inflow ring of the SBV, was 24 mm with an annular perimeter of 76.2 mm; no relevant left-ventricular outflow tract (LVOT) or annular calcifications were found. The acquired CT-scan images were used to calculate the virtual THV-to-coronary ostium distance (VTC) and the virtual THV-to-sino tubular junction (VTSTJ). The VTC was 4 mm for the right coronary artery and 5 mm for the left coronary artery, with a VTSTJ >2.5 mm. The risk of coronary obstruction was low (Type 3A according to the VIVID classification). The peripheral accesses were suitable for TAVI, with no significant calcifications or vessel tortuosity.\n\nConsidering the prohibitive surgical risk and suitable anatomy, the Heart Team recommended TAVI as the best treatment strategy. Transcatheter heart valve sizing was determined based on MDCT data and with the ViV digital app. The procedure was performed through right transfemoral access obtained with echo-guided puncture; the right radial artery was used as secondary access for contrast injection. Venous access was unnecessary as rapid pacing was performed using the patient’s permanent pacemaker. A supra-annular Acurate Neo2 self-expanding valve (SEV) (Boston Scientific, MA, USA), size M, was advanced on a Safari pre-shaped 0.035″ wire (Boston Scientific, MA, USA) and successfully deployed 3 mm under the lower edge of the Enable valve. Post-dilatation was performed with 24 mm balloon (Simvalve Force, Simeks, EU) obtaining a good final angiographic result. Transthoracic echocardiography showed a residual mean gradient of 4 mmHg without evidence of paravalvular leak (PVL). The patient showed significant improvement after the procedure and was discharged after 3 days. In consideration of the patient’s high bleeding risk due to advanced age and CKD, and the lack of evidence supporting the use of anticoagulation following ViV procedures, we chose to proceed with single antiplatelet therapy using Aspirin. At 6-month follow-up, the patient was asymptomatic and completely satisfied with the procedural result hesitating in an improved functional capacity (NHYA I). Transthoracic echocardiography confirmed good valve performance (Vmax 1.65 m/s, mean gradient 6 mmHg, absence of PVL).",
    "summary": "A 91-year-old man was admitted to our hospital presenting with dyspnoea due to severe aortic regurgitation in a degenerated 3F Enable sutureless valve. Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) was successfully performed using a self-expanding Acurate Neo2 valve, yielding good haemodynamic results without overt interaction between the prosthesis. A 6-month follow-up echocardiogram confirmed excellent valve performance."
  },
  {
    "id": "multiclinsum_gs_en_351.txt",
    "fulltext": "Clinical History\nA 12-year-old boy presented to our hospital with a one-month history of foreign body sensation and a fleshy pedunculated conjunctival mass that grew larger over time. There was no history of trauma or similar lesions to other side of the body. A 15mm pinkish pedunculated fleshy mass of the right palpebral conjunctiva is discovered during an ophthalmologic examination. The visual acuity was within normal limits. The child was diagnosed as Pedunculated Squamous Cell Papilloma and underwent excisional biopsy of the lesion.\n\nMacroscopic and Microscopic Findings\nWe received one formalin-fixed tiny firm ovoid grey white tissue fragment measuring 1.5x1cm for pathology. A hyperplastic polypoid lesion with multiple globular cysts in the conjunctival submucosa was found in microscopic sections, coupled with a significant inflammatory infiltration constituting of lymphocytes, plasma cells, and neutrophils, as well as enormous thick-walled sporangia with numerous endospores. Endospores were released after some of the matured sporangia were ruptured. Conjunctival Rhinosporidiosis was diagnosed histopathologically. There was no recurrence or sign of Rhinosporidiosis in the eye or any other area of the body at the patient’s last examination, which was 7 months following surgical excision.",
    "summary": "A 12-year-old boy with a fleshy pedunculated conjunctival mass was brought to Jimma University Medical Center with a 1-month history of foreign body sensation. The patient was diagnosed with Pedunculated Squamous Cell Papilloma and had an excisional biopsy of the lesion. The mass was found to be a hyperplastic polypoid lesion with numerous globular cysts within the conjunctival submucosa, surrounded by a heavy inflammatory infiltrate of lymphocytes, plasma cells, and neutrophils, as well as large thick-walled sporangia with numerous endospores on microscopic sections. Conjunctival Rhinosporidiosis was diagnosed histopathologically."
  },
  {
    "id": "multiclinsum_gs_en_525.txt",
    "fulltext": "A 69-year-old man was evaluated for gradually progressive and sequential painless loss of vision. He first experienced painless “fogginess” in his right eye, followed by vision loss in his left eye after a few weeks. His past ocular history was non-contributory except for mild cataracts. Medical history revealed sarcoidosis (pulmonary biopsy proven, inactive since 2011), hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, coronary artery bypass grafting in 2007, and subsequently, a heart transplant in 2012, which resulted in prolonged oral sirolimus 2 mg daily for 93 months as well as mycophenolate 2000 mg and dapsone 100 mg daily.\n\nBest-corrected visual acuity (BCVA) was 20/150 OD and 20/80 OS, with impaired color vision in each eye (Ishihara 0/10) and no relative afferent pupillary defect. The anterior segment, ocular motility, and intraocular pressures were normal. Fundus exam showed sector optic disc edema OD and diffuse optic disc edema OS. Humphrey visual field revealed advanced constriction and depression in both eyes. Optical coherence tomography (OCT) revealed increased average retinal nerve fiber layer (RNFL) thickness of 104 μm OD and 164 μm OS and decreased average ganglion cell complex (GCC) thickness of 66 μm OD and 60 um OS. Brain and orbit magnetic resonance imaging (MRI) with contrast revealed T2 hyperintensity and possibly increased thickness of the optic nerves near the chiasm; no post-contrast enhancement in optic nerves or chiasm was observed. These findings have been previously seen in toxic optic neuropathies rather than ischemic optic neuropathies.2 Laboratory workup was all negative and included Lyme, Toxoplasma, QuantiFERON, Syphilis, COVID-19, Herpes simplex virus, Herpes zoster virus, Varicella-zoster virus, Epstein–Barr virus, Bartonella, Cytomegalovirus, liver function tests, basic metabolic panel, thyroid panel, vitamin B1, B12, folic acid, rheumatoid factors (RF), antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA), and angiotensin converting enzyme (ACE). Spinal tap showed a normal opening pressure of 16.5 cmH2O, normal cerebrospinal fluid analysis, negative culture, and cytology. Given the MRI pattern and exclusion of other etiologies, a toxic etiology was considered. He was on multiple immunosuppressive agents including sirolimus for 8 years, and blood sirolimus levels were always within normal limits. After cardiology consultation, sirolimus was replaced with cyclosporin 50mg, and prednisone 60mg daily initiated during the workup was tapered down to a maintenance dose of 5 mg daily. Over 19 weeks, BCVA gradually improved to 20/70 OD and 20/30 OS, the visual field improved as well, and the optic disc edema resolved. Repeat OCT after 17 weeks showed an average RNFL thickness of 68 microns OD and 80 microns OS. Given the improvement in visual acuity and resolution of optic disc edema (although may be non-specific for toxic optic neuropathy), with the exclusion of other optic neuropathy etiologies with comprehensive evaluation, the clinical course is consistent with sirolimus-induced toxic optic neuropathy.",
    "summary": "A 69-year-old male with a history of cardiac transplantation presented with progressive, sequential, and painless vision loss. Visual acuity was 20/150 OD and 20/80 OS, with impaired color vision in both eyes (Ishihara 0/10) and bilateral disc pallor and mild optic disc edema in the left eye. Visual field was constricted in both eyes. The patient was on prolonged sirolimus therapy for over 7 years. Orbital MRI revealed bilateral chiasmatic thickness and FLAIR hyperintensity, without optic nerve enhancement post gadolinium. After extensive work up, other etiologies such as infectious, inflammatory, and neoplastic lesions were ruled out. Subsequently, sirolimus was substituted with cyclosporin that led to gradual improvement of vision and visual fields bilaterally."
  },
  {
    "id": "multiclinsum_gs_en_498.txt",
    "fulltext": "A 63-year-old man presented to our emergency department with a history of frequent hematuria. Physical examination was unremarkable and his blood work was normal with a serum creatinine of 1.2 mg/dL. A contrast-enhanced abdominal computed tomography (CT) revealed a large infiltrative bladder growth, more on the right lateral wall and dome with moderate left-sided hydroureteronephrophy and a right-sided, small, intact bladder, excluding a bladder perforation. A diagnostic cystoscopy with transurethral biopsy was scheduled. However, he presented to the emergency department 2 weeks later with instability, abdominal distension and respiratory distress requiring intubation and ventilatory support. His biochemical panel showed high creatinine (20 mg/dL), hyperkalemia (9 mEq/L) and hyponatraemia (128 mEq/L), and his blood gases showed severe metabolic acidosis (pH 7.1). When questioning the patient's caregivers later, a history of oliguria with gradually increasing abdominal distension over the previous 2 days was obtained, for which he had undergone an external collection of \"ascitic\" fluid in a center. Anti-hypokalaemic measures were initiated. An ultrasound at the bedside showed left hydroureteronephrophy with severe right hydroureteronephrophy and free fluid in the abdomen. In view of the instability and unavailability of haemodialysis in our facility, a bedside emergency nephrostomy was performed with a single-sided nephrostomy catheter. Under ultrasound guidance, a percutaneous nephrostomy was inserted at the bedside and the patient's general condition improved. There was an initial diuresis with a fall in creatinine to a nadir of 2 mg/dL. Due to persistently elevated creatinine levels, the CT was repeated 4 days after the nephrostomy and, to our surprise, we noted that the tip of the pigtail catheter was in the left perirenal space acting as a percutaneous drain with complete resolution of free fluid in the abdomen. The chronology of events of an initial extremely elevated serum creatinine that had fallen dramatically after the drainage of the extravasated fluid adjusted to a clinical picture of pseudo renal failure due to absorption of extravasated urine. We hypothesised that the source of the extravasated urine was most likely a rupture of the renal fornix due to a high-pressure obstruction on the left side. In view of the still elevated creatinine and the gradual decrease in the output of the pigtail catheter, a percutaneous nephrostomy was inserted into the collection system under ultrasound guidance, followed by normalisation of his creatinine. A nephroscopy with cystogram was performed in the sequence and showed a distal left ureteral obstruction and a small, intact bladder, excluding a bladder perforation. A cytoscopy biopsy of the bladder growth confirmed it as an invasive muscular squamous carcinoma. We explained the diagnosis and prognosis to the patient and performed a laparotomy exploration 2 weeks after the biopsy. During intra-operative observation, a dense desmoplastic reaction was observed around the bladder, which was shrunk and glued to the left pelvic walls and the pubic bone. Due to the inoperable nature of the disease, the radical cystectomy plan was abandoned and a palliative bypass of the ileal conduit with right-sided nephrectomy was performed. The patient did well in the post-operative period and was discharged 5 days later. However, he developed multiple thoracic metastases in the following months and his general condition deteriorated steadily, resulting in his death 3 months after surgery due to cachexia.\n",
    "summary": "We report a case of bladder carcinoma that presented with features similar to acute renal failure, and later proved to be a pseudo renal failure due to intraperitoneal urine extravasation from a renal fornix rupture. The patient was treated as an emergency with a percutaneous drainage followed by a percutaneous nephrostomy, which led to normalization of creatinine. Cystoscopy revealed the growth of the bladder in an intact bladder of small capacity and the biopsy confirmed it as an invasive muscular squamous carcinoma. Due to the advanced nature of his malignancy, he underwent a palliative ileal conduit diversion, but later developed thoracic metastasis and eventually succumbed to the disease.\n"
  },
  {
    "id": "multiclinsum_gs_en_320.txt",
    "fulltext": "A 53-year-old Southeast Asian man presented to a local physician with abdominal pain. He had no specific previous medical history or prior treatments. Abdominal ultrasonography revealed hepatomegaly. Since his abdominal pain was resistant to any medication, he was referred to our hospital for a comprehensive examination and subsequent treatment. Upper gastrointestinal endoscopy revealed an ulcer in the duodenal bulb, although he had been taking a histamine H2 antagonist. Helicobacter pylori infection was not detected in any examinations. Plain abdominal computed tomography (CT) revealed intrahepatic reticulated calcification, indicating the presence of Schistosomiasis japonica. Contrast-enhanced CT demonstrated early enhancement of the pancreatic head and superior mesenteric vein in the late arterial phase. Maximum intensity projection (MIP) images revealed blood flow from the gastroduodenal artery (GDA) and superior mesenteric artery (SMA) to tortuous vessels, subsequently draining into the portal venous circulation. Based on these results, we diagnosed the patient with pancreatic AVM. His abdominal pain persisted despite treatment with oral acetaminophen and proton pump inhibitors. Continuous intravenous fentanyl injection relieved his abdominal pain. However, the duodenal ulcer did not improve upon the second upper gastrointestinal endoscopic examination. We considered that the duodenal ulcer was likely caused by the abnormal peri-pancreatic circulation due to the pancreatic AVM, and surgical resection of the pancreatic head was needed to alleviate his symptoms. Considering the risk of increased intraoperative blood loss due to abundant arterial blood flow caused by the presence of the AVM in the pancreatic head, preoperative arterial embolization was scheduled for the day before surgery. Angiography revealed the existence of the AVM in the pancreatic head, which was supplied by the GDA and anterior/posterior pancreaticoduodenal artery (AIPDA/PIPDA) branching from the SMA. After selective arterial embolization of the GDA, APIDA, and PIPDA using gelatin sponges (Serescue; Nippon Kayaku, Tokyo, Japan), AVM was no longer visible under angiography of the celiac axis or SMA. We did not use coils because we were concerned that intra-arterial coils might hamper arterial ligation and division. No complications occurred after arterial embolization until the next day. Since there were no abnormal laboratory data just before surgery, SSPPD was performed. After laparotomy, GDA and peripancreatic arterial branches from SMA were firstly divided to reduce the pancreatic blood flow. The intraoperative findings did not demonstrate any impact of arterial embolization on the pancreatic parenchyma. The operation time was 453 min, and the blood loss was 336g. The patient was discharged on the 16th postoperative day with no complications and has not experienced abdominal pain since.\n\nPathological examination revealed the presence of dilated vessels of unequal sizes, which was consistent with the features of pancreatic AVM. Eggs of Schistosoma japonicum were observed within pancreatic tissue and in the dissected lymph node around the pancreatic head.",
    "summary": "A 53-year-old Southeast Asian man was referred to our hospital with abdominal pain. Contrast-enhanced computed tomography revealed enhancement of the pancreatic head and superior mesenteric vein in the early arterial phase, suggesting the presence of an arteriovenous malformation. Maximum intensity projection images and angiography revealed arterial branches from the gastroduodenal artery and superior mesenteric artery to the arteriovenous malformation, subsequently draining into the portal venous circulation. We supposed that abdominal pain resistant to medical treatment was due to the pancreatic arteriovenous malformation, and surgical resection was deemed necessary. Subtotal stomach-preserving pancreaticoduodenectomy was safely performed on the day after arterial embolization of pancreatic arterial branches to reduce intraoperative blood loss. The procedure resulted in an intraoperative blood loss of 336g. The patient was discharged on the 16th postoperative day with no complications and has not experienced abdominal pain since."
  },
  {
    "id": "multiclinsum_gs_en_464.txt",
    "fulltext": "An eleven-year-old female patient with lower back pain for five years associated with bilateral radiation to the lower extremities, which is more pronounced on the left side. The pain was insidious in onset, worsening over a 2-month period. On the neurological exam, motor power became 3/5 on hip flexion and knee extension; the other lower extremity muscle power was 5/5; the tone was normotonic; and reflexes had been +2 in all deep tendons. She was referred to our center for surgical intervention; otherwise, she had no history of spinal trauma or any spinal procedure, including a lumbar tap.\n\nLaboratory examinations on the day of admission included a complete blood count and biochemical studies, which showed no apparent abnormalities. Contrast-enhanced lumbosacral magnetic resonance imaging (MRI) showed type 1 (T1) hypointense and T2 hyperintense, 6 cm cranio-caudally and 2 cm antero-posteriorly, expansile lesions that extended from L2–L4 with involvement of the conus and cauda equina. It shows marginal enhancement after contrast administration. In the operating room, under general anesthesia, a prone position was made and a vertical skin incision was made to expose the operative area. An L2–L4 complete laminectomy with L1/L5 partial laminectomy is done as the tumor extends in both the cranial and caudal poles and the dura opened on the midline. Intraoperatively, the mass anchored the conus intradurally, filling the spinal canal and displacing the caudal roots anteriorly and laterally, with adherence to the nerve roots on each aspect from L2–L4. Surgical microscopic examination revealed a subpial thin-walled cyst with a grayish content. We did no longer have intraoperative motor evoked potential (MEP), sensory evoked potential (SEP), electromyography (EMG), or cavitron ultrasonic surgical aspirator (CUSA) for debulking; for this reason, we did no longer use them in this case either. Tumor dissection started at the posterior median sulcus. Few reviews have advocated the use of ultrasonography before myelotomy in difficult instances. The whitish cyst contents are expelled effortlessly because they were suckable; the cyst wall was excised in part, and the capsule, which was firmly adherent to the spinal cord parenchyma, was left in a few areas to not sacrifice neural tissue in an attempt to reap total capsulectomy. Care taken to prevent spillage of the cyst into the subarachnoid area. A postoperative lumbosacral MRI confirmed near total excision. The jelly-like cyst content and its wall were sent for histopathological examination, which confirmed a fragmented fibrous cyst wall coated through maturing stratified squamous cells with scattered keratin flecks and fragments of bland skeletal muscle and adipose tissue, which are typical of epidermoid cysts. The postoperative path was uneventful; the pain had resolved, motor and sensory function were intact, and the patient was discharged on the third postoperative day. She had been being followed in our outpatient clinic for the last 6 months; throughout the follow-up, the pain had completely resolved, the neurologic exam became uneventful.",
    "summary": " An 11-year-old female patient had back pain with radiation to both lower extremities but worsened on the left side for 5 years. On neurological examination, motor strength was 3/5 for hip flexion and knee extension bilaterally and 5/5 for other key muscle groups. Contrast-enhanced lumbosacral magnetic resonance imaging (MRI) revealed T1 hypointense and T2 hyperintense lesions in the L2-L4 intramedullary conus and cauda equina. Laminectomy and near total resection were done, and histopathological examination revealed an epidermoid cyst. On the third postoperative day, the patient was discharged with completely resolved back pain and an improvement in lower extremity motor power. At monthly follow-up visits for a further 6 months, her back pain and weakness completely resolved, and she had no neurologic deficits. A postoperative lumbosacral MRI was done and confirmed near total excision of the tumor."
  },
  {
    "id": "multiclinsum_gs_en_302.txt",
    "fulltext": "60-year-old man with a history of Gleason 8 (4+4) prostatic adenocarcinoma involving both prostate lobes, treated with radical prostatectomy and ilio-obturator lymphadenectomy (pT3b-N0-Mx). After 2 years of control, he presented a biochemical relapse (prostate-specific antigen of 1.9 ng/mL) and a small, subcentimetric, hypermetabolic, hypogastric adenopathy (S.U.V.: 3.8) visible on a fluorocholine-enhanced PET-CT.\n\nMultidisciplinary ateneo decided to perform salvage lymphadenectomy with preoperative marking with activated carbon guided by imaging. Due to the depth of the lymph node, preoperative marking with local anesthesia by computed tomography was performed prior to surgery. The adenopathy was surrounded by the hypogastric artery and vein in the front and the side, respectively, and by the L5 nerve root in the back. Its medial margin was free. Due to the arrangement of these structures around the target, marking was performed with a contralateral approach using a trans-sacral access with a T-Lok Bone Marrow Biopsy Standard 4\" needle, 11 gauge (Argon Medical). Anesthesia was performed by planes until the periosteum of the sacrum was reached with 2% lidocaine (10 cm3). However, once the procedure began, intestinal peristalsis mobilized the sigmoid colon in the path of the needle. To avoid transgression of hollow viscera, hydrodissection was performed using diluted contrast solution to displace it. Instrumental progression was performed under tomographic supervision to ensure colon displacement and finally the marking was carried out coaxially with 1 ml of 4% activated carbon (Temis Lostaló) using a Chiba needle of 15 cm, 20 gauge (Argon Medical).\n\nAfter the marking was completed, the needles were removed and a final tomographic control was performed, where the absence of complications related to the procedure was verified. After a brief observation period in the diagnostic imaging department, the patient was transferred to the operating room without pain or haemodynamic disorders. The surgery was performed without complications and the marked lymph node was removed. The pathological anatomy confirmed a lymph node with infiltration by carcinoma.\n",
    "summary": "60-year-old man with a history of prostatic adenocarcinoma on a hypogastric adenopathy resection plan. Preoperative image-guided marking was indicated.\n\nResults: Preoperative marking was performed with local anaesthesia under CT scan with transosseous access and hydrodissection.\n"
  },
  {
    "id": "multiclinsum_gs_en_271.txt",
    "fulltext": "The patient was an 81-year-old woman with a medical history of hypertension and hyperlipidemia. The patient was brought to our hospital with severe right hemiparesis and total aphasia, and the National Institutes of Health Stroke Scale (NIHSS) score at admission was 16. The last known well (LKW) to door time was 12 hours. At our facility, we follow a time-based imaging protocol for acute stroke cases: cases within 4.5 hours from onset undergo CTA first, while cases beyond 4.5 hours are evaluated with MRI first. MRI demonstrated cerebral infarction in the left middle cerebral artery area, and the diffusion-weighted imaging Alberta Stroke Program Early CT Score (DWI ASPECTS) was 7. MRA revealed left M2 segment occlusion. However, findings from the chest X-ray indicated a possible anomaly in the aortic arch, leading us to perform additional CTA to assess the access route for thrombectomy. CTA revealed RAA with mirror-image branching. The patient did not receive an intravenous recombinant tissue plasminogen activator. Although there is limited evidence supporting MT in such scenarios, we carefully evaluated the patient’s condition based on several factors: the pre-stroke modified Rankin Scale (mRS) was 0, the DWI ASPECTS was 7, and the presentation was a wake-up stroke with a DWI-FLAIR mismatch, suggesting that the actual time from onset might not be as prolonged as indicated by LKW. Additionally, the patient exhibited severe symptoms with an NIHSS score of 16. Based on these factors, we judged that MT was appropriate, as it provided a chance to improve the patient’s outcome.\n\nWe chose the usual guidance system. A 9-Fr sheath was inserted into the right common femoral artery. A guidewire (Radifocus; Terumo, Tokyo, Japan) and 6-Fr JB2 catheter (Medikit, Tokyo, Japan) were advanced using a 9-Fr OPTIMO balloon guide catheter (Tokai Medical Products, Aichi, Japan).\n\nThe guide catheter was advanced from the abdominal aorta in the middle of the spine to the thoracic aorta on the right side of the spine and was easily placed in the left internal carotid artery in the usual way with reference to the CTA. Left internal carotid angiography revealed a left M2 inferior trunk occlusion. Thrombolysis in the cerebral infarction 2B reperfusion was achieved using Trevo NXT 3 × 32 mm (Stryker, Fremont, CA, USA) and Catalyst 6 (Stryker) after 3 passes. The time from puncture to recanalization was 61 min (10 min, from puncture to placement of the guide catheter in the left internal carotid artery; 51 min, from placement of the guide catheter to recanalization). Post-procedural CT revealed a small subarachnoid hemorrhage.\n\nAtrial fibrillation was not detected, and whole-body contrast-enhanced CT was performed to further search for the embolic source. Deep vein thrombosis (DVT) and pulmonary embolism (PE) were observed in the right deep femoral vein and both pulmonary arteries, respectively. Transesophageal echocardiography demonstrated patent foramen ovale (PFO). Despite antinuclear antibodies and coagulability being examined using blood tests, these were not the causes of the cerebral infarction. The pathogenesis of the cerebral infarction was determined as a paradoxical embolism, and apixaban was administered after DVT and PE were revealed. The thrombus in the femoral vein and pulmonary artery almost disappeared, and cerebral infarction did not recur. Right hemiparesis and aphasia persisted, and at discharge, the mRS score was 5.",
    "summary": "An 81-year-old woman presented with severe right-sided hemiparesis and aphasia. The National Institutes of Health Stroke Scale score was 16, MRI demonstrated a diffusion-weighted imaging Alberta Stroke Program Early CT score of 7, and MRA revealed left M2 occlusion. CTA revealed a right aortic arch with mirror image branching. Mechanical thrombectomy was conducted using the usual system, and effective recanalization was achieved with a stent retriever and aspiration catheter after 3 passes. CTA revealed pulmonary embolism and deep vein thrombosis (DVT) in the right deep femoral vein, and transesophageal echocardiography demonstrated a patent foramen ovale. Electrocardiography did not reveal atrial fibrillation, and other examinations did not reveal any other cause; therefore, a paradoxical cerebral embolism was diagnosed. After anticoagulant therapy, no recurrence of infarction, pulmonary embolism, or DVT was observed. Severe right hemiparesis and total aphasia did not improve, and the patient was discharged on day 37 after admission with a modified Rankin Scale score of 5."
  },
  {
    "id": "multiclinsum_gs_en_372.txt",
    "fulltext": "61-year-old male patient who attended the emergency department of a high-complexity hospital in Santa Marta, Colombia, with the query \"my face hurts a lot\", who was referred from the oral and maxillofacial surgery department. with initial diagnosis of acute ethmoidal sinusitis. The patient reported a systemic history of high blood pressure under prescription with metoprolol 100 mg twice a day, uncontrolled type II diabetes mellitus managed by food compensation and a history of severe COVID-19 two months ago, which required management in the intensive care unit with anti-inflammatory therapy with two doses of IV tocilizumab.\n\nThe patient had had pain for two weeks and it had worsened two days before admission. The pain was described as a localized, throbbing, high intensity pain in the frontal skull and right ethmoidal region, associated with nasal drainage after rhinoscopy performed prior to the appointment with a report of left ethmoidal sinusitis (scheduled for anterior and posterior ethmoidectomy) and periorbital cellulitis.\n\nOn admission to hospital, paraclinical tests were requested that revealed leukocytes of 15,100/mm3 and blood glucose of 290mg/dl. Antimicrobial, anti-inflammatory and analgesic treatment was instituted with ampicillin/sulbactam 3 g IV every 6 h, dexamethasone 8 mg IV every 8 h, diluted dipyrone 3 mg IV every 8 h, and the pharmacological treatment was supplemented with insulin glargine 15 u pm and omeprazole 40 mg IV every 24 hours.\n\nThe oral examination performed by the department of maxillofacial surgery revealed the presence of necrotic-looking segments of the upper jaw, ill-fitting metal-porcelain restorations, multiple foci of infections in dental organs and the presence of a right oropharyngeal antral communication. The patient was treated with parenteral antibiotic therapy (cefepime, meropenem 2 g IV every 8 h), vancomycin (1.5 g IV every 12 h), and parenteral antifungal therapy (fluconazole 400 mg IV every 12 h) was used.\n\nPhysical examination revealed edema, erythema and nodulation in the right eyelid. The tomographic images described changes in the cranial bone table, suggesting the exclusion of multiple myeloma. In the cranial bone table, multiple saline-like lytic lesions were observed. Thickening of the mucoperiosteum of the right maxillary sinus was also observed. An MRI was performed where cerebral abscesses were observed in the left frontal region (MRI section: 37/60) in late capsular phase, with discrete peripheral vasogenic cerebral edema, correlating with the results of the microbiological analyses.\n\nSurgical procedure\nUnder general anaesthesia, after asepsis, antisepsis, surgical drapes and with the patient in supine position with the head at zero degrees, following the fold of expression. A transverse frontal incision was performed, dissection was performed by planes to the bone and the procedure was performed. A surgical motor and 5 mm burr was used, a trepanation of the anterior wall of the frontal sinus was performed where thickened mucosa with purulent material was observed, which was aspirated, curetted and irrigated with abundant saline solution and hydrogen peroxide. Finally, a sterile absorbable sponge was placed and the pedicled galea flap was repositioned. Subsequently, a cranialization of the frontal sinus was performed by trepanation with burr and aspiration of the abscess without complications by catheter no. 14. The galea flap was sutured with vicryl 2/0 and the skin, with simple sutures of nylon 4/0. In the area of maxillofacial surgery, surgical extirpation of the bone sequestrum, drainage, curettage and subsequent washing of the area with aspiration of secretions was performed.\n\nSinuses secretions, frontal brain abscesses and sinus mucosa were sent for study and reported as labelled culture no. 1 intracerebral abscess secretion: negative for aerobic germs; culture no. 2 frontal sinus (liquid syringe sample): isolated germ: Klebsiella pneumoniae, ssp pneumoniae and culture of frontal sinus no. 3: (tissue sample) positive, isolated germ: Enterobacter cloacae complex.\n\nThe definitive diagnoses were bacterial meningoencephalitis, frontal cerebral abscess and pansinusitis with frontal and maxillary osteomyelitis with primary infectious focus: maxillary osteonecrosis-osteomyelitis derived from the oro-antral communication after a tooth extraction due to COVID-19; as a precipitating factor of the infectious process, the application of the corticoid tocilizumab for severe pneumonia due to COVID-19. Likewise, the right oro-antral communication was established as a conditioning factor of the unfavorable evolution of the patient, which continued active until the patient was treated.\n\nThe patient was hospitalized with parenteral medication and orders for serial hematological tests every 5 days, complete blood count, BUM, creatinine, ionogram, OCT, TGP, VSG and PCR. As an adjunctive to improve the clinical picture, 20 sessions of hyperbaric chamber of 1.5 ATA (absolute atmospheres) were ordered for 2 hours/day to oxygenate the tissues and improve their biological response to healing. A reevaluation consultation was scheduled for 5 months in which there was no evidence of secretions in the operated areas. The patient reported pain in the maxillofacial area treated with levofloxacin 750 mg orally. In general, from the hyperbaric chamber therapies the improvement was quite noticeable. The current state of the patient is appreciated, with a coral pink mucosa, well moisturized, which shows the clinical health of the patient and the healing of the frontal fistula. We can also observe that, despite the loss of cortical, there is no perforation of the Schneider membrane, which is something positive if we compare it with the initial state in which the patient arrived.\n\nThe patient's latest MRI scans show a favorable evolution of the osteomyelitis process. Compared to previous MRI scans, there is a significant decrease in edema and infiltration of the bone marrow at the level of the upper jaw, as well as a reduction in the area of bone destruction and the extent of the lesion. In addition, the findings reveal a better definition of the bone margins, with less involvement of the paranasal sinuses and a lower inflammatory reaction of the adjacent soft tissues. These positive changes in the MRI image support the clinical improvement of the patient and the effectiveness of the antibiotic and surgical treatment. The detailed evaluation of the MRI studies has been fundamental to monitor the progression of the osteomyelitis and guide the therapeutic decision-making in this case.\n",
    "summary": "This report presents the case of a 61-year-old male patient with diabetes, hypertension, and a history of severe COVID-19, with osteomyelitis of the frontal sinus and maxilla. The patient reported severe pain in the facial and maxillary area for two months. Computed tomography imaging showed a mucoperiosteal thickening of the maxilla, and magnetic resonance imaging showed multiple lytic lesions at the level of the frontal sinus, as well as brain abscesses in the left frontal region that correlated with microbiological cultures. In the intraoral clinical examination, necrotic-looking segments of the maxilla, orosinusal fistula, and multiple dental infectious foci were observed. The patient was treated with antibiotics, analgesics, anti-inflammatory drugs, insulin, and proton pump inhibitors. Trepanation of the frontal sinus, drainage of the abscess, and a sequestrotomy in the maxilla were performed, and sessions with a hyperbaric chamber were requested.\n"
  },
  {
    "id": "multiclinsum_gs_en_168.txt",
    "fulltext": "A 21-year-old single female patient with a known history of hypertension and metastatic pheochromocytoma presented to our hospital. Her cancer has metastasized to the bladder, bones, and lungs. She also has a strong family history of malignancy, particularly pheochromocytoma. The patient was admitted due to uncontrolled hypertension and chronic symptoms related to her condition.\n\nOn admission (09/06/2024), the patient was normotensive (BP: 104/66 mmHg), her heart rate was approximately 90 beats per minute, afebrile at 36.9°C, and had an oxygen saturation of 99% on room air. Physical examination indicated an Eastern Cooperative Oncology Group (ECOG) performance status of 2, pallor consistent with chronic anemia, regular heart beat with no murmurs or additional sounds. The abdominal examination was unremarkable, and no edema or ecchymosis was noted in the lower limbs.\n\nThe patient has a history of hypertension and paraganglioma, her medication includes (Doxazosin 2 mg, Labetalol 100 mg, Oxybutynin 5 mg, Paraffin oil, Nifedipine 30 mg). Her surgical history includes a right adrenalectomy at age ten, and she has received various treatments, including somatostatin analogues and palliative radiotherapy. Family history reveals a familial succinate dehydrogenase subunit B mutation (SDBH mutation) with a significant history of endocrine malignancies, including pheochromocytomas in her father and sister and pancreatic cancer in her grandmother.\n\nLaboratory investigations including Complete Blood Count revealed significant anemia, with a hemoglobin level of 7.5 g/dl. There was evidence of hemolysis, as indicated by the high reticulocyte count, indirect bilirubin, and Lactate Dehydrogenase. Haptoglobin was low. Laboratory results are shown in. Coagulation profile excluded Disseminated Intravascular Coagulation (DIC), which shows (PT: 15.6, PTT: 23.3, fibrinogen: 489, D-dimer: 0.63). Direct Coombs test to exclude autoimmune hemolytic anemia was negative. Peripheral blood smears showed the presence of schistocytes, echinocytes a few teardrop cells in addition to thrombocytopenia, all pointing towards microangiopathic hemolytic anemia (MAHA). Given the context of metastatic cancer, the patient was diagnosed with paraneoplastic microangiopathic hemolytic anemia in march/2024.\n\nThe patient was scheduled for CVD protocol (cyclophosphamide, vincristine and doxorubicin), but without cyclophosphamide due to the anemia-inducing effect of alkylating agents. The patient received a total of 5 cycles. As an indicator of clinical response, the patient no longer experienced anemia or thrombocytopenia. A new peripheral blood smear revealed normal cells, which suggests a clinical response to the MAHA that coincides with the improvement of the underlying malignancy. This aligns with the definition of MAHA as a paraneoplastic syndrome.\n\nThe patient medications on discharge are dexamethasone 2 mg tablet, 4 mg peroral (PO) once daily (OD) for 3 days, ondansetron tablet 8 mg PO OD for 3 days, metoclopramide10 mg tablet PO Trible daily for 3 days, calcium 600 mg with vitamin D PO OD for 1 day, labetalol100 mg tablet PO BID for 1 day, doxazocin 2 mg tablet 4 mg PO BID for 1 day, citalopram20 mg tablet PO for 1 day, omeprazole 20 mg, 40 mg PO for 1 day, paracetamol 500 mg tablet, 1000 mg PO BID for 1 day, aprepitant 125 mg/80 mg capsules, 1 capsule PO OD for 3 days (with a prescription).\n\nThe patient had a follow up in 01/07/2024, clinically the patent looks well and active. The patient underwent laboratory investigations including Complete Blood Count (WBC 6.59 10e3/ul, RBC 4.47 × 10^6/ul, HGB 13.2 g/dl, 40.0%, MCV 89.4 fL, PLT 41.5 10e3/ul), Blood Urea Nitrogen 33.8 mg/dl, Creatine kinase-MB 36.1 u/l, Serum Creatinine 0.97 mg/dl, Chloride 101.5 mmol/l, Potassium 4.52 mmol/l, Sodium 135 mmol/l.",
    "summary": "In this case report, we present a 21-year-old single female with a strong family history of endocrine malignancy. She was referred to our hospital for chemotherapy due to a diagnosis of malignant pheochromocytoma, which had metastasized to the urinary bladder, bone, and lung. Additionally, she developed microangiopathic hemolytic anemia as a paraneoplastic syndrome."
  },
  {
    "id": "multiclinsum_gs_en_206.txt",
    "fulltext": "48-year-old man with a history of liver cirrhosis with Child Pugh C classification, MELD score 10, hepatitis C virus (HCV) viral load 756 663.0 IU/ml Log: 5.88, alcoholism, oedematous ascites syndrome with multiple hospital admissions for evacuating paracentesis, and umbilical hernia. Daily medication: 100 mg spironolactone, 20 mg furosemide, 12.5 mg carvedilol and 1 mg clonazepam. He consulted for abdominal pain of colic type and vomiting of 48 hours of evolution. On physical examination, irreductible umbilical hernia was observed with incoercible local pain and absence of air-water sounds. Umbilical hernia was diagnosed as stuck. 15 cm resection of devitalised small intestine was performed with end-to-end anastomosis and drainage of 3600 ml of ascites fluid. He was admitted to the intensive care unit (ICU) in immediate postoperative vigil, with good respiratory mechanics, haemodynamically unstable, requiring noradrenaline. Clinical analyses of admission (Table 1) showed leukocytosis, acute renal failure, hyponatraemia and metabolic acidosis. Severity scores, SOFA (Sepsis Related Organ Failures Assesment) totaled 5 points and APACHE II (Acute Physiology And Chronic Health Classification System II) 17 points. Ascites fluid, blood and urine were cultured, and treatment with meropenem and vancomycin was initiated. He intercurred with postoperative ileus and hyperactive delirium that was treated with dexmedetomidine plus antipsychotics. C. tertium was isolated in two blood cultures and in ascites fluid and Escherichia coli (Table 2), the antibiotic scheme was adjusted according to the sensitivity to piperacillin tazobactam. He evolved with resolution of haemodynamic and renal failure. On the 10th day of admission he presented with dehiscence of intestinal anastomosis and tertiary peritonitis with isolation of Candida albicans. A new surgical intervention was performed and fluconazole was added. He evolved unfavourably, progression of organ dysfunctions, septic shock, resulting in death 16 days after admission to the ICU.\n",
    "summary": "A 48-year-old man with a history of cirrhosis and hepatitis C virus infection presented with a stuck umbilical hernia requiring resection and intestinal anastomosis, with abdominal fluid and blood cultures positive for Clostridium tertium.\n"
  },
  {
    "id": "multiclinsum_gs_en_243.txt",
    "fulltext": "A 44-year-old female presented to the emergency department of our hospital with a history of right lower abdominal pain for 3 days associated with abdominal distention, a few episodes of vomiting, and anorexia. The pain was not associated with fever. The patient had a history of total abdominal hysterectomy (TAH) done 1 year back at a local hospital for abnormal uterine bleeding (AUB). The patient had no other significant medical comorbidities. She did not have a history of any psychiatric illness. On physical examination, her body mass index was 23.5 kg/m2, and her vitals were stable. The abdomen was distended with a Pfannenstiel scar present at the lower abdomen with tenderness over the right iliac fossa; rebound tenderness was present; however, there was no guarding or rigidity. Bowel sound was present but sluggish. On digital rectal examination, the rectum was empty, and no mass was felt. The rest of the physical examination was unremarkable. On blood investigation, hemoglobin was 8.5 g/dl, total leukocyte count was 11,000/cumm with neutrophils of 70 % and lymphocytes of 25 %. The rest of the blood investigations were within normal limits. The modified Alvarado score was calculated as 7/9. Ultrasonography of the abdomen showed features suggestive of acute appendicitis with an appendicular diameter of 8 mm with minimal peri-appendiceal collection. The X-ray abdomen erect view demonstrated multiple air-fluid levels suggestive of intestinal obstruction. With the preoperative diagnosis of acute appendicitis, open appendectomy was planned by Gridiron incision. The operative finding was an inflamed appendix with a healthy base. There was 50 ml of serous peri-appendiceal collection. The ileum was dilated with a doughy consistency. With suspicion of gossypiboma, an enterotomy was performed, and 30 cm × 30 cm long-tailed surgical gauze was present, about 25 cm proximal to the ileocecal junction, which was retrieved through the enterotomy. Enterotomy was repaired in two layers with an interrupted absorbable suture. Post-operative recovery was uneventful; an oral diet was started on the 2nd postoperative day, and the patient was discharged on the 6th postoperative day. On retrospective history taking, the patient denies ingestion of foreign bodies, and there was no history of pica in the past. On the 14th day's follow-up, the patient had no issues, and the wound was healing well. On 1-month, 3-month, and 6-month follow-ups, the patient showed no symptoms or signs of intestinal obstruction.",
    "summary": "We present a case of a 44-year-old female who underwent total abdominal hysterectomy (TAH) a year ago and presented with right lower abdominal pain, distension, and vomiting. Ultrasonography suggested acute appendicitis and intestinal obstruction, prompting an open appendectomy. During surgery, a retained surgical gauze was discovered 25 cm proximal to the ileocecal junction. The gauze was removed via enterotomy, and the enterotomy was repaired. The patient had an uneventful postoperative recovery."
  },
  {
    "id": "multiclinsum_gs_en_368.txt",
    "fulltext": "42-year-old man with a history of major depressive disorder on treatment with venlafaxine, clonazepam and mirtazapine presents a history of worsening mood with thoughts of death, for which he consumes rodenticide 20 mg of the active Brodifacoum with an attempt at self-harm. He was hospitalized one day after the event, treated with intravenous vitamin K and transfusion of fresh frozen plasma, and was discharged 24 hours after normalization of the INR. At his home, he presented anterior epistaxis 5 days later. Emergency consultation where oxaloacetic transaminase, SGOT 63 U/L (VR 10-40 U/L); pyruvic transaminase, SGPT 93 U/L (VR 10-55 U/L); alkaline phosphatase, FA 139 (VR 45-115 U/L); prothrombin time, TP 9% (VR 70-120%); International normalized ratio, INR 7; activated partial thromboplastin time, TTPA 73.2s (VR 25-37s), concordant with coagulopathy due to Brodifacoum ingestion.\n\nDuring hospitalization, the patient presented variable INR measurements, with initial ranges between 7 and 11.6 in the first three days. During the fourth day, the INR ranged between 3.6 and 1.8. After this, the patient achieved stable therapeutic ranges with INR between 1.5 and 1.2. The total daily doses of vitamin K administered during the hospitalization period varied between 20 and 40 mg depending on the results obtained from the INR measurements. Finally, an optimal dose of supplementation for the normalization of the INR of 10 mg intravenous every 8 hours (30 mg a day) was reached. The frequency of the coagulogram controls performed and the respective doses of oral vitamin K administered, until the optimal dose of supplementation with vitamin K for normalization of the INR was reached, are described.\n\nDischarge was indicated and an optimised dose of vitamin K 10 mg orally every 8 hours was maintained, in addition to daily control of the INR with a haematologist and guidance on the importance of adhering to the medication and the need to avoid substances that may increase the risk of bleeding. In addition, a period of control in the polyclinic of anticoagulant treatment and outpatient control with haematology and psychiatry was indicated.\n\nThe patient was contacted at 4 months and indicated that he had not presented episodes of bleeding during this period. He reported that he had maintained the treatment with 10 mg of vitamin K, with which the INR level had been maintained in the therapeutic range. The patient did not report adverse effects, however, he reported difficulty in accessing the drug due to the cost of treatment and the low availability in pharmacies.\n",
    "summary": "We present the case of a 42-year-old man who ingested a toxic dose of rodenticide in a suicide attempt, with epistaxis, INR of 11.6 and need for hospitalization. During 7 days, serial checks of coagulation tests were performed, with optimization of different doses of vitamin K supplementation.\n"
  },
  {
    "id": "multiclinsum_gs_en_11.txt",
    "fulltext": "73-year-old patient, diagnosed with chronic obstructive pulmonary disease (COPD), arterial hypertension (HTA), bipolar disorder, anxiety, depression, hypothyroidism and rheumatoid arthritis, conditions for which she is prescribed the treatment reflected in Annex I.\n\nYou call the community pharmacy to ask about a new medication prescribed for a urinary tract infection and vitamin D deficiency diagnosed after a full blood count in the emergency department of a private hospital.\n\nThe patient is totally dependent and does not leave the house. Her carer is the person who always takes her medication and makes the weekly pillboxes.\n\nThe drugs prescribed for the treatment of the urinary infection were cefuroxima 250 mg (1 tablet every 12 hours for 5 days) and butylscopolamine 10 mg (1 tablet in the morning if uncomfortable).\n\nFor vitamin D deficiency, he was prescribed cholecalciferol 50,000 IU (1 capsule once a month for two months) and cholecalciferol 25,000 IU (1 capsule once a month after finishing the 50,000 IU package).\n\nSTUDY AND EVALUATION\nThe dispensing service (SD) is carried out without incident, following the methodology set out in the Practical Guide for the Professional Pharmaceutical Assistance Services in the Community Pharmacy. Subsequently, the patient contacts the community pharmacy, concerned that the new medication has generated confusion, since she was taking some orange capsules for her vitamin D deficiency prescribed by her primary care doctor a few months ago and in the part of the emergency report in which the treatment appears, a new medication for the same health problem was reflected. In addition, it coincided with the fact that her usual carer will no longer be able to work with her and will not be able to help her with her medication. Therefore, the patient is offered the service of Review of the Use of the Medication (RUM) with the aim of assessing the degree of knowledge that the patient has regarding her pathologies and her treatment, as well as being able to resolve possible errors in the administration of the different drugs that are part of it. She is explained what the whole procedure consists of and decides to accept.\n\nAfter this, the carer was summoned to the pharmacy with the patient’s health card, her medication bag to carry out a thorough check of her medicine cabinet and the latest emergency report in order to gather all the necessary information to carry out the care service by telephone. During the call with the patient, the RUM form was completed, which was subsequently entered into the SEFAC e_XPERT ® platform. In addition, tools such as CIMA (where the technical sheets of the medicines were consulted) and BotPlus (where the possible pharmacological interactions were consulted) were used to correctly evaluate all the pharmacological treatment.\n\nINTERVENTION\nFollowing the initial contact via the telephone interview and a review of the medicine cabinet, it was detected that the patient and her carer were not managing the medication properly. Following a review of her medicine cabinet, expired packs were found with incorrect notes on their use, blisters with broken tablets that should not have been broken and accumulation of several packs of the same medicine. As the patient was dependent, was taking many medicines and had problems in managing her treatment correctly before and during the absence of her usual carer, it was decided, in order to guarantee pharmaceutical safety and improve adherence to the treatment, to refer the patient to the personalised dosage system (PDS) service. Through the SEFAC e_XPERT® platform, a referral report was drawn up for her primary care doctor (MAP) in the National Health System (SNS) (see Annex II), detailing the inclusion of the patient in the medicine use review service and her subsequent referral to the PDS service. In addition, the following proposals for intervention were recorded:\n\nRevision of the dosage schedule of tramadol 50 mg delayed release due to a possible error in the prescription.\n\nReview of the prescribed treatment for vitamin D deficiency due to the existence of a therapeutic duplication.\n\nChange of the absorbent of incontinence of type pants to elastic alleging the situation of dependency of the patient and the difficulties to make a correct placement by the carer when she is in bed most of the time. The corresponding National Codes (CN) were provided.\n\nReview of treatment for COPD due to inhaler difficulties and lack of adherence to therapy.\n\nRESULTS\nDuring the appointment, the primary care physician received the referral report given to the nurse and requested contact with the community pharmacy to properly initiate the SPD service. After speaking with the nurse by phone, the following changes were made to her treatment:\n\nVitamin D deficiency: Calcifediol cancellation and replacement with cholecalciferol prescribed in the emergency department.\n\nRheumatoid arthritis: Modification of the tramadol extended release schedule to 1-0-1 and use of 1000 mg paracetamol 1-1-1 if necessary.\n\nUrinary incontinence: replacement of absorbent pants with elastic.\n\nCOPD: No change in treatment was made. The primary care physician considered daily supervision by the caregiver at each inhaler dose appropriate.\n",
    "summary": "Patient 73 years old, dependent, polypharmaceutical and multi-pathological, contacted the community pharmacy by phone to request information about a new prescription treatment for a urine infection and a vitamin D deficiency. The dispensing of the medication to her carer led to further doubts for the patient, so she was offered the service of review of the use of the medication (RUM). During the provision of the service, several incidences in her treatment were detected, so it was decided to make a referral report to the primary care doctor for a complete review of the treatment and to be able to refer the patient to the Personalised Dosage System (SPD) service in order to guarantee the patient's pharmacotherapeutic safety and improve her adherence to the treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_102.txt",
    "fulltext": "60-year-old female, former smoker, overweight, with rheumatoid arthritis, treated with methotrexate and golimumab. She had a history of pelvic tumor excision en bloc, with rectal resection, colorectal anastomosis reconstruction, and distal sacrectomy at the level of the fourth sacral vertebra (S4). The pathologic anatomy corresponded to a multilocular cystic formation of 22 x 8.5 cm. The histologic sections showed a fibrous tissue wall with a mature squamous or columnar epithelial lining and lymphohistiocytic infiltrates, ectatic blood vessels, and occasional glandular structures with reactive-type changes. These findings were consistent with a mature cystic teratoma.  Two years after the resection, she presented with discomfort at the sacral level. A CT scan and MRI were requested, which showed, at the level of the last sacral vertebrae, the presence of a heterogeneous soft tissue formation close to 60 mm in diameter, associated with rarefaction of fat planes and scarce adjacent fluid. A thick needle biopsy was performed, the result of which confirmed the recurrence of a mature teratoma. After staging, which did not show systemic disease, she was evaluated by a multidisciplinary tumor committee and surgical treatment with en bloc resection was indicated. A posterior approach was performed, resecting the previous scar, partial section of the gluteal and pyramidal muscles, sacral section at the level of S2-S3, respecting both S3 roots, release of the presacral space and excision of the piece. The patient evolved favorably in the postoperative period. The macroscopic pathologic anatomy showed a 7.8 x 6 x 4.5 cm tumor formation adhered to the sacral bone. It was predominantly solid, of heterogeneous consistency with sectors of friable appearance, cystic areas with liquid and gelatinous content and multiple focal areas of calcified consistency. The histologic sections showed bone involvement by neoplastic glandular structures with moderate nuclear pleomorphism, formation of micropapillary structures, mucin production and areas of necrosis. In some cystic areas of the periphery, a mature columnar epithelium was recognized . The surgical margins of resection were free of neoplastic involvement. The immunomarking techniques were positive for CK20, calretinine, p53 and, focally, for CDX2, and negative for CK7, WT-1, PAX8 and CA125. These findings were consistent with a recurrence of mature teratoma with somatic malignant transformation into a colorectal-type adenocarcinoma. A video colonoscopy was performed, which was normal, confirming the diagnosis of somatic malignant transformation of the sacral teratoma. She remained under multidisciplinary control. After 24 months free of disease, she presented deterioration of the general condition and rapid elevation of CA 19.9, so a PET/CT was performed, which showed multiple hypercapturing images at the visceral, soft tissue and bone level, consistent with secondary disease. Due to rapid functional deterioration, she could not receive systemic treatment and died two months later.\n",
    "summary": "A 60-year-old woman with a history of presacral pelvic tumour resection was presented with a mature teratoma in the pathological report. She presented with sacroiliac pain 2 years later. Imaging studies revealed a 6 cm tumour with bone involvement of the last sacral vertebrae. A core needle biopsy was performed and reported a recurrence of a mature teratoma. After staging for systemic disease, she was evaluated by a multidisciplinary committee and surgical treatment was indicated. A resection was performed with distal sacrectomy at the level of S3 and surrounding muscles. The pathological report reported the presence of a mature teratoma with malignant transformation, with a component of colorectal-type adenocarcinoma. The resection margins were free of tumour. After a new multidisciplinary evaluation, a control strategy was decided. She remained disease-free for 24 months, after which she presented with general deterioration associated with disease progression and died 2 months later.\n"
  },
  {
    "id": "multiclinsum_gs_en_37.txt",
    "fulltext": "A 25 years old primigravida woman presented to Daaru-Xannaan Hospital for cesarean delivery after she was informed to have placenta previa. Her last normal menstrual period (LNMP) was unknown but from early ultrasound done at a gestational age of 15+4 weeks, the gestational age at current admission became 37 + 3 weeks. At admission, her complaint was dull aching intermittent abdominal pain, which worsens with fetal movement and abdominal palpation, and the symptom was incriminated for labor and intraamniotic infection. During the course of the pregnancy, she had frequent antenatal visits to nearby health facilities with the complaint of non-specific abdominal pain, loss of appetite, nausea, vomiting and spotty vaginal bleeding throughout the pregnancy. For these complaints, she was frequently admitted and treated for acute pyelonephritis and serial obstetric ultrasound scans revealed normal intrauterine pregnancy.\n\nOn physical examination, she was chronically ill looking with the following vital signs; Blood Pressure: 130/80, Pulse Rate: 116, Temperature: 36.7°C. On abdominal examination, she had mild-to-moderate abdominal tenderness, and fetal heart beat (FHB) of 140–156/min. With the diagnosis of Term pregnancy + Placenta Previa + Chorioamnionitis, she was worked-up with Complete Blood Count (CBC), Renal Function Test (RFT), Liver Function Test (LFT) and Urine analysis. She was resuscitated with 1000mL of crystalloid, started broad spectrum IV antibiotics, 2 units of blood typed and cross-matched and was taken for an emergency Cesarean delivery (CD).\n\nThrough a Pfannenstiel abdominal incision abdominal cavity was entered. Immediately after the peritoneum was bluntly entered, the fetal hand appeared in the surgical field, and the diagnosis of abdominal pregnancy was made. A 3.5kg healthy female neonate was delivered with an Apgar score of 8 and 9 in the 1st and 5th minute. The cord clamped and abdominal cavity explored after converting the abdominal incision to a vertical midline incision (inverted T incision) for a better visualization and accessibility. The abdominal cavity cautiously explored and the placenta was attached mainly to the infracolic omentum, left adnexa, and the left pelvic side wall. The left fallopian tube and ovary were embedded within the placental tissue. The uterus was normal non-pregnant sized and pushed towards the right pelvic wall. The right fallopian tube and ovary appear adhered to the pelvic side wall with fibrinous adhesions. After a thorough examination of the placental insertion sites, infracolic omentectomy and left adnexectomy was done to successfully remove the major part of the placenta. Small nodes of placental tissue, which have been attached to the large bowel and small bowel were left in situ. After placental removal, there were multiple oozing sites from the bowel surface, left pelvic side wall, and posterior cul-de-sac. Bowel loops and bladder were evaluated for inadvertent injury. Abdominal cavity lavaged with 1 liter of warm normal saline, drainage tube inserted, and tight gauze pack left in the peritoneal cavity before abdominal wall closure.\n\nImmediately after delivery the neonate was evaluated and the external findings include facial deformity, which is prominent on the right mandible, bilateral club foot, multiple finger pressure deformities and scoliosis. The neonate vital signs remained stable and feeding well.\n\nDuring the 1st 24hrs of postoperative course the patient was transfused with 03 units of fresh whole blood, vital signs remained within normal range and the drainage output was 400mL. After 48 hours, the patient was then transferred to the operation theatre for re-laparotomy to remove the abdominal gauze pack. The abdominal gauze pack, remaining placental tissue that was attached to the left adnexa and pelvic side wall, and blood clots in the peritoneal cavity removed. There were no sites of bleeding, peritoneal cavity lavaged with 1 liter of normal saline and abdominal wall closed in layers with abdominal drainage in situ.\n\nThe patient hemodynamic condition was stable, tolerated feeding and then discharged with her neonate on the 10th post-operative day.",
    "summary": "Twenty-five-year-old primigravida from the Federal Republic of Somalia at a gestational age of 37 + 3 weeks was admitted for elective cesarean section with a diagnosis of Placenta Previa. She had frequent antenatal visits to nearby health facilities with non-specific abdominal symptoms and spotty vaginal bleeding. Intraoperatively, the uterus and right adnexa were normal, while the fetus, chorioamniotic membrane, and placenta were found in the peritoneal cavity and the diagnosis of abdominal pregnancy was made. A 3.5kg live female fetus was delivered with Apgar score of 9 and 10 in the 1st and 5th minutes. Placenta removed through infracolic omentectomy and left adnexectomy. The neonate had facial deformity, bilateral club foot, scoliosis and finger deformities. The mother discharged in good health on the 10th post-operative day and the neonate was linked to orthopedic surgeon for further management."
  },
  {
    "id": "multiclinsum_gs_en_511.txt",
    "fulltext": "A 72-year-old obese patient with hiatal hernia, asthma and a history of pancreatic cancer relapsed to chemotherapy was admitted for 24 hours for the neurolysis of splanchnic nerves.\n\nThe procedure was performed under ultrasound guidance with local anaesthesia (lidocaine 2% without epinephrine). The patient was positioned in a prone position. A left unilateral posterior approach was used. The right retrocrural access was limited by vertebral osteophytes. After planning the procedure, a PL 21 gauge needle was inserted in a sterile manner under ultrasound guidance into the retrocrural space between the D11 and D12 vertebrae. The needle was positioned in the desired space and a contrast agent was injected into the space. After confirming adequate diffusion of the contrast agent in the prevertebral space, a 70%/30% mixture of 96% ethanol and 7.5 mg of ropivacaine (total volume of alcohol approxiamtely 21 ml) was injected slowly. Immediate post-procedure monitoring showed no complications and no diffusion of the contrast agent or alcohol into the thoracic cavity. The patient tolerated the procedure satisfactorily and was transferred to her room for monitoring. However, 50 minutes after the procedure, desaturation to 85% ambient air was observed without changes in respiratory mechanics or auscultation or signs of cardiac insufficiency. The patient had not been resuscitated during the study or received medication that could produce ventilatory depression. A venous acid-base state did not demonstrate hypercapnia. An electrocardiogram did not reveal any alterations. A thoracic angiotomy was performed to detect pulmonary thromboembolism, which was negative, with a mild bilateral pleural effusion with laminar pericardial effusion. Life support measures were provided with a 2-litre/minute supplemental oxygen cannula with a saturation correction of 95%. 12 hours after the onset of the condition, the patient corrected her saturation disorder without specific therapeutic intervention.\n\nThe patient was discharged at 24 hours with corrected saturation, no additional disorders and good pain management. No pleural or pericardial effusion was evident on examination 10 days after the procedure.\n",
    "summary": "We present the case of a 72-year-old woman with pancreatic cancer and poor pain management despite opioid use. She was given splanchnic nerve neurolysis under inpatient care.\n\nResults: Post procedure, she presented good pain management, however she developed hypoxemia, bilateral pleural and pericardial effusions. Common causes of these events were ruled out. The patient was discharged 24 hours later with good pain management.\n"
  },
  {
    "id": "multiclinsum_gs_en_352.txt",
    "fulltext": "A 35-year-old nulliparous woman with a history of infertility presented to the outpatient clinic. She reported a three year history of cyclical dull pain at her umbilicus. The pain was associated with an umbilical nodule that bled during menstruation. Of note, the pain worsened during menstruation and was relieved by analgesics. The patient also reported dysmenorrhea, menorrhagia and dyspareunia. The patient had a copper IUD inserted 3 years prior and had been using Zinnia P (levonorgestrel and ethinylestradiol) for the last 3–4 months in order to try relieve the pain. Her past gynecological history was otherwise unremarkable and she had a regular menstrual cycle. There was no medical, surgical or social history of note.\nOn examination, her vital signs were stable. A hyperpigmented swelling (3 × 2 cm) at the umbilicus was noted on abdominal examination. The swelling was firm, immobile, non-tender, not reducible and was not tethered to underlying structures. An abdominal MRI revealed an ill-defined enhancing mass measuring 3 × 4 × 6 cm located along the right anterior abdominal wall and was connected to a sinus tract extending inferiorly to the suprapubic region but did not communicate with the peritoneal cavity, findings suggestive of endometriosis. The differential diagnosis was broad, including an umbilical hernia, granuloma, keloid scar, nodular malignant neoplasms and embryological abnormalities. Additionally, bilateral adnexal lesions were noted, they were hyperintense with focal hypointense areas and variable restrictions, the right side lesion measured 1.6 × 1.7 cm and left side lesion measured 2.0 × 0.8 cm, findings consistent with bilateral ovarian endometriomas.\n\nThe patient was scheduled for surgical local excision of the umbilical nodule. The specimen was sent for histopathological examination. The results revealed a normal epidermis with scattered endometrial glands and stroma within the dermis. Photomicroscopy highlighted the presence of endometrial stroma and subcutaneous fat tissue. This morphology is consistent with endometriosis. The patient's postoperative recovery was uneventful, and she was deemed fit for discharge on postoperative day 2. She received counseling regarding her future fertility and possibility of IVF, risk of recurrence and was scheduled for a follow-up visit in two weeks. She was commenced on Dienogest, Visanne and a combined oral contraceptive for the management of endometriosis. She has been monitored clinically every four weeks, and no symptoms or signs of local recurrence have been observed during the 8-month follow-up period. Of note, despite her condition remaining stable following management, she did not conceive over the course of the following year.",
    "summary": "Herein we present the case of a 35-year-old nulliparous woman in Northern Tanzania with a 10-year history of infertility. On presentation this patient reported a three-year history of a cyclical aching pain associated with an umbilical mass. An abdominal MRI revealed an ill-defined, enhancing mass measuring 3 × 4 × 6 cm located along the right anterior abdominal wall. The mass was connected to a sinus tract extending inferiorly to the suprapubic region but showed no communication with the peritoneal cavity, suggestive of endometriosis. Furthermore, bilateral adnexal lesions demonstrated hyperintense signals with focal hypointense areas and variable restrictions, consistent with bilateral ovarian endometriomas. The patient underwent excision of the umbilical mass, and histopathological examination confirmed the diagnosis of primary umbilical endometriosis. Despite her stable condition following management, she did not conceive over the course of the following year."
  },
  {
    "id": "multiclinsum_gs_en_219.txt",
    "fulltext": "The patient was a 54 year old, para 2 mother, who came from a rural area to the Nekemte Compressive Specialized Hospital with the complaint of a mass in her vagina of 3 years duration. Three years ago, she encountered a protrusion of mass through her vagina, which gradually grew in size over time. She had two babies, last delivery being 12 years ago. Both deliveries were at home as the health facility is too far from her residency area, being assisted by traditional birth attendant, and she claimed that it was smooth. Initially, 3 years back, there was bleeding and an offensive discharge from the mass but that stopped in the last year. She developed lacerations on the mass 6 months back. For this reason she divorced and isolated herself from all social life for this long period of time. Now, she was brought to hospital by her older sister and other relative specifically for reason of the mass lacerations. She had no other known chronic medical illness.\n\nPertinent PE Finding\nVital sign: BP = 100/60 mm hg, PR = 84 bpm, RR = 20 bpm, T° = 36.5C°, weight = 47 kg.\n\nGUS: there is pinkish mass per vagina which is about 7 cm from hymenal ring.\n\nUterine fundus is a leading part of the mass.\n\nThere was abouta 5 cm sized longitudinal laceration on the right side of the mass.\n\nThere was no bleeding and discharge from the mass nor laceration area.\n\nLaboratory\nCBC: hemoglobin = 12 g/dl, PLT = 285 thousand, neutrophil = 74% percent.\n\nUrine analysis: normal finding.\n\nBlood group = A, RH = positive.\n\nHIV test = negative.\n\nHBSAg = negative.\n\nUltrasound: partially full bladder seen in abdomen, uterus not seen in abdomen. Otherwise no other pertinent finding.\n\nChest X-ray: normal Chest X-ray finding.\n\nFor this finding, she was diagnosed with chronic uterine inversion. Images were taken pre-operatively and post-operatively, the uterine fundus was the leading point of the mass which protruded completely through the vagina and there was chronic laceration developed on the endometrial surface and after the operation, normal vaginal canal was seen. After reviewing management options with her and her family, she was scheduled for surgery and an abdominal hysterectomy was performed the following day. It was abdominal surgery and it was easy to take the uterus into the abdomen. As tissue was redundant and distorted, anatomical reference and surgical landmarks are difficult to identify. Due to this, the surgery was difficult and there was an intraoperative transactional right ureteral injury and an end=to=end anastomosis was done. She was discharged on her 10th day of operation being improved. She was given a follow up appointment 2 weeks later, and when she was evaluated it was found that she was doing well.",
    "summary": "A 54 year old woman came to our hospital with the complaint of a painless mass in her vagina of 3 years duration. Three years ago, she encountered a protrusion of mass through her vagina, which gradually grew in size over time. On physical examination, uterine fundus was the leading point of the mass and it protruded 7 cm below the hymenal ring. As a result, she was diagnosed with chronic uterine inversion and underwent an abdominal hysterectomy. She was discharged home improved. We report this case because of an unidentified factor eliciting the uterine inversion, late presentation of the disease and difficulty in surgical treatment."
  },
  {
    "id": "multiclinsum_gs_en_276.txt",
    "fulltext": "11-year-old boy with bilateral occipital and frontal headaches associated with vomiting for 12 hours after a fall on the sacroiliac region. History of MS due to a missense mutation in heterozygosity in the FBN1 gene c.2243G>A.\n\nNeurological and instrumental examination was normal, except for the marfanoid habit. A general analysis and a sacrococcygeal radiography were performed, both without alterations. The headache improved, becoming absent in the supine position, but reappeared when standing up and he could not tolerate standing, so he was admitted.\n\nHe showed little response to analgesia during admission. A cranial computed tomography (CT) scan was performed that showed increased density of the transverse sinuses in probable relation to slow venous flow. Given the suspicion of a HIE in relation to a possible CSF fistula, a cranio-medullary magnetic resonance (MR) was requested. The MR showed a mild decrease in the size of the tonsils (5 mm) and detachment of the dura with liquid collections outside of it at the dorsal and lumbosacral level, compatible with a CSF fistula; in addition, perineural Tarlov cysts were visualized at the sacral location. This image was not compatible with a dural ectasia, and the patient did not have previous neuroimaging.\n\nTreatment was prescribed with hyperhydration, minor analgesics (dexketoprofen and metamizol), intravenous hydrocortisone initial dose 8 mg/kg/day, oral caffeine 2.5 mg/kg/day, along with bed rest in the Trendelenburg position. After five days the patient began progressive mobilization, showing a favorable evolution, with improvement of the headaches and tolerating standing. He was able to be discharged from the hospital after 12 days.\n\nAfter four months without symptoms, the clinical symptoms reappeared coinciding with the start of sports activities at school. The control MRI showed the disappearance of the dorsal collection with persistence of sacral collections. He received the same conservative treatment as in the previous admission.\n\nThe control MRI one year later showed resolution of the subdural or extradural collections in the spinal canal and a new finding was identified as a fine image of dorsal midline hydromyelia. Two years after the first admission, he consulted again for orthostatic headaches and an MRI was performed, showing a re-fistulization originating at the L5-S1 level. In view of the relapse, treatment with a lumbar epidural blood patch (L4-L5) was decided by the anaesthetics department. One year after its implementation and three years since the start of the clinical trial, the patient remains asymptomatic.\n",
    "summary": "We present a 11-year-old boy with orthostatic headaches and vomiting for 12 hours after a fall on the sacrococcygeal region; a history of Marfan syndrome. Cranio-spinal MRI showed extradural fluid collections at the dorsal and lumbosacral level consistent with CSF fistula. The condition resolved after treatment, but there were two new episodes during follow-up, so a hematic epidural patch was applied two years after the onset.\n"
  },
  {
    "id": "multiclinsum_gs_en_360.txt",
    "fulltext": "A 60-year-old female, with rural origins, patient presented with acute right iliac pain that had onset since 4 days. The pain was dull, intermittent, and became increasingly severe. The patient did mention episodes of paroxysmal abdominal pain months earlier which were disregarded. She reported also fever, nausea, and vomiting. She didn't had diarrhea or blood in her stool. Furthermore, there was no history of recent travel to tropical countries.\nThe physical examination showed a high temperature at 38.9 °C and tenderness in the right hemiabdomen. No palpable abdominal mass was detected. Laboratory findings found Hemoglobin level at 12 g/dL, leukocytosis (14,650/mm3) and an elevated C-reactive protein (CRP) level of 176 mg/L. The abdominal CT scan revealed irregular, non-stenosing caecal thickening measuring 7 cm, with surrounding fat stranding and hypodense components suggestive of a perilesional abscess. An infected caecal tumor was suspected.\n\nAn exploratory laparotomy was performed. Intraoperatively, a 7 cm caecal mass with adjacent necrotic tissue infiltrating the retroperitoneal region was identified. A right hemicolectomy was performed, followed by a terminalized mechanical side-to-side ileocolic anastomosis. The patient was maintened on antibiotics with association of C3G and metronidazole for 07 days totally. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day.\nHistopathological examination of the specimen showed multiple colonic ulcerations with perforation of the serosal layers. There were abundant acute and chronic inflammatory cells and areas of necrosis. Amoebic trophozoites were readily identified within the necrotic areas in the colonic wall. The resection margins of the ileum were clear. A colonoscopy was scheduled two months after the surgery; however, she did not attend.",
    "summary": "We report a case of a 60-year-old female presenting with acute right iliac pain, fever, and nausea, but no diarrhea or recent travel history. Imaging revealed irregular cecal thickening with features suggestive of a perilesional abscess. Exploratory laparotomy identified a 7 cm cecal mass with necrotic tissue, leading to a right hemicolectomy. Histopathology confirmed amoebic colitis with trophozoites in necrotic areas. Postoperative recovery was uneventful with antibiotic therapy."
  },
  {
    "id": "multiclinsum_gs_en_387.txt",
    "fulltext": "A 17-year-old female adolescent presented to our clinic with a two-month history of left-sided chest pain and a one-week history of left-sided back pain at the level of T7. The chest pain was accompanied by palpitations and dyspnea occurring 3 to 4 days per week. A week before the first visit, the palpitations and dyspnea became less frequent, and she developed a daily intermittent dull pain on the left side of the chest and middle back without radiation, simultaneously in most cases. The pain occurred both on exertion and at rest, lasting for hours, with no alleviative or aggravating factors. She reported pain intensity of 2 to 6 on a 10-point scale. The intensity changed during an attack, and the average was 4. She was healthy otherwise. There was no limitation in daily life. She visited a local doctor one month prior to visiting our clinic. Holter electrocardiographic and laboratory test findings were normal. Her medical history included migraine for three years. Her regular medications were lomerizine, loxoprofen, and naratriptan for the prevention and acute treatment of migraine. Her migraine was well controlled, and she rarely experienced attacks. She denied trauma or prior surgeries. She denied suspected symptoms or family history for autoimmune or inflammatory conditions.\n\nHer blood pressure was 107/60 mmHg and pulse rate was 62 beats/min. She was 162 cm in height and 43 kg in weight, with a body mass index of 16.4 kg/m2. No murmur or arrhythmia was audible on her cardiovascular examination. The lungs were clear to auscultation bilaterally. Chest palpation provoked non-reproducible local pain in the lower sternocostal joints; horizontal arm traction maneuver and the crowing rooster maneuver provoked no pain. There was no tenderness on muscles and bones in the upper body.\n\nElectrocardiographic and laboratory findings, including thyroid function, were normal. Chest and thoracic radiographic examination showed straightening of the upper thoracic spine and a loss of normal kyphotic curvature. Lower rib radiographs revealed no fracture or pneumothorax. We suspected straight back syndrome, according to the two different diagnostic criteria proposed by Davies et al and DeLeon et al. The distance between the middle of the anterior border of T8 to a vertical line connecting T4 to T12 was 0.91 cm. The anteroposterior diameter was 74.0 cm, and the transverse diameter was 243.2 cm. We advised her to start and continue chiropractic therapy to increase thoracic kyphosis. We proceeded with watchful waiting for one month in outpatient care.\n\nAfter this first visit, the chest and back pain gradually relieved. Palpitations and dyspnea scarcely occurred. All symptoms disappeared within three weeks. At the one-month follow-up visit, echocardiography was performed, revealing trivial mitral regurgitation without prolapse. We confirmed the diagnosis of straight back syndrome. We reassured the patient that the disease is benign, and advised her to continue chiropractic therapy. She has not had relapse of severe symptoms or the need to visit the hospital. She never visited our clinic in the subsequent year.",
    "summary": "A 17-year-old female adolescent presented with her mother to our clinic with a two-month history of left-sided chest pain and a one-week history of middle back pain. We diagnosed straight back syndrome based on the chest and thoracic radiographic findings and symptoms of chest pain, palpitations, and dyspnea. We reassured the patient that the disease was benign and advised her to start and continue chiropractic therapy. All symptoms, including back pain, disappeared in three weeks."
  },
  {
    "id": "multiclinsum_gs_en_331.txt",
    "fulltext": "A 24-year-old male patient presented to our clinic in November 2023 with a history of blunt trauma to the right eye in October 2023. He had a hyphema at the time of the trauma, so a proper fundus exam was not performed at that time. Upon examination, visual acuity was (20/50), anterior segment examination was unremarkable, and fundus exam revealed a full-thickness macular hole. OCT revealed a full-thickness macular hole with a diameter of 320 um and a base diameter of 925 um. Surgery was offered, but the patient was reluctant, and a one-month follow-up was given to reconsider surgery. Two months later, he presented with a visual acuity of (20/100), and OCT showed an enlargement of the macular hole with a diameter of 368 um and a base diameter of 1233 um. Pars plana vitrectomy (PPV) was performed in January 2024, posterior vitreous detachment (PVD) induction followed by staining with trypan blue (Membrane blue dual, DORC, Netherlands). ILM peeling was initiated inferotemporally and advanced nasally then superiorly and concluded with an inverted temporal ILM flap over the hole. At this stage, the flap was not stable over the hole; it was tucked gently with a soft tip cannula, and a dispersive viscoelastic was applied over the flap; careful fluid-air exchange was performed at 30 mmHg with the flap observed flat over the hole, and SF6 20% flush was performed. After the surgery, the patient was instructed to maintain a face-down position. At two weeks postoperatively, the patient reported maintaining a strict face-down position and came with an improved visual acuity to (20/50). OCT showed successful hole closure, and the flap could be seen bridging the fovea. At three months postoperatively, the patient came back to the clinic with a complaint of a very faint central floater. Visual acuity was (20/30), and fundus exam revealed a clear vitreous cavity and a closed hole. OCT showed a partially detached flap that is still hinged temporally to the fovea. No intervention was offered to the patient since the floater is very minimal.",
    "summary": "A 24-year-old male patient presented with a history of a blunt trauma and a full-thickness macular hole. Visual acuity was (20/50) then deteriorated to (20/100) prior to surgery. He underwent pars plana vitrectomy with an inverted ILM flap and gas tamponade. Postoperatively, successful closure of the hole was noted with a visible hinged ILM flap observed over the retina in optical coherence tomography (OCT). Three months later, the patient presented with a complaint of a central floater. Visual acuity was (20/30) and a partially detached ILM flap was noted in the OCT."
  },
  {
    "id": "multiclinsum_gs_en_208.txt",
    "fulltext": "Clinical Data\nA 19-year-old male presented at the endocrinology department of our hospital on January 11, 2023. Two months prior, the patient developed emotional agitation without obvious inducement, accompanied by chest tightness, hand-shaking, and diarrhea. Thyroid function was examined at another hospital on November 8, 2022, and revealed the following: triiodothyronine (T3), 2.85 (normal range, 1.01–2.95) nmol/L; thyroxine (T4), 196.00 (normal range, 55.34–160.88) nmol/L; free triiodothyronine (FT3), 8.69 (normal range, 2.77–6.50) pmol/L; free thyroxine (FT4), 37.50 (normal range, 10.43–24.32) pmol/L; and TSH, 3.48 (normal range, 0.40–4.34) mIU/L. At that time, the patient was unable to receive further diagnosis and treatment for personal reasons. One week before presenting at our hospital, the patient developed palpitations, and the reported symptoms were slightly worse than before. The outpatient clinic examined his thyroid function and revealed the following: T3, 2.20 (normal range, 1.01–2.95) nmol/L; T4, 209.90 (normal range, 55.34–160.88) nmol/L; FT3, 8.63 (normal range, 2.77–6.50) pmol/L; FT4, 34.06 (normal range, 10.43–24.32) pmol/L; TSH, 4.13 (normal range, 0.40–4.34) mIU/L; thyroid peroxidase antibody (TPOAb), 43.80 (normal range, <60) U/mL; and thyroglobulin antibody (TGAb), <15 (normal range, <60) U/mL. The patient was admitted to the hospital from the outpatient clinic with suspected syndrome of inappropriate secretion of TSH (SITSH). During the course of the disease, the patient did not experience fever, chills, or sweating. The patient’s appetite was unaffected, and he did not experience weight loss, fatigue, constipation, or other discomfort. The patient was in good health and had no history of chronic disease or radiation exposure to the neck. His parents were not consanguineous, and no genetic history in the family.\n\nPhysical examination revealed the following: body temperature, 36.5°C; pulse, 97 bpm; breathing, 19 bpm; blood pressure, 120/78 mmHg; height, 172 cm; weight, 70 kg; BMI, 23.66 kg/m2; clear mind; normal development, intelligence, vision, and hearing; no exophthalmos; free eye movements; mild thyroid enlargement and softness, with no tenderness and with swallowing up and down; no vascular murmur; no positive signs in the heart, lung or abdomen; normal muscle strength and tension of the extremities; no mucinous edema of lower limbs.\n\nSupplementary Examination\nRe-examination of thyroid function on January 12, 2023, revealed the following results: T3, 1.99 (normal range, 1.01–2.95) nmol/L; T4, 184.30 (normal range, 55.34–160.88) nmol/L; FT3, 8.17 (normal range, 2.77–6.50) pmol/L; FT4, 32.74 (normal range, 10.43–24.32) pmol/L; TSH, 2.30 (normal range, 0.40–4.34) mIU/L; TPOAb, 52.00 (normal range, <60) U/mL; TGAb, <15 (normal range, <60) U/mL; thyroid stimulating receptor antibody (TRAb), <0.10 (normal range, <1.00) U/L; and reverse triiodothyronine (rT3), 66.13 (normal range, 35.00–95.00) ng/dl. There were no obvious abnormalities in the blood routine, biochemistry, cortisol rhythm, adrenocorticotropin, growth hormone, or sex hormone test results. The 2-hour thyroid iodine uptake rate was lower than the normal value, and the 6-hour thyroid iodine uptake rate was normal. Thyroid color Doppler ultrasound revealed a right thyroid follicular cyst (TI-RADS-II). Thyroid single photon emission computed tomography revealed an enlarged thyroid volume. Bone age: adult bone age. No obvious abnormalities were found on routine or enhanced magnetic resonance imaging (MRI) of the pituitary gland. The patient’s electrocardiogram results were normal.\n\nGenetic Testing\nThe patient showed elevated FT3, FT4, and T4 levels and some manifestations of thyrotoxicosis; however, his TSH and thyroid autoantibody levels were normal, and the thyroid iodine uptake rate decreased, which did not support the diagnosis of primary hyperthyroidism. The physical and other auxiliary examinations also ruled out thyroiditis, TSH secreting pituitary adenoma (TSHoma), and other central hyperthyroidism. The patient was highly suspected to have RTH. Genetic analyses were performed on the patient and his family after obtaining informed consent. The full exome of genomic DNA was captured and sequenced by KingMed Diagnostics Co., Ltd. The result revealed a heterozygous mutation in the THRB gene encoding thyroid hormone receptor β (TRβ) on chromosome 3. The 947 base G in the gene’s coding region was converted to A, and the nucleotide codon changed from CGC to CAC, converting amino acid 316 from arginine to histidine (R316H). Missense mutations can lead to RTH. The mother and the patient had a heterozygous mutation at the same site; the father had no mutation.",
    "summary": "We report a 19-year-old male patient with elevation of thyroid hormones. Serological examination showed elevated thyroid hormone levels, and thyroid-stimulating hormone levels within the reference interval. The patient was finally diagnosed with RTH after genetic testing that identified a gene mutation inherited from his mother. Due to timely diagnosis, the patient’s condition has been well controlled, and his prognosis is good."
  },
  {
    "id": "multiclinsum_gs_en_232.txt",
    "fulltext": "The patient was a 0-day-old newborn female of Han Chinese ethnicity, born at 36 weeks of gestation to a gravida 3, para 2 woman, weighing 2650 g. She was delivered by emergent cesarean section owing to fetal distress, with Apgar scores of 6 at 1 min and 5 min. Her blood type was O, and RhD was positive. At birth, she presented with pallor, scattered ecchymosis across multiple areas of the body, mucosal bleeding, and respiratory failure, with minor hemorrhagic oozing also observed at venipuncture sites. Umbilical artery blood gas analysis showed a hematocrit of 0.08 and hemoglobin of 23 g/L. The patient required endotracheal intubation and mechanical ventilation. After red blood cell suspension transfusion, initial blood counts revealed severe thrombocytopenia (platelet count of 12 × 109/L), anemia (hemoglobin of 46 g/L), and leukopenia (leukocyte count of 1.11 × 109/L).\n\nThe patient was admitted to the neonatal intensive care unit at 3 hours of life for further treatment. During hospitalization, she was diagnosed with disseminated intravascular coagulation (DIC), with activated partial thromboplastin time (APTT) 73.10 seconds, prothrombin time (PT) 25.4 seconds, fibrinogen (FIB) 1.01 g/L, international normalized ratio (INR) 2.26, and D-dimer > 20 mg/L. She was supported with mechanical ventilation, correction of acidosis, and transfusion of fresh frozen plasma. Despite multiple transfusions of red blood cells and platelets, hemoglobin and platelet levels remained below normal (hemoglobin 106 g/L and platelets 11 × 109/L on day 3). She also received anti-infective treatment, cardiotonic therapy, vasopressors, and other symptomatic treatment. A peripheral smear showed enlarged pale staining areas of red blood cells, with a reticulocyte proportion of 1.5% and a negative direct Coombs test. Bone marrow aspiration was not performed owing to her severe condition. There was no clinical or laboratory evidence of neonatal sepsis, and tests for toxoplasma, rubella, cytomegalovirus, and herpes simplex virus (TORCH); hepatitis virus; and Treponema pallidum were negative. Physical examination on admission revealed poor mental status, decreased muscle tone in the extremities, and sluggish pupillary reflex to light. All other findings were normal. Bedside cranial ultrasound and electroencephalogram revealed severe intracranial hemorrhage and low voltage, respectively. Echocardiogram findings were suggestive of patent ductus arteriosus, patent foramen ovale, and pulmonary hypertension. Abdominal ultrasound indicated gastrointestinal hemorrhage. Despite all efforts, the patient died on the third day of life due to multiple organ failure and massive intracranial hemorrhage (detailed information can be found in the Supplementary Report).\n\nThe patient’s parents were non-consanguineous and both had thalassemia. The mother, who shared the same blood type as the patient, had mild anemia during pregnancy (hemoglobin level of 97 g/L) and a history of induced abortion. Prenatal examinations showed no abnormalities, including no fetal hydrops, and she did not receive any medications during pregnancy that could lead to early-onset hemorrhagic disease in the newborn. The patient also had a 1-year-old brother who was in good health. Her grandfather had a history of mild anemia (specifics unknown).\n\nInformed consent was obtained from the patient’s parents, and Sanger sequencing was performed to discover the cause of the disease. A novel heterozygous MECOM frameshift mutation [NM_001105078: c.157_158del (p.Met53Glyfs*2)] was detected in the proband. This variant changed the 53rd amino acid from methionine (codon ATG) to glycine (codon GGT), followed by an early termination. The mutation was not found in the parents or elder brother. The variant was classified as pathogenic according to American College of Medical Genetics (ACMG) guidelines [14]. The “AutoPVS1” algorithm provided strong support for the PVS1 interpretation of p.Met53Glyfs*2, indicating pathogenicity. The variant has not been previously reported in the Human Gene Mutation Database (HGMD) or Clinvar. Conservation analysis showed that the Met53 residue is highly conserved across mammalian species (including human, mouse, rat, chimpanzee, and bovine) using Clustal Omega. Three-dimensional protein structure models of the wild type and mutant MECOM proteins were generated using SWISS-MODEL, indicating that the frameshift mutation caused early termination of amino acid synthesis, significantly altering the protein structure.",
    "summary": "We report a 0-day-old female Han Chinese neonate who presented with severe thrombocytopenia and intracranial hemorrhage, ultimately succumbing to multiple organ failure and intracranial hemorrhage on the third day after birth. Genetic sequencing identified a heterozygous frameshift variant, c.157_158del, within the MECOM gene. This variant led to a substitution of the 53rd amino acid from methionine to glycine, terminating at the 54th amino acid. A comprehensive review of literature indicated that MECOM gene mutations included missense (68.3%), deletion (8.5%), splice site (8.5%), frameshift (7.3%), and nonsense (7.3%) mutations. Patients with missense mutations frequently exhibited radioulnar synostosis, while bone marrow failure was more commonly associated with the other four types of mutations."
  },
  {
    "id": "multiclinsum_gs_en_122.txt",
    "fulltext": "A 74-year-old woman was admitted to our hospital because of dyspnea and chest pain for 1 month. She was previously diagnosed with hyperthyroidism due to heart failure with atrial fibrillation 11 years prior, which was treated with medication prescribed at a private clinic. However, she had discontinued taking medication for hyperthyroidism against medical advice several years prior. Two months before the most recent hospital admission, a thyroid function test (TFT) was administered to determine the cause of weight loss, and she was diagnosed with recurring hyperthyroidism; however, she refused treatment with medication.\n\nInitial chest roentgenography showed bilateral pulmonary edema and pleural effusion, and electrocardiography showed atrial fibrillation. Transthoracic echocardiography (TTE) showed moderate left ventricle dysfunction (ejection fraction, 43%) with regional wall motion abnormalities at the area of the right coronary artery (RCA) and left circumflex artery (LCX). Subsequent coronary angiography revealed chronic total occlusion (CTO) of the RCA with collateral blood flow from the LCX, 90% obstruction of the LCX, and 80% obstruction in the mid portion of the left anterior descending artery (LAD). Initial cardiac markers showed normal creatine kinase-muscle/brain (CK-MB, 1.8 ng/mL; reference range, < 3.4 ng/mL) and mildly elevated troponin I (Tn I, 0.28 ng/mL; reference range, < 0.12 ng/mL) levels. TFT showed decreased thyroid stimulating hormone (TSH) (0.01 uIU/mL; reference range, 0.55–4.78 uIU/mL) and elevated T3 (2.39 ng/mL; reference range, 0.6–1.81 ng/mL) and free T4 (3.321 ng/dl; reference range, 0.89–1.76 ng/dl) levels and positive test results for thyroglobulin and thyroid peroxidase antibodies.\n\nAnti-thyroid medication treatment with 10 mg methimazole three times per day was initiated, and she was scheduled to undergo CABG surgery after normalization of the thyroid function. Chest roentgenography showed improving pulmonary edema and pleural effusion after medical management for 1 week. However, results of the TFT remained elevated (T3, 2.21 ng/ml; free T4, 3.77 ng/dl), and she developed fever (37.9 °C) without any sign of infection.\n\nOn day 8 of hospitalization, the patient exhibited loss of consciousness (LOC) with 7 s of sinus pause during the 6-min walk test and then again for 30 s at night. We performed electroencephalography to exclude seizure as a cause, and the findings were normal.\n\nWe concluded that sick sinus syndrome (SSS) caused the LOC. A follow-up chest roentgenography showed aggravation of pulmonary edema with pleural effusion and an elevated CK-MB level (8.9 ng/mL; Tn I, 1.82 ng/mL). A subsequent TTE showed no differences in findings compared to those from the initial TTE. We considered delaying CABG surgery because we could not determine whether the patient’s syncope was related to CTO of the RCA.\n\nWe decided to perform surgery on the patient after consulting with an endocrinologist who recommended iodine solution administration (Lugol’s solution, 5 drops two times per day) and continuous use of antithyroid medication until surgery. However, results of the TFT remained elevated (T3, 1.89 ng/ml; free T4, 3.64 ng/dl) before surgery. On day 14 of hospitalization, CABG surgery was performed under cardiopulmonary bypass (CPB). The left internal mammary artery was anastomosed to the LAD, and the saphenous vein was anastomosed to the obtuse marginal artery. Graft patency was normal on blood flowmetry. She was successfully weaned from CPB. However, she exhibited extreme tachycardia (> 140 bpm) refractory to the intravenous beta-blocker (esmolol) and was, therefore, transferred to the intensive care unit after the intravenous administration of 130 mg of esmolol bolus injection.\n\nIntravenous esmolol was administered by continuous infusion (range, 20–200 mg/h) and twenty-one 790 mg bolus injections on the day of surgery. In addition, she was administered cortisol (50 mg q 8 h), and the antithyroid medication dosage (15 mg methimazole three times per day) was increased after consultation with the endocrinology department. Twenty-hours after surgery, extreme tachycardia was not present; therefore, continuous infusion and bolus injection of esmolol were discontinued. Follow-up TTE results were the same as those seen preoperatively.\n\nOn day 2 after surgery, she exhibited tachycardia (> 160 bpm) for 30 min, which was controlled with five bolus injections of esmolol intravenously (120 mg total). Thereafter, she did not exhibit extreme tachycardia requiring intravenous beta-blocker. The steroid was discontinued on day 3 after surgery for a total of nine bolus injections (450 mg total). Results of the TFT showed decreased thyroid hormone levels (T3, 0.87 ng/ml; free T4, 2.86 ng/dl) on day 4 after surgery. Subsequent chest roentgenography showed haziness of the right upper lung field, and Klebsiella pneumonia was detected in the sputum. Despite appropriate antibiotic treatment, her condition was exacerbated and she developed multiple organ failure resulting from the deterioration of adult respiratory distress syndrome. She subsequently died 8 days after surgery.",
    "summary": "A 74-year-old woman with a history of antithyroid medication discontinuation against medical advice underwent urgent CABG. The patient exhibited extreme tachycardia postoperatively, which is highly suggestive of thyroid storm. Although a higher infection risk is an important consideration, a high-dose steroid was used to control the intractable tachycardia that did not respond to beta-blocker administration. Despite appropriate antibiotic treatment, the patient’s condition was exacerbated, and she developed multiple organ failure resulting from adult respiratory distress syndrome progression, and she died on day 8 after surgery."
  },
  {
    "id": "multiclinsum_gs_en_23.txt",
    "fulltext": "Nine-year-old male school patient with attempted suicide. Product of second pregnancy, unplanned, unwanted, but accepted. Preeclampsia was reported at eight months of pregnancy with unspecified pharmacological management, obtained at term via abdominal, weight of 3,500 grams.\n\nHead trauma at age 2 years from a fall from approximately 50 centimeters, without loss of alertness or medical attention. The 31-year-old father had symptoms of unspecified anxiety at age 26 without attention; the 14-year-old brother reported academic difficulties and irritability. Resto questioned and denied.\n\nThe family was disintegrated by the parents' separation when the patient was three years old, so he had been living for a year in a large family nucleus with his father, and living with his mother during school holidays. Low socioeconomic status.\n\nAbout an hour before admission to hospital, and following a disagreement with his brother, the minor impulsively locked himself in the bathroom, where he got the shower curtain around his neck. When found by a relative, without knowing how much time had passed, he was observed with a loss of alertness, and was taken to a hospital unit near his home for treatment. On admission, he was reported to have a temperature of 35ºC, blood pressure of 80/44 mmHg, heart rate of 100 beats per minute, respiratory rate of 30 breaths per minute, weak central pulse, dilated pupils, hypertonic, with generalised cyanosis, ecchymosis in the left side of the neck and pulmonary fields with respiratory roughness, so advanced airway management and aminergic support with norepinephrine at a dose of 0.2 mcg/kg/min was carried out.\n\nHe was sent to a third level unit to continue his care, where a tomography of the skull was performed, which showed data of mild edema with decreased subarachnoid space and loss of the convolutions. He was kept sedated and neuroprotective in the pediatric intensive care unit, and was extubated five days later without incident. He was started on oral medication tolerating the diet.\n\nHe was referred to the mental health service for assessment and identification of potentially related risk factors. During his stay in the hospital area, the minor was directly questioned and symptoms of insidious onset, chronic course, with a factor associated with the separation of the parents and little contact with his mother were detected. He presented a picture characterised by sadness most of the time, hyporexia, recurrent dreams where he sees himself alone, with feelings of guilt, a decrease in the ability to think and concentrate (mainly in school), thoughts of death, which generated dysfunction in the family and school areas and attempted suicide a few days earlier. Based on the above, a diagnosis of severe depressive episode was made, and pharmacological treatment with fluoxetine at 20 mg/day was initiated.\n\nThe family structure and organization was found to be lacking a shared hierarchy between both parents, with confusion in the lines of responsibility and rules of living together, without clear boundaries, along with ambivalent parenting practices ranging from authoritarian to indifferent and inadequate supervision. In terms of communication, problems were observed manifested by discomfort in expressing ideas and feelings, which consequently led to the transmission of confusing messages. The older brother had a parental role to the patient. Consequently, the family showed dysfunction and psychotherapeutic intervention was granted to both the patient and his relatives.\n\nThe patient was discharged fifteen days after admission to the hospital, as he showed improvement and stability. He continued with follow-up in the outpatient department where the presence of a persistent pattern of inattention, hyperactivity and impulsivity was detected, which, according to the mother, was noticeable from the age of two years. This could hinder his development and functioning, as in the case of the acquisition of reading, as he presented learning difficulties (he succeeded in learning up to the third grade of primary school with the help of the Regular Education Support Unit, USAER).\n\nThe results of the psychological tests (Bender test and human figure) indicated neurological immaturity, which supported the diagnosis of attention deficit disorder with hyperactivity (ADHD). Treatment with methylphenidate 20 mg/day was initiated.\n\nRegarding his evolution, an improvement in the symptomatology was observed, so after a year of follow-up he was discharged to his General Hospital of the Zone to continue surveillance. Currently, the minor has remained with remission of affective symptoms, stability in symptoms of inattention, hyperactivity and impulsivity and without presenting suicidal behaviors.\n",
    "summary": "The nine-year-old male patient put his life at risk by attempting suicide by hanging in the bathroom. He received emergency care and was in the intensive care unit. During his hospitalization he was approached by the mental health service. Among the factors that have been previously associated with suicide attempts in school age that could be identified in the patient are: family disintegration, symptoms of severe depressive episode, difficulty in learning to read and a disorder of attention deficit with hyperactivity. The patient received treatment and follow-up, and to date has not returned to suicidal behaviour. He is currently thirteen years old.\n"
  },
  {
    "id": "multiclinsum_gs_en_560.txt",
    "fulltext": "30-year-old male patient who presented to the Dermatology consultation referred from Family Medicine in October 2021. As personal background, he reported active smoking since the age of 14, consumption of eight cigarettes a day, no chronic degenerative or hereditary background in the examination. He denied allergies to medicines or food. Tattoos were identified on the inner face of the right forearm (made five years ago) and in the external region of the ipsilateral arm (made two years ago), with green, red and black pigments.\n\nCame for dermatosis of one month of evolution, located in the right upper extremity, in the inner face of the forearm and in the outer face of the arm, which is unilateral, asymmetric, of monomorphic aspect, consisting of artificial macula, caused by red ink (tattoo), with development of lesions of papular aspect in original trace, pruritic, of moderate to intense form, without modification after initial treatment with oral antihistamines.\n\nA physical examination identified a raised, erythematous, pruritic lesion with a red tattoo ink pigmented portion located in the inner region of the right forearm and in the outer region of the ipsilateral deltoid. The lesion was only present in the area with red outlines, the rest of the tattoo and the surrounding skin were uninjured. A biopsy was performed with informed consent using a punch biopsy, with the following histopathological report: mononuclear infiltrate and pigment deposit in the middle and partially in the deep dermis (foreign body reaction).\n\nPartial improvement of pruritic symptoms was reported after the use of low-potency topical steroids.\n",
    "summary": "30-year-old male patient who presented with a localized dermatosis in the right upper extremity, unilateral, asymmetric, monomorphic in appearance, consisting of artificial macula, caused by red ink (tattoo), with development of papular lesions in the original line, pruritic, reported time of evolution of one month. The histopathological finding corresponds to a reaction to a foreign body with partial response to low-potency topical steroids.\n"
  },
  {
    "id": "multiclinsum_gs_en_501.txt",
    "fulltext": "He is a 16-year-old boy who in the months prior to consultation suffers occasional sleep paralysis, after a few minutes of the postprandial nap, which causes him a lot of anxiety, the main reason why he comes to the consultation. Occasionally, these sleep paralyses were accompanied by hypnopompic hallucinations (which he associated with dreams or not being fully awake). He has a nightly sleep schedule of about seven hours plus two hours of nap that are very refreshing. He has good academic performance. When we asked him a directed history, he said that after months of suffering these sleep paralyses, episodes of shaking of arms and legs appeared, especially when he laughed, which almost made him fall (he thought it happened to everyone). Afterwards, these symptoms were added to three short nightly awakenings, with immediate subsequent reconciliation and occasional attacks of sleep in the morning, which he associated with mathematics classes (the teacher is very boring). After clinical suspicion, we requested a multiple sleep latency test and a nightly polysomnographic study, which are conclusive with the diagnosis of narcolepsy (very short sleep latency, REM sleep latency, somewhat fragmented sleep, average in the multiple sleep latency test of 2.1 minutes and the presence of four sleep onset REM). Since the episodes of drowsiness occur every day at the same time, we prescribed a short morning nap that refreshed him a lot and he reported being able to continue with his school activities. Afterwards, we had to add modafinil at the same time (200 mg). We recommended venlafaxine for cataplexy or even initiate treatment with sodium oxybate (the latter he does not want to take because of the discomfort of the second dose, and he also rejects venlafaxine because of fear of the side effects). We agreed that he would comply with good sleep hygiene, take modafinil and continue with the scheduled naps (the afternoon one he already took and the morning one) and, if it got worse, we would add other treatments. He is doing well with this schedule, he does not perceive much fragmentation of nightly sleep (one or two very brief awakenings after which he falls asleep again without problems); in fact, he wakes up rested, the cataplexy is occasional and does not interfere with his daily life, and the sleep attacks are very controlled. He reports feeling better and without major limitations in his daily life (good academic performance, he does not drink alcohol, but he does not care because he has never drunk, he keeps regular sleep hours and he exercises regularly).\n",
    "summary": "16-year-old male presenting after seeing several specialists with sleep paralysis during naps, which causes fear and occasional dropping of objects from hands (diagnosed as possible myoclonus). In the history, we were surprised by the presence of sleep paralysis immediately after the onset of naps and, in the directed history, these sudden movements caused by emotions were consistent with cataplexy, so we performed a nocturnal polysomnographic study and a multiple sleep latency test. With the evolution, hypnopompic hallucinations and fragmented night sleep appeared, as well as occasional daytime somnolence (the typical symptomatological tetrad of narcolepsy with cataplexy of type 1 was completed).\n"
  },
  {
    "id": "multiclinsum_gs_en_109.txt",
    "fulltext": "88-year-old woman with a history of hypertension and residual dysphonia secondary to right PCV from prior thyroidectomy. She presented with a sudden onset of vertigo and was evaluated in the emergency department with a two-hour history. She had blood pressure of 200/110 mmHg. On neurologic examination, she had a left upper limb asymmetry, mild dysarthria, and multidirectional nystagmus, with a National Institutes of Health Stroke Scale (NIHSS) score of 2. An urgent multimodal brain CT scan was performed, which identified a distal occlusive thrombosis of the left vertebral artery, with no established ischemic lesion. The patient had a rapid symptomatic improvement with blood pressure control, becoming almost asymptomatic (NIHSS: 1; mild dysarthria), and no revascularization therapy was performed. She was started on simple antiplatelet therapy with acetylsalicylic acid and was admitted to the stroke unit. Four hours later, she developed a severe inspiratory stridor with respiratory failure. An emergent laryngoscopy revealed bilateral PCV in adduction with complete airway obstruction. An urgent tracheotomy was performed, with resolution of respiratory symptoms. There was a suspicion that the cause of the acute left PCV was the progression of vertebral thrombosis that produced acute bulbar ischemia, which, in combination with the previous right PCV, caused airway obstruction. A 24-hour follow-up brain CT scan showed a definite infarction in the left hemisphere and lateral bulbar region, consistent with the territory of the left inferior posterior cerebellar artery. The patient remained clinically stable until two days later, when she progressed to a sudden coma. A new multimodal brain CT scan revealed a complete occlusive thrombosis of the basilar artery. Given the poor prognosis, and in accordance with the patient's previously expressed wishes, interventional therapy was discarded. Subsequent clinical evolution was unfavorable, and she died within 48 hours.\n",
    "summary": "88-year-old woman with dysphonia sequelae to post-thyroidectomy right vocal cord paralysis who presented with a sudden onset of vertigo, dysmetria, and mild dysarthria (National Institutes of Health Stroke Scale: 2) associated with arterial hypertension. Urgent brain CT scan demonstrated occlusive distal thrombosis of the left vertebral artery without established ischemia. Due to symptomatic improvement with blood pressure control, revascularization therapy was not performed. Four hours later, the patient developed a sudden onset of inspiratory stridor and severe respiratory failure due to bilateral vocal cord paralysis with complete airway obstruction. An urgent tracheotomy was performed with respiratory improvement. A 24-hour follow-up brain CT scan showed an established infarction in the left hemisphere and lateral bulbar region consistent with the territory of the left inferior posterior cerebellar artery.\n"
  },
  {
    "id": "multiclinsum_gs_en_337.txt",
    "fulltext": "38-year-old female patient from Sullana, Piura in the north coast of Peru, previously healthy, who was diagnosed with dengue without alarming signs in a local health center, with positive ELISA IgM test, receiving symptomatic ambulatory treatment.\nFour weeks later, she presented with severe pain in the anterior cervical region, irradiated to the jaw and auricular region, accompanied by increased volume in the area, general malaise, odynophagia, dysphagia, palpitations and tremors in the extremities. She was evaluated in a hospital in her town, where she underwent a cervical ultrasound that showed a thyroid gland with heterogeneous echogenicity, with the presence of a solid, hypo-echogenic nodule in the left thyroid lobe, with irregular margins, measuring 27x15 mm, with no calcifications, classified as ACR-TIRADS 4 (American College of Radiology classification). In addition, multiple cervical and supra-sternal bilateral adenopathies were observed, increased in size, rounded, with well-defined contours, homogeneous structure, hyper-echogenic ganglionic hilum and increased vascular flow, predominantly hilar and central. During the ultrasound, the patient experienced severe cervical pain when she was in contact with the transducer. Due to the finding of a nodule with suspicion of malignancy, the patient was referred to Lima to complete the imaging and laboratory studies.\nThe patient presented with palpitations and resting tremor compatible with signs of thyrotoxicosis on admission to our hospital. Thyroid stimulating hormone (TSH) was found at 0.043 uUI/mL, free thyroxine (T4L) and free triiodothyronine (T3L) elevated, antithyroid peroxidase antibodies (ATPO) and antithyroglobulin antibodies (ATG) negative, and elevated levels of thyroglobulin (Table 1).\nThe thyroid scintigraphy with technetium-99m showed no uptake of radionuclide, consistent with thyroiditis. Due to the echographic characteristics of the nodule of the left thyroid lobe, ultrasound-guided fine needle aspiration biopsy (FNAB) was performed, with a Bethesda II result.\nThe patient received corticosteroid therapy for two months, based on prednisone, whose initial dose was 50 mg/day, being progressively decreased until it was discontinued. The patient reported significant decrease of pain one week after initiating corticosteroid therapy. After one month, she presented a heart rate of 70 beats per minute and the thyroid gland (goiter grade Ib) was palpable with irregular surface, not painful to the touch and without tremor.\nAfter two months, the patient was asymptomatic, without corticosteroids, and the laboratory results showed TSH 8.81 uUI/mL and free T4 0.95 ng/dL. After two more months, the patient remained asymptomatic and was found to have TSH 2.4 IU/mL, free T4 1.37 ng/dL, and normal thyroglobulin levels (Table 1).\nThe patient's identity has been protected for the purposes of this article. Her informed consent and permission from the head of the endocrinology department of the Edgardo Rebagliati Martins National Hospital were obtained for publication.\n",
    "summary": "We present the case of a 38-year-old woman who had dengue without warning signs a month ago, presented with pain and cervical volume increase, palpitations, tremor and dysphagia. The hormonal evaluation, ultrasound and thyroid scintigraphy were consistent with TSA. She received corticotherapy for two months, and the condition resolved after four months. TSA is characterized by cervical pain, fever and symptoms of thyrotoxicosis. It is associated with viral infections. It comprises a phase of thyrotoxicosis followed by hypothyroidism. Its diagnosis involves hormonal, biochemical, ultrasound and scintigraphy tests. It is managed with non-steroidal anti-inflammatory drugs and corticosteroids, depending on the severity.\n"
  },
  {
    "id": "multiclinsum_gs_en_460.txt",
    "fulltext": "A 53-year-old African man with a medical history of hypertension diagnosed in his mid-20s, systolic CHF and non-ischaemic cardiomyopathy presented with worsening exertional dyspnoea, lower extremity oedema, paroxysmal nocturnal dyspnoea and orthopnoea for approximately 1 week. The patient was on six hypertensive agents as an outpatient including clonidine, hydralazine, isosorbide mononitrate, valsartan and furosemide. Despite compliance with medications, he had frequent admissions for CHF exacerbations. He denied tobacco, drug or alcohol use. Although he was diagnosed with hypertension at a young age, the patient did not recall having additional testing for secondary causes of HTN at the time of diagnosis. He did recall a diagnosis of chronic hypokalaemia, which had been attributed to furosemide use, and he had been prescribed potassium supplements intermittently in the past. He denied any known family history of PA or uncontrolled HTN. Vital signs revealed a blood pressure of 163/103 mm Hg, heart rate of 74 beats per minute, respiration rate of 17 and 95% oxygen saturation on 3 L nasal cannula. Pertinent findings on physical examination included jugular venous distention, bilateral lower extremity pitting oedema, bilateral rales and a prominent S3 gallop.\n\n\nInvestigations\n\nEKG showed no acute ischaemic changes, sinus rhythm with chronic left bundle branch block. Troponins were negative on three consecutive occasions. Chest X-ray revealed bilateral pulmonary vascular congestion. Transthoracic echocardiography revealed moderate left ventricular hypertrophy and dilatation with global hypokinesis and an ejection fraction of 10%–15%. No valvular abnormalities were noted. Cardiac MRI showed areas of myocardial fibrosis likely related to hypertrophy, atypical for ischaemic disease and atypical for previous infarct or amyloidosis. Laboratory studies showed serum potassium of 2.6 mmol/L and bicarbonate of 34 mmol/L. PA was suspected, and further testing revealed an elevated plasma aldosterone level of 154 ng/dL (normal less than 39.2 ng/dL), a decreased plasma renin activity (RA) of less than 2.1 ng/mL/hour and a plasma aldosterone concentration/plasma RA (PAC/PRA) ratio of 73.3 (ng/dL)/(ng/mL/hour).\n\nResults of an overnight dexamethasone suppression test, thyroid function testing and plasma and urine metanephrines were normal. An oral salt loading suppression test was not performed for fear that it would exacerbate his pulmonary oedema and heart failure. CT of the abdomen and pelvis with contrast showed a 1.2×2.4 cm well-defined, homogeneous adenoma of the left adrenal gland. Subsequent adrenal vein sampling confirmed unilateral PA with lateralisation to the left adrenal gland (table 1.) The adrenal vein cortisol to inferior vena cava cortisol ratio for both the left and right adrenal vein was greater than 3, consistent with successful adrenal vein cannulation. The left and right adrenal vein aldosterone to adrenal vein cortisol ratio were 14.8 and 2.2, respectively. A lateralisation ratio greater than 4 is consistent with unilateral disease, whereas a lateralisation ratio less than 3 is consistent with bilateral disease. Our patient’s lateralisation ratio of left to right was 6.7, consistent with unilateral disease. The patient was started on spironolactone treatment with improvement of his blood pressure, and hypokalaemia and was referred for left adrenalectomy.",
    "summary": "A 53-year-old African man with a 25-year history of uncontrolled hypertension and systolic heart failure presented with an acute congestive heart failure exacerbation. He was found to have severe hypokalaemia, so additional testing was performed, and primary aldosteronism was confirmed. CT scan showed a 1.2×2.4 cm well-defined, homogeneous adenoma of the left adrenal gland. Adrenal vein sampling confirmed unilateral primary aldosteronism with lateralisation to the left adrenal gland. The patient was started on spironolactone and was referred to surgery for laparoscopic left adrenalectomy."
  },
  {
    "id": "multiclinsum_gs_en_177.txt",
    "fulltext": "This is a case of a 42-year-old female from Kenya who immigrated to Australia in 2011. She presented with a 2-year history of intermittent painful eye redness associated with blurring of vision of both eyes. Ocular symptoms began soon after childbirth. There were no associated systemic symptoms. Hypertension and hypothyroidism were the only known comorbidities and were well-controlled.\n\nOn examination, she presented with a best corrected visual acuity (BCVA) of 6/18 and 6/30 on the right and left eyes, respectively. Conjunctival hyperaemia, large keratic precipitates, posterior synechiae, poorly dilating pupil, anterior subcapsular cataract and +2 anterior chamber (AC) cells and flare were noted on both eyes. No iris atrophy and iris transillumination defects were seen. Intraocular pressures (IOP) were within normal limits. Fundus examinations showed no signs of vitritis, retinitis, and vasculitis; however, dull foveal reflexes were noted on both eyes. Macular optical coherence tomography (OCT) showed bilateral cystoid macular oedema (CMO).\n\nDexamethasone 0.1% eye drop 6 times a day and atropine 1.0% eye drop 3 times a day to both eyes were initiated at initial visit. A week later, CMOs were still present in both eyes, which led to a decision to perform bilateral subtenon injections of 16 mg triamcinolone.\n\nTwo weeks post-subtenon injections, the BCVA improved to 6/12 on the right eye and 6/9 on the left eye. In the anterior chamber of both eyes, only 0.5 cells with resolution of flare and KPs were noted. On macular OCT, the CMO in the right eye partially resolved while it completely resolved in the left eye. IOP measured at 32 mmHg and 34 mmHg on the right and left eye, respectively, were attributed as a steroid response, which were treated with topical anti-glaucomatous medication. The patient was monitored every 2 weeks.\n\nSubsequent visits showed further improvements. BCVA was 6/9 on both eyes and IOP of both eyes were back to normal range. No AC cells were appreciated in both eyes. However, the patient still presented with poorly dilating pupils due to posterior synechiae, and an anterior subcapsular cataract in both eyes. Macular OCT showed complete resolution of CMO in both eyes.\n\nThe patient tested positive for serum HSV IgM, which resulted in initiation of Valacyclovir 1 g three times a day. Autoimmune and other infectious aetiologies were excluded. HSV DNA were not detected on aqueous humour PCR analyses of both eyes.\n\nOn the last visit, there were no recurrence of eye redness, pain and signs of active intraocular inflammation. Although the patient reported cloudy blurring of vision, this was attributable to the cataract formation in both eyes. Dexamethasone 0.1% eye drop was reduced to 4 times a day and atropine 1.0% eye drop to once at night, and oral valacyclovir 1 g three times a day was continued.",
    "summary": "A 42-year-old Kenyan female presented with a 2-year history of intermittent painful eye redness associated with blurring of vision of both eyes. Symptoms started after childbirth. There were no associated systemic symptoms. She presented with a best corrected visual acuity (BCVA) of 6/18 and 6/30 on the right and left eyes, respectively. On examination, conjunctival hyperaemia, large keratic precipitates (KPs), posterior synechiae, poorly dilating pupil, anterior subcapsular cataract and +2 anterior chamber (AC) cells and flare were noted on both eyes. Intraocular pressures (IOP) were within normal limits. Optical coherence tomography (OCT) showed bilateral cystoid macular oedema (CMO). Serum herpes simplex virus (HSV) IgM was detected, whereas autoimmune and other infectious aetiologies were excluded. Aqueous humour samples from both eyes tested negative for HSV. Bilateral 16 mg subtenon triamcinolone injection were done. Dexamethasone 0.1% eye drops and atropine 1.0% eye drops were started. Topical anti-glaucomatous medication was started due to IOP >30 mmHg on both eyes and Valacyclovir 1g three times a day was initiated. Final visit showed an improvement of BCVA to 6/9 on both eyes. There was complete resolution of AC cells and flare, and CMO on OCT."
  },
  {
    "id": "multiclinsum_gs_en_431.txt",
    "fulltext": "A male born at 38 weeks of gestation and without prenatal obstetric controls, product of an eutoxic delivery without complications with a weight of 2,678 g and Apgar 7 and 8 at the minute and at 5 minutes of life, respectively; derived by suspicion of necrotizing enterocolitis at 7 days of life. At birth, in his hospital of origin, congenital malformations were ruled out and an orogastric probe was placed to verify the esophageal permeability, obtaining 200 ml of amniotic fluid. Subsequently, he initiated oral feeding but due to weak suction and biliary vomiting he was admitted to the neonatal intensive care unit. At 4 hours of life a abdominal radiography was performed observing a double bubble atypical image, for which they performed a radiological control 48 hours later identifying intestinal gas apparently distal, and presented meconiorexis at 50 hours of life. Two days later he restarted oral feeding, after which he presented again biliary vomiting and abdominal distension that improved with fasting and orogastric probe; for which necrotizing enterocolitis was suspected indicating absolute diet, total parenteral nutrition and antibiotherapy with ampicillin and amikacin. At seven days of life and due to the persistence of symptoms despite the treatment initiated, he was referred to our center. On his arrival he presented abdominal distension, without intestinal noises or signs of peritoneal irritation, for which an intestinal transit was performed without distal progression and colon by enema with finding of microcolon, all suggestive of intestinal atresia and jejunoileal atresia. After the imaging studies and with the suspicion of intestinal atresia, a laparotomy was performed by transverse supraumbilical approach, observing hepatoileal adhesions, an internal hernia through a mesenteric defect with incarceration of a jejunal loop and jejunoileal atresia type IV. Two sites of atresia were identified at 56 cm from the Treitz angle and 36 cm from the ileocecal valve, with an inter-atresic segment of 10 cm with intraluminal meconium and changes in colouration with a violet appearance but without perforation; the difference in intestinal diameters proximal to distal had a 3:1 ratio. It was decided to dissect the mesentery and resect the blind loop (10 cm) to perform a term-oblique jejunoileal anastomosis, corroborating the distal permeability with intraluminal probe and administration of physiological solution until it presented rectal evacuation. The histopathology report confirmed a jejunoileal atresia type IV with mild chronic enteritis. The patient evolved favourably and at the 5th day postoperatively initiated oral feeding with adequate progressive tolerance and gradual decrease of total parenteral nutrition with withdrawal at the 8th day postoperatively. At the 6th day of the intervention he presented spontaneous depositions and at 20 days of life was discharged without complications. Twelve months later the patient continues asymptomatic with adequate weight gain and tolerance to complementary feeding with daily depositions of normal characteristics.\n",
    "summary": "Neonate male, born at term, referred for vomiting, loose stools and abdominal distension. At 8 days of age and after excluding various causes of abdominal distension, exploratory laparotomy was performed, identifying a transmesenteric hernia and two sites of intestinal atresia. Resection of the atresic segment and primary anastomosis was performed, with good evolution.\n"
  },
  {
    "id": "multiclinsum_gs_en_581.txt",
    "fulltext": "A 30-year-old female was evaluated for a two-month history of progressive pain and decreased vision OD. Two weeks before the development of ocular symptoms, the patient began prednisone taper as a treatment for her systemic inflammatory symptoms. Past medical history includes inflammatory arthritis, gastrointestinal symptoms suggestive of inflammatory bowel disease, and 20-pound weight loss prior to presentation. The complete details of the patient’s case were reported previously and are summarized herein along with additional ocular fluid chemokine and cytokine analysis.13\n\nOn examination, BCVAs were 20/40 OD and 20/20 OS, and pupils were 9 mm and akinetic OD and 5 mm with brisk light reactivity OS. Intraocular pressures were 65 mmHg OD and 21 mmHg OS. Slit-lamp examination showed pigmented, granulomatous keratic precipitates (KP) within the inferior cornea, 3+ anterior chamber cell, diffuse iris atrophy with pigment on the zonules, and ectropion uveae OD, and OS was unremarkable. Gonioscopy showed 3+ pigmented cells within the inferior angle OD. Fundus examination was unremarkable in both eyes. A diagnostic anterior chamber paracentesis was positive for VZV DNA by PCR testing, and serologic testing was positive for VZV IgG antibody. Subsequently, she was diagnosed with VZV-associated hypertensive anterior uveitis, prompting initiation of oral acetazolamide and ophthalmic timolol, dorzolamide, and brimonidine for ocular hypertension, as well as valacyclovir 1g TID and prednisolone acetate 1% every 2 hours. The patient’s disease course and further details of her management were previously described.13\n\nThe patient was diagnosed with a cerebrovascular accident (CVA), thought to be due to VZV-associated CNS vasculopathy, and was hospitalized for 2 weeks during which her ocular symptoms gradually improved. She, however, developed worsening pain and vision in the right eye two months after her CVA, and her BCVA declined to 20/100 with an elevated IOP of 39 mmHg OD. Examination revealed 1+ ciliary injection and 3+ anterior chamber cell, and she was switched from prednisolone to difluprednate with minimal improvement. Subsequently, she underwent a glaucoma filtration procedure with an Ahmed shunt due to her persistent elevated IOP despite maximum tolerated ocular hypertensive therapy. An aqueous humor sample of the right eye was obtained during filtration surgery for a chemokine/cytokine profile analysis. The levels of 22 cytokines and chemokines including IFN-γ, IL-10, IL-12p70, IL-17A, IL-1β, IL-2, IL-5, IL-6, IL-8, TNF-α, IL-18, IL-1RA, IL-1a, IL-1α, IP-10, MCP-1, MIP-1α, MIP-1β, SDF-1α, IL-21, IL-22, IL-23, and IL-27 were estimated using the multiplex bead immunoassay technique. Concentration levels of 7 cytokines/chemokines were detected including IL-6, IL-8, IL-18, MIP-1b, IP-10, MCP-1, and IL-1RA. IL-1RA was the most abundant cytokine (1000 pg/mL), while IP-10 and MCP-1 were the second most abundant cytokines (150–200 pg/mL). IL-18 and MCP-1b levels of 10–20 pg/mL were detected but at minimal levels in this AqH sample. IL-6 and IL-8 were detected but found to be the least abundant cytokines, each with levels of <10 pg/mL.\n\n",
    "summary": "Case 2 was a 30-year-old female with a two-month history of progressive pain and decreased vision OD. She was diagnosed with hypertensive anterior uveitis after diagnostic anterior chamber paracentesis. Despite successful therapy for the anterior uveitis, her intraocular pressure remained elevated and required a glaucoma filtration procedure. Ocular fluid sample was collected at the time of surgery for cytokine/chemokine profiles analysis, and levels of 7 cytokines/chemokines were detected including IL-6, IL-8, IL-18, MIP-1β, IP-10, MCP-1, and IL-1RA with IL-1RA being the most abundant cytokine."
  },
  {
    "id": "multiclinsum_gs_en_241.txt",
    "fulltext": "A 31-year-old woman with no comorbidities, with a history of cesarean section with spinal anesthesia, who 15 days after the procedure began with a stabbing, intense, gradual onset, headache without irradiation or accompaniments, without improvement with the administration of analgesics. After five weeks, the patient presented blurred vision and dysarthria, so she went to the emergency department and was admitted with a diagnosis of probable meningitis. A study of cerebrospinal fluid was reported with pleocytosis at the expense of polymorphonuclear cells (290 cells with 69% neutrophils and 31% monocytes), with hypoglycorraquia (glucose 30 mg/dL) and proteins of 100 mg/dL. Gram staining, BAAR and Chinese ink were performed, all with negative results, as well as cultures for bacteria without development. Empirical treatment was initiated with vancomycin, ceftriaxone, ampicillin and fluconazole for 21 days; however, the evolution was torpid. It was decided to extend the study with a polymerase chain reaction (RT-PCR) of cerebrospinal fluid for viruses, bacteria and fungi, as well as RT-PCR (GeneXpert) for tuberculosis, with negative report for all studies. Finally, because she lived in an endemic area, antibodies against Coccidioides spp were measured, which were also negative.\n\nAfter eight weeks of the initial picture, the patient presented neurological deterioration with decreased alertness that required advanced airway management. Due to the above, an imaging study was performed that evidenced hydrocephalus and intracranial hypertension, for which an emergency ventriculostomy was placed. A second study of cerebrospinal fluid reported increased pleocytosis (1906 cells), elevated lactate (10.2), increased protein (323 mg/dl) and glucose of 24 mg/dL.\n\nInfectious disease was consulted. During the evaluation, the patient was sedated with a RASS of -4, ventilatory support and dependent on vasoactive amines to maintain mean arterial pressure > 65 mmHg. Although the neurological examination was not fully assessable due to the state of sedation, the photomotor and consensual reflexes were assessed and were present, there was no neck stiffness or abnormal postures. The evaluation also showed a functional ventriculostomy drainage.\n\nDue to the patient's subacute evolution, the findings of cerebrospinal fluid, the increase in lactate and the poor response to the previously administered antibiotics, neuroinfection by agents such as mycobacteria or fungi was suspected. Considering the above, coverage was increased with carbapenem, linezolid and moxifloxacin that cover mycobacteria, as well as intravenous voriconazole, as an antifungal. After adjusting the medication, the patient's clinical evolution improved, so a neurological window was performed and extubation was decided.\n\nDifferential diagnoses\nBacterial Meningoencephalitis\nThe clinical presentation of the patient suggested a bacterial meningitis, as this is one of the most common causes of central nervous system (CNS) infection. However, the presentation was not typical and the expected response to treatment was not observed. The patient's only history was the surgical procedure performed three weeks prior to the onset of the clinical presentation, and this type of etiology generally occurs acutely after the surgical procedure. Similarly, the cellularity in the cerebrospinal fluid study showed a predominance of polymorphonuclear cells with hypoglycorrhea, which initially suggested this etiology. However, since the microbiological study did not show any development and the RT-PCR for multiple bacteria did not show any replicating genetic material, the case was classified as aseptic meningitis.9\n\nMycobacterial meningoencephalitis\nThe patient's clinical picture began with a headache lasting more than 4 weeks, which led to the study of the picture as subacute. One of the suspected diagnoses was infection with Mycobacterium tuberculosis, however, the result of the RT-PCR of cerebrospinal fluid was negative. It should be noted that this etiology cannot be completely ruled out since these infections can be paucibacillary and give a false negative.\n\nThere are reports of other CNS mycobacteria, especially those that are fast-growing, that could explain the subacute presentation in this case. Infections with M. abscessus as well as M. chelonae have been reported in the literature.10,11\n\nThere are reports in the literature suggesting the use of carbapenems in combination with linezolid and moxifloxacin or clarithromycin for the management of non-tuberculous mycobacteria in CNS. Another drug recommended for the treatment of non-tuberculous mycobacteria is tigecycline, although it is not recommended in CNS infections due to its low penetration, so it was not included in the scheme.12,13\n\nFungal Meningoencephalitis\nThe patient's subacute evolution also required the study of fungal infections. In case reports there has been an increase in incidence each year,6,14 so it was taken as one of the differential diagnoses based on the temporal nature of the clinical picture. Although the patient did not have any relevant risk factors, with the exception of her postpartum period, risk factors for yeast infections such as Candida and Cryptococcus, as well as some filamentous fungi such as Aspergillus, Fusarium or Mucormycetes, such as Mucor or Rhizopus, were intentionally sought and questioned.\n\nDue to reports of cases where the use of regional anesthetics was associated with subacute meningitis, with isolation of Aspergillus spp, treatment with voriconazole was initiated, considering the high possibility of some fungal infection.4 In addition, in the literature search, other causative agents were found during the application of regional anesthesia, including Exserohilum rostratum, Aspergillus fumigatus and Exophiala dermatitidis as contaminants of the medicine, causing infection in CNS.15 Likewise, sensitivity to voriconazole was reported by these agents, so the established therapy was continued while the development of cultures was obtained.\n\nDiagnosis\nFungal culture was requested in cerebrospinal fluid in Sabouraud and Mycosel medium, and the development of a filamentous fungus was obtained. Staining with lactofenol blue was performed in the culture colonies, in which septate hyphae and groups of canoe-shaped macroconidia were observed, very suggestive of Fusarium spp. Diagnostic confirmation and species identification was performed with the MALDI-TOF system, with the result of Fusarium solani. Study of susceptibility to antimycotics was performed by microdilution technique in broth with minimum inhibitory concentration (MIC) of voriconazole: 2 ug/mL-1 (susceptible) and amphotericin MIC: 4 mg/mL (susceptible).\n\nTargeted treatment\nThere is evidence that Fusarium has intrinsic resistance to echinocandins (also no CNS penetration) and has multiple mechanisms to acquire resistance to various antifungal agents. A dual regimen with liposomal amphotericin B and voriconazole has now been established as a first-line therapy for Fusarium spp.5 As soon as macroconidia were visualized, liposomal amphotericin B 5 mg/kg every 24 hours was added to voriconazole therapy at 4 mg/kg every 12 hours.\n\nThe patient showed clinical improvement with a decrease in leukocytosis, however, at 16 weeks from the onset of the clinical picture, she showed a sudden deterioration in alertness. A brain tomography was performed in which a hypodense area of irregular borders of 66x45 mm was reported, located on the right side of the occipital lobe, being an image suggestive of ischemia and peripheral cerebral edema. In the angiotomography the patient showed data compatible with multi-infarct disease and the clinical evolution continued in an unfavorable way, the death occurred in the following hours.\n",
    "summary": "A patient with meningoencephalitis caused by Fusarium was presented during the late puerperium period. The patient's main symptom was a holocranial headache with low response to analgesics, in addition to dysarthria and blurred vision. Initially, it was classified as aseptic meningitis due to the absence of bacterial isolation, however, 8 weeks after the onset of the condition, the development of Fusarium was obtained in the cerebrospinal fluid cultures. Directed treatment with liposomal amphotericin and voriconazole was established, with partial improvement at the beginning; however, 16 weeks after the onset of the clinical condition, the patient presented a sudden deterioration of alertness, an ischemic zone was evidenced in the occipital lobe by imaging study, which quickly led to the patient's fatal outcome.\n"
  },
  {
    "id": "multiclinsum_gs_en_574.txt",
    "fulltext": "4-year-old patient with no family history of interest was referred to the dermatology department for congenital ichthyosiform syndrome since birth. Erythematous plaques with active desquamative border were observed on the scalp, face, trunk, elbows, knees, extremities, palms and soles. Skin biopsy revealed hyperkeratosis consistent with seborrheic eczema.\n\nLaboratory findings were normal except for aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Persistent hypertransaminemia was observed. The clinical morphology of the lesions suggested the clinical diagnosis of probable erythrokeratoderma variabilis given the changing and migratory character of the hyperkeratotic lesions. However, the alteration of the hepatic tests forced to evaluate other possibilities. The ichthyosiform aspect of the process associated with hepatopathy required to rule out the Chanarin Dorfman syndrome.\n\nReview of the peripheral blood smear (PBS) was requested, revealing multiple cytoplasmic vacuoles within granulocyte series cells and platelets. Thus, the picture of generalized dry ichthyosiform erythroderma and the presence of lipid vacuoles in the polymorphonuclear (PMN) cells of the PBS suggested that the most likely diagnosis was neutral lipid storage disease, also known as Chanarin-Dorfman syndrome. Examination of the PBS smear of the patient's parents did not show the presence of vacuoles in the PMNs.\n\nThe diagnosis was confirmed by Sanger sequencing of the CGI-58 gene, the causative gene of the syndrome. It was performed in the index case and parents, and a nonsense mutation in exon 6 (934G→T; R312X) inherited from the father and an insertion/deletion at position 617 in exon 4 inherited from the mother were detected. The latter caused a change in the reading frame that resulted in a premature stop codon. The patient turned out to be a carrier of both mutations in homozygosis.\n\nFollowing the diagnosis, ophthalmological examination, evaluation of muscle enzymes, otorhinolaryngological examination to rule out hearing disorders and neuropaediatric examination were recommended. In addition, periodic checks by the dermatology service were advised and contact was made with the nutrition and dietetics service to make an assessment. The ophthalmological and neuropaediatric examination was unremarkable; however, mild neurosensorial hearing loss and creatine kinase levels of 2 to 5 times the upper normal limit were observed despite no muscular pains.\n\nAs there is no specific treatment for this disease, the only effective treatment was the restriction of long chain triglycerides in the diet and supplementation with medium chain triglycerides. After six months of treatment, the patient showed clinical improvement manifesting a reduction of the scaling areas, without finding a significant variation in the levels of AST, ALT and FAL.\n",
    "summary": "4-year-old patient with generalized erythematous-scaly ichthyosiform syndrome since the first days of birth. The laboratory report highlighted persistent hypertransaminemia. Among other complementary tests, the peripheral blood smear (SP) was performed, revealing the presence of multiple cytoplasmic vacuoles inside the polymorphonuclear leukocytes (PMN) and platelets. The ichthyosiform lesions together with the presence of lipid vacuoles in the SP PMN are signs compatible with Chanarin-Dorfman syndrome. The diagnosis was confirmed by genetic sequencing.\n"
  },
  {
    "id": "multiclinsum_gs_en_489.txt",
    "fulltext": "A 58-year-old female presented to the Emergency Department with a 6-month history of worsening dyspnea. Over the preceding 10 days, her symptoms had acutely worsened, accompanied by mild chest discomfort and bilateral leg swelling. Her medical history included asthma and hypertension. On arrival, she was found to be hypoxemic with an oxygen saturation of 74%, which improved to 94% with 5 liters of supplemental oxygen. Physical examination revealed bilateral inspiratory crackles and pitting edema in the lower extremities.\n\nLaboratory investigations demonstrated an elevated NT-proBNP (Brain natriuretic peptide) level of 2110 ng/mL (range <125 ng/mL) and normal troponin levels. Computed tomography (CT) chest angiography revealed mild bilateral patchy ground-glass infiltrates, an enlarged pulmonary artery (PA) trunk, and dilatation of the right atrium (RA) and right ventricle (RV) with no evidence of pulmonary embolism. Transthoracic echocardiography (TTE) showed a left ventricular ejection fraction (LVEF) of 75% to 80%, moderate RA and RV dilatation, systolic and diastolic flattening of the interventricular septum, reduced RV systolic function, and an estimated PA systolic pressure of 55 to 60 mm Hg. No intracardiac shunt was identified on color Doppler or agitated saline contrast injection.\n\nThe patient was initiated on intravenous furosemide. Right heart catheterization (RHC) performed the following day, while the patient was receiving 3 liters of supplemental oxygen via nasal cannula. The procedure confirmed PH, with a mean pulmonary artery pressure (mPAP) of 41 mm Hg and a high cardiac output of 8.46 L/min by the Fick method. A vasoreactivity test using the standard adenosine protocol confirmed that the patient was non-vasoreactive, indicating calcium channel blocker therapy would not be beneficial. Further investigations, including complete blood count, thyroid-stimulating hormone, HIV screening, antinuclear antibody screen, rheumatoid factor, and thiamine levels, were unremarkable. Imaging studies, including CT angiography of the chest and abdomen and Doppler ultrasound of the liver, ruled out systemic shunts, pulmonary arteriovenous malformations, and splenomegaly. At the time of discharge, the patient’s hypoxemia had resolved with diuresis.\n\nOutpatient evaluation included a pulmonary function testing that showed mild obstructive ventilatory defect. The sleep study and ventilation-perfusion study were unremarkable. As RHC demonstrated a pulmonary artery occlusion pressure (wedge pressure) of 11 mm Hg (<15 mm Hg) and a high transpulmonary gradient of 26 mm Hg (>12 mm Hg), Group II PH due to left heart disease was excluded. She was prescribed a corticosteroid inhaler, and oral furosemide (20 mg daily) was continued. Pulmonary hypertension-specific therapy was not initiated, given her PH was categorized as group III, attributed to obstructive lung disease. During follow-up appointments, the patient reported an initial improvement in her perceived dyspnea, which later stabilized. She consistently remained in the intermediate-low risk category according to the 4-strata risk assessment tool for PH follow-up.\n\nTwo years later, she returned with worsening dyspnea and leg swelling after discontinuing furosemide. Repeat CT pulmonary angiography revealed findings similar to her initial imaging but additionally identified an anomalous left pulmonary vein draining into the left brachiocephalic trunk. A retrospective review of her initial CT confirmed the missed anomaly. The TTE showed LVEF of 60%, moderate RA and RV dilation, reduced RV systolic function, and an estimated pulmonary artery systolic pressure of 50 to 55 mm Hg. In contrast to previous RHC, the shunt evaluation this time demonstrated a 6% step-up in oxygen saturation between the superior vena cava (SVC) and RA, confirming a left-to-right shunt. This discrepancy was due to the SVC saturation measurement being appropriately obtained above the drainage of the left brachiocephalic trunk, now guided by the knowledge of PAPVR from the CT findings. The shunt fraction (Qp/Qs) was calculated to be 1.52. Consequently, her PH was reclassified as group I due to adult congenital heart disease.\n\nThe patient received treatment with intravenous diuretics. Due to her mild PH and intermediate-low risk classification based on the 4-strata risk assessment tool (WHO-FC III, NT-proBNP 81 pg/mL, and a 6-min walk distance of 460 m), PH-specific therapy was not advised. She declined additional evaluations, including cardiac magnetic resonance imaging (MRI) and referral to an adult congenital heart disease center, choosing instead to continue with close outpatient monitoring.",
    "summary": "We report the case of a 58-year-old woman who initially presented with progressive dyspnea and was diagnosed with group III pulmonary hypertension attributed to obstructive lung disease. Two years later, she returned with similar symptoms after discontinuing diuretic therapy. Further evaluation uncovered a previously undetected anomalous left pulmonary vein draining into the left innominate vein."
  },
  {
    "id": "multiclinsum_gs_en_532.txt",
    "fulltext": "The patient is a 55-year-old well-fit male with a distinguished career in military service. He first noted symptoms approximately a year ago, with the onset of swelling and discomfort in his right leg. It was an unexpected development, as he had no prior history of trauma or similar conditions to the affected leg. Initially, the symptoms were subtle and intermittent; however, over the course of the year, they progressed, compelling him to seek medical attention.\n\nThe physical examination revealed a swelling in the right proximal leg. Notably, the overlying skin appeared intact, with no observable signs of inflammation or infection such as redness, heat, or pus. The pain, although not severe, was consistent, disrupting his daily activities.\n\nPrompt diagnostic tests were performed, beginning with an AP and lateral X-ray of the affected leg. The radiographic images showed a right anterior tibial, mid diaphyseal lytic expansile lesion with internal trabeculations. The lesion has a narrow zone of transition with associated solid type of periosteal reaction. There are also small adjacent lytic satellite lesions. An abdominal ultrasound was further conducted, which was nonrevealing. Additional tests, such as a chest X-ray, were also carried out to exclude any potential systemic issues which was unremarkable.\n\nIn a context with limited resources, the patient faced constraints in accessing certain diagnostic and treatment options. The challenge of obtaining CT or MRI scans in a timely manner in our setting led the multidisciplinary team to opt for an excisional biopsy of the leg lesion. The histopathology results showed biphasic tumoral tissue composed of mildly atypical round to oval cells arranged in tubular structures and basaloid nests along with variably cellular fibrous stroma which confirmed a diagnosis that was least expected: adamantinoma, a rare and often aggressive type of bone tumor.\n\nUpon diagnosing adamantinoma, the patient was promptly connected with an oncology team experienced in orthopedic cancers. The X-ray findings clearly displayed extensive involvement of the proximal tibia beyond the bone cortex. Taking into account the patient’s overall health, the aggressive nature of adamantinoma, and its specific location, the team concluded that amputation was the most viable treatment option, given the limited availability of alternative treatment methods. Following the amputation, the patient’s wound healed effectively with no evidence of either distant metastasis or local recurrence. Subsequently, the patient was discharged and scheduled for a follow-up appointment.",
    "summary": "A 55-year-old military personnel, with no history of trauma, who presented with a one-year history of right leg swelling and pain. Radiological examination showed right anterior tibial, mid diaphyseal lytic expansile lesion with internal trabeculations and excisional biopsy led to the diagnosis of adamantinoma. Below knee amputation was done as a definitive management."
  },
  {
    "id": "multiclinsum_gs_en_509.txt",
    "fulltext": "Patient presentation: newborn at J1 of life, male, from a non-consanguineous marriage and from a first uncomplicated pregnancy and carried to term, no family history of genetic diseases, born by caesarean section due to suspicion of chorio-amniotitis. Adaptation to extra-uterine life was good with an APGAR score of 8/10 and birth weight: 2295g, birth size: 48cm, head circumference: 31cm (-3DS), facial dysmorphia and clubfoot more accentuated on the right.\n\nClinical examination: he was admitted on J1 for cranio-facial dysmorphia and refusal to breast feed with examination on admission: SaO2: 95% at ambient air, FC: 142 beats/min, TRC< 3s, baby pink, cranio-facial dysmorphia including micro-cranium and hypertelorism, hypotonia, normal stretched fontanelle, weak suction, eupneic, cardiopulmonary auscultation without anomalies, flexible and depressible abdomen, no visceral enlargement, club foot more marked on the right, rest of the examination was without particularities.\n\nDiagnosis: During the hospitalisation, a high-pitched monochromatic cry mimicking a cat meow was observed. The figure illustrates the cranio-facial dysmorphism as well as the more pronounced club foot on the right. A chest radiograph with nasogastric tube in place was performed and returned without anomalies. A constitutional cytogenetic study (FISH) was performed: the analysis by molecular cytogenetic techniques from the specific probes of the cry of the cat (Vsys probe) highlighted a micro deletion of the locus in 5p15.2 in all interphases cells studied. This result correlates with the diagnostic suspicion.\n\nTherapeutic interventions: in the presence of a positive infectious history (suspicion of chorio-amniotic infection and weak suction), the newborn was initially given a probabilistic antibiotic therapy (cefotaxim 100 mg/kg/12 h IV and gentamycin 3 mg/kg/j IVL, parenteral and then enteral feeding by gavage and newborn care).\n\nFollow-up and results of therapeutic interventions: a malformative assessment was performed and returned without anomalies (transfontanellar, cardiac and abdominal ultrasound, brain MRI). A specialised ophthalmological examination was without particularities. The parents were informed about the disease, its long-term prognosis and the interest of genetic counselling in the case of a possible subsequent pregnancy. Therapeutic education sessions were given to the parents. The clinical evolution was marked by respiratory and haemodynamic stability. The antibiotic therapy was stopped after the negative infection assessment; he was discharged on J15.\n",
    "summary": "He was a male newborn of one day old, from a non-consanguineous marriage and primigravida mother, with a pregnancy that was uncomplicated and carried to term. The delivery was performed by emergency cesarean section due to suspicion of chorioamniotitis with good adaptation to extrauterine life and a birth weight of 2295g. The clinical examination revealed a cranio-facial dysmorphia with hypertelorism and microcephaly, hypotonia, poor suction and a more marked club foot on the right, with the rest of the examination being without particularity. During the hospitalisation, a monochromatic high-pitched cry imitating a cat's meow was observed. The clinical diagnosis was confirmed by fluorescence in situ hybridisation, which showed a deletion of the short arm of chromosome 5 (5p15.2). The basic malformative assessment did not reveal any other anomalies.\n"
  },
  {
    "id": "multiclinsum_gs_en_444.txt",
    "fulltext": "We present the case of a 63-year-old female patient who consulted the emergency department for jaundice associated with cholora, acholia and asthenia of 4 days evolution (year 2016). On physical examination, the patient was hemodynamically stable, with mild jaundice evident in skin and mucous membranes, and a soft, depressible and painless abdomen to the touch. On questioning, the patient denied risk factors for infectious diseases. A laboratory test was requested that showed a cholestatic pattern: total bilirubin of 7 mg/dL, a direct bilirubin of 5.5 mg/dL, an alkaline phosphatase of 408 IU/L, a glutamic oxalacetic transaminase (GOT) of 166 IU/L, a glutamic pyruvic transaminase (GPT) of 271 IU/L, without leukocytosis or associated anaemia. The ultrasound showed dilated intra- and extrahepatic bile ducts (13 mm) with the presence of hypoechoic material in the middle third, without being able to visualize the distal portion.\n\nA contrast-enhanced abdominal MRI was requested and showed a poorly defined, expansive mass that involved the common hepatic duct (CHD) and extended caudally.\n\nA stenosis in the HCC was identified that extended approximately 17 mm, causing dissociation of the intrahepatic bile ducts, with the middle and lower third of the common bile duct having adequate calibre. This process included the portal vein and compromised the hepatic artery in its path through the hilum, in association with regional adenomegaly.\n\nDue to the location and characteristics of the neoplastic process, a Klatskin tumor was suspected and tumor markers were requested to evaluate the same. Given the increase in bilirubin values and the negativity of the alpha fetoprotein, Ca 19.9 and carcinoembryonic antigen (CEA) tumor markers, admission for a possible surgical resection was decided.\n\nConventional surgery was performed, where biliary compromise associated with bilateral vascular compromise of the hepatic artery and the portal vein was observed, for which the inoperability of the same was decided. Biopsies of the hepatic pedicle mass were taken for subsequent chemotherapy. The patient evolved adequately, without postoperative complications.\n\nThe pathological anatomy report showed infiltration by large cell B lymphoma double expressor. The patient was clinically stable and in a position to begin chemotherapy treatment, so it was decided to begin with a RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) regimen. She completed 5 cycles and, as she was a double complement expressor, a sixth cycle with an ascending dose EPOCH (etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin) was started. She responded favorably to the chosen regimen, with only two hospitalizations between the different cycles, the first for febrile neutropenia secondary to mucositis, and the second for a cholangitis that resolved with antibiotics without the need to remove the stent.\n\nA positron emission tomography (PET) was performed prior to the fourth cycle of the chemotherapy schedule, which showed a decrease in the size of the known liver lesion in the III segment at the level of the carrefour, which measured 12.5 mm, prior to 25 mm.\n\nThe patient completed the chemotherapy regimen in early 2017 and went into remission but began to have repeated intercurrences. She had numerous episodes of cholangitis associated with the presence of a CHC stenosis, for which repeated endoscopic retrograde cholangiopancreatographies (CPRE) were performed for the drainage of the bile duct with multiple replacements of bile stents. The stenosis generated the suspicion of a relapse, for which it was decided to carry out a cholangioscopy with a spyglass for the taking of biopsies under direct vision. The result was negative for atypical cells, confirming that the cause of the stenosis was a fibrosis as a response of the lymphoma to the chemotherapy.\n\nDue to the large number of intercurrences in the patient since her referral (year 2017), a surgical resolution was decided in a multidisciplinary ateneo (year 2020). A scheduled surgery was carried out, where a hepatic jejunum anastomosis in Roux Y and a cholecystectomy were performed. She required low-dose inotropic and empirical antibiotics with imipenem but she evolved favorably in the intensive therapy. She was discharged on the seventh day without complications.\n\nFollow-up was performed in an outpatient setting with MRI and laboratory studies, which did not show evidence of disease recurrence at 6 years of remission.\n",
    "summary": "For this reason, we present the case of a 63-year-old female patient who consulted for jaundice, cholouria, acholia and asthenia. A laboratory showing a cholestatic pattern and an ultrasound with dilated intra- and extrahepatic bile ducts led to a abdominal cholangioresonance that showed a large, poorly defined formation that compromised the common hepatic duct associated with stenosis of the common hepatic duct. The initial suspicion was a Klatskin tumor and a biopsy was performed, the anatomopathological result of which reported infiltration of a double-expressor large B-cell lymphoma as the primary tumor of the bile duct. She received chemotherapy treatment with a R CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) regimen and went into remission. Due to continuous episodes of cholangitis, a jejunum-hepatic Y-Roux anastomosis with reconstruction of the bile duct was performed. She is currently in remission 7 years after diagnosis.\n"
  },
  {
    "id": "multiclinsum_gs_en_31.txt",
    "fulltext": "76-year-old woman with a history of hypertension 14 years ago, on treatment with candesartan, without other findings of interest. She went to the emergency department with a history of stroke 48 hours after the onset, with clinical signs of dysarthria and right hemiparesis that resolved in a few hours and recurred 24 hours later. She arrived at the emergency department with a 5-hour history. Physical examination showed normal vital signs, drowsiness, disorientation in time and space, preferential gaze to the left, homonymous right hemianopsia, 0/5 muscle strength in the right hemicorpus on the Daniels scale; hyperreflexia in the lower limbs 3/4 and hyporreflexia in the upper limbs 1/4, bilateral plantar extensor response, without other findings. Immediately a computed tomography (CT) scan was performed, which showed a hyperdense extraaxial image in relation to the lateral left face of the medulla oblongata that extends superiorly to the bridge, with multiple densities at that level. The urgent study was completed with a cerebral angiotomography that showed a basilar dolicoectasis with a diameter of 5.09 mm and a fusiform aneurysm at the level of the left vertebral artery, approximately 20 x 9 mm, partially obliterated with mural thrombus and calcified, with adequate passage of the contrast medium. The magnetic resonance imaging in the following hours showed a restriction to diffusion in the territory of the anterior choroidal artery and in the basilar territory in the protuberance.\n",
    "summary": "76-year-old woman presented to the emergency department with an ischemic stroke that involved the left anterior and basilar artery territories. Imaging studies showed basilar dolicoectasis associated with a fusiform aneurysm with thrombi within the left vertebral artery. Both anatomic abnormalities are associated with ischemic stroke.\n"
  },
  {
    "id": "multiclinsum_gs_en_121.txt",
    "fulltext": "A 25-year-old nulliparous white woman, 36 weeks pregnant, was admitted to hospital with new onset of severe HF. Shortly before pregnancy, the patient had suffered from orthostatic fainting and had had an echocardiogram performed, which revealed no abnormalities, including normal left ventricle size with LVEF of 60%.\n\nAt admission, echocardiography revealed dilated, hypokinetic LV with an ejection fraction (EF) of 25–30% and significant mitral insufficiency. A cesarean section under general anesthesia was performed in a cardiac surgery operating theatre, and a healthy male infant was delivered. Afterwards, standard HF pharmacotherapy and bromocriptine were introduced. Cardiovascular magnetic resonance confirmed nonischemic cardiomyopathy with severe impairment of the left and right ventricle (RV) function with a RVEF of 22%. In the eighth week of treatment, the patient’s condition improved. The patient was discharged in the tenth week with an LVEF of 32%. However, in the fourth month, the patient presented with postpartum thyroiditis. Due to an increasing number of VT episodes, the patient required radio-frequency ablation treatment. The bromocriptine was continued for almost 12 months due to an increasing level of serum prolactin (503 mIU/l) after a temporary discontinuation of treatment. At 12-month follow-up, LVEF improved up to 54%, but the LV longitudinal systolic function remained at a depressed level and significant mitral insufficiency persisted.\n\nThe patient was referred for clinical genetic testing. Next-generation sequencing (NGS) in the proband was performed using the TrueSight One (TSO, Illumina, San Diego, California, United States) sequencing panel. A novel frameshift insertion NM_001267550: p.Leu23499fs/c.70497_40498insT of TTN gene was identified in the proband and in the proband’s asymptomatic 50-year-old mother but not in her younger sister. The patient’s father had died at the age of 40 in an accident.",
    "summary": "Patient: Female, 25\n\nFinal Diagnosis: Peripartum cardiomyopathy\n\nSymptoms: Fatigue • orthopnoea • pulmonary edema • tachycardia\n\nMedication: —\n\nClinical Procedure: —\n\nWe report the case of a 25-year-old woman with a severe course of PPCM with left ventricle ejection fraction of 25–30%, complicated by ventricular arrhythmia and postpartum thyroiditis. As no traditional risk factors of PPCM were identified, the patient was referred for genetic testing. Next-generation sequencing revealed a novel titin gene-truncating mutation NM_001267550: p.Leu23499fs/c.70497_40498insT in the proband as well as in her mother.\n\nIn the patient, a very late recovery >12 months postpartum was observed, which required long-term medical treatment with bromocriptine."
  },
  {
    "id": "multiclinsum_gs_en_117.txt",
    "fulltext": "A 17-year-old female inpatient was referred from the Pediatrics Department to the Oral Medicine Department at Hasan Sadikin Hospital with complaints of painful mouth ulcers, dryness of the lips and difficulties in swallowing. This condition made it difficult for the patient to eat and drink, resulting in the patient’s physical condition becoming weak and debilitated. The ulcer has been present for 3 days, has not improved and tends to bleed. However, the bleeding has stopped since the previous day. The Pediatrics Department administered Kenalog in Orabase® in response to this patient’s oral condition.\n\nThe patient complained of body aches, rashes and hair loss 2 months ago. This condition was examined at Kebon Jati Hospital, and the diagnosis of SLE was confirmed. Approximately 2 weeks ago, the patient complained of the same condition and finally decided to be treated at Hasan Sadikin Hospital. Comprehensive and multidisciplinary examinations established that, in addition to SLE, the patient was also diagnosed with hepatosplenomegaly, during the third week of hospitalisation. Enlargement of the liver and spleen were found during abdominal CT scan.\n\nDuring this two-week period, the patient took a diverse drug regimen that administered by the Pediatrics Department, which includes Levofloxacin, Amikacin, Ampicillin-Sulbactam and Ethambutol for the antibiotics. Fluconazole was given intravenously. Steroidal anti-inflammatory drugs were given IV Methylprednisolone and Triamcinolone Acetonide topically. Omeprazole and Ca. Carbonate as antacid and PPI. Vitamin D and Curcuma as dietary supplements and Paracetamol were also given.\n\nOn extraoral examination, the patient’s conjunctiva was anemic, and there was dryness and exfoliation of the lips that tends to bleed along with hemorrhagic crusts with serous sanguinolenta. During intraoral examination, there were lesions covering on almost all areas of the oral mucosa. Multiple ulceration on the upper and lower labial mucosa. A painful ulceration on the left buccal mucosa measuring 5 × 6 mm with erythema border. Central palatal erythema was seen on the palatum durum. Candidiasis pseudomembrane was also seen on the dorsum of the tongue, accompanied by papillae elongation.\n\nCase Management\nNaCl 0.9% was administered and used to perform several instructions related to the patient’s oral condition. Cleaning the teeth using a saline-moistened gauze was the most important thing because during the 2 weeks of hospitalisation, the patient neglected her oral hygiene. Hemorrhagic crusts on the lips and labial mucosa were also instructed to be dressed using moist gauze (NaCl 0.9%) as often as possible. This was done five times a day, with the aim of moistening lips and removing the crusts.\n\nThe condition of multiple and widespread ulcerations on the upper and lower labial mucosa, a topical steroid ointment mixture, was administered to the patient. A mixture containing Dexamethasone 0.5 mg mixed with Lanolin 2.5 mg and petroleum jelly added up to 25 mg was instructed for the patient to use it three times a day, after applying saline dressing. Considering other ulcerations, one of which was on the left buccal mucosa and also other ulcers that were difficult to reach by hand, 0.025% hyaluronic acid was administered to relieve inflammation locally.\n\nDuring the second visit, on 22 November 2022, it was seen that the general condition of the patient’s oral cavity had improved. The patient’s tongue still showed whitish plaque, which was finally given Nystatin® oral suspension, but had to be stopped after 2 days of administration regarding the hepatosplenomegaly condition. The ointment was stopped and replaced with petroleum jelly. The other medication was continued until the next evaluation, for the next 6 days. On 28 November 2022, the patient had no complaints about his oral cavity, but clinically there was still a presence of exfoliative cheilitis, coated tongue and ulcer in the left buccal mucosa, which had subsided.\n\nThe patient was discharged 2 days later and continued outpatient care. The last visit was conducted on 16 December 2022. The patient had no complaints, could follow oral hygiene instructions and gave advice to the patient to extract radix of deciduous teeth 55 and 65.",
    "summary": "A 17-year-old female patient was referred from the Pediatrics Department with mouth ulcers accompanied by dry lips and a tendency to bleed. The most concerning lesion was located on the left buccal mucosa, a single ulceration measuring 5x6mm. Multiple ulcerations spread over the upper and lower labial mucosa, with haemorrhagic crusts on the lips. Painful ulceration can lead to difficulties in mouth opening and impaired function in eating and drinking. Central erythema was seen on the palate. Pseudomembranous candidiasis was also seen on the patient’s tongue. The hepatosplenomegaly was confirmed by CT scan, with enzyme values of SGPT (386 U/L) and SGOT (504 U/L).\n\nCase Management\nAdministration of 0.9% NaCl was instructed to the patient to maintain oral hygiene and help moisturize lips in order to remove haemorrhagic crusts. Administration of 0.025% hyaluronic acid mouthwash and topical steroid ointment mixture for ulcerated and inflammatory conditions. Drug adjustments were made based on laboratory tests and the patient’s clinical condition was improving."
  },
  {
    "id": "multiclinsum_gs_en_236.txt",
    "fulltext": "47-year-old female with cirrhosis of the liver of alcoholic etiology, Child-Pugh B (7 points), without regular medication due to non-compliance. The patient reported a recent episode of hemorrhage with a starting point in isolated duodenal varices, instability of hemodynamics and the need for sclerotherapy with cyanoacrylate (1 mg of Hystoacril® and 1 mg of Lipiodol®), without immediate complications. She was discharged with 10 mg of propranolol twice daily. After one month, she was re-admitted with a week of fever, chills and malaise with a week of evolution. She reported abstinence from alcohol since the episode of hemorrhage. In the emergency, she was conscious, cooperative and oriented although slowed down, febrile (38.3ºC oral temperature) and hemodynamically stable, without ascites or peripheral oedema. The rest of the objective examination was irrelevant. Analytically, she presented anemia and thrombocytopenia, hepatic panel within its usual values, but with elevation of inflammatory parameters (Table 1). She underwent a thoraco-abdomino-pelvic computed tomography (CT) without evidence of infectious focus. She was admitted, and was given a therapeutic course with amoxicillin/clavulanate 1.2 g 8/8 h. During the 70-day admission, four episodes of bacteremia were documented. Initially, she was isolated Escherichia coli multi-sensitive, complying with 10 days of amoxicillin/clavulanate with apyrexia and inflammatory lysis. On the 13th day of admission, there was a resurgence of fever and inflammatory parameters, with isolation of Klebsiella pneumoniae ESBL+ and Escherichia coli, microorganisms progressively more resistant to justify the expansion of the antibiotic spectrum to tigecycline and colistin. This scheme was suspended five days later due to renal injury to colistin, and antibiotherapy was changed to ceftazidime 2 g 8/8 h that complied for 17 days with good clinical and analytical evolution. The bacteriological cultures performed between episodes of bacteremia were sterile.\n",
    "summary": "The case report a 47-year-old female patient with liver cirrhosis who underwent sclerotherapy of duodenal varices with cyanoacrylate after upper gastrointestinal bleeding. She subsequently developed five episodes of bacteremia with no obvious source. The definitive diagnosis of recurrent bacteremia with a starting point in cyanoacrylate was only possible after an exhaustive study to exclude other infectious foci.\n"
  },
  {
    "id": "multiclinsum_gs_en_591.txt",
    "fulltext": "An 80-year-old man was admitted to the hospital on January 17th, 2022, presenting with worsening dyspnea and fatigue for 2 months following a cold. His medical history included chronic bronchitis, occasional atrial premature contraction, Grade I hypertension, optic nerve atrophy in the left eye, and PCV in the right. He had a smoking history of 20 cigarettes per day for 30 years but had quit 17 years before. He denied alcohol consumption and had no family history of heart disease. Upon physical examination, the patient’s vital signs were normal except for mild pitted edema in both legs. Initial laboratory tests showed an elevated N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (HS-TnT). Electrocardiograph (ECG) revealed atrial premature contractions, while ultrasonic cardiogram (UCG) unexpectedly showed heart enlargement (Left atrium (LA) 48.0 mm, left ventricle (LV) 69.7 mm, right atrium (RA) 48.9 mm) and reduced left ventricular ejection fraction (LVEF, 43%) without significant valvular lesions. The primary diagnosis was heart failure for this admission. Upon reviewing his previous UCG, it was noted that his LV and LVEF were normal until six months prior (from 2021.05 to 2022.01). The reason for the sudden heart enlargement within this short timeframe remains unclear.\n\nFurther examinations were conducted to investigate the patient’s condition. Based on the patient’s symptoms and the results of coronary computerized tomography angiography (CTA), ischemic cardiomyopathy was essentially ruled out. On the one hand, the patient had not reported any chest pain or other symptoms of myocardial ischemia clinically; on the other hand, the coronary CTA revealed no significant stenosis: left main trunk (LM): 20% (degree of stenosis, so as below); left anterior descending branch (LAD): 50%; left circumflex branch (LCX): 30–50%; right coronary artery (RCX): 30%. Despite considering potential causes such as myocarditis, valvular heart disease, cardiac amyloidosis, and Takotsuba syndrome, cardiac magnetic resonance (CMR) did not provide conclusive evidence. The CMR findings indicated enlargement of the left ventricle and bilateral atria, diffuse thinning of the left ventricular myocardium, particularly in the anterior and lateral walls near the middle, and a diffuse decrease in myocardial contraction and diastole amplitudes. Regurgitation signal shadows were noted in the mitral valve area during left ventricular systolic period, with a few were observed in the aortic valve area during left ventricular diastolic period. No abnormal blood flow signal was detected in the tricuspid valve area. Additionally, myocardial resting perfusion scan showed no significant perfusion delay or defects in any myocardial segment. Measurements from the CMR showed left ventricular end-diastolic dimension (LVEDD) of 7.8 cm, right ventricular end-diastolic dimension (RVEDD) of 3.9 cm, LA of 4.3 cm, RA of 4.5 cm, interventricular septal (IVS) of 0.8 cm, left ventricular posterior wall (LVPW) thickness of 0.6 cm, left ventricular inferior wall (LVIW) thickness of 0.7 cm, LVEF of 19%, end diastolic volume (EDV) of 361 ml, end systolic volume (ESV) of 292 ml, cardiac output (CO) of 5.2 L/min, and left ventricular mass of 225.4 g. Connective tissue disease-related cardiomyopathy was ruled out as serum protein (free) light chain and autoimmunity indicators were normal. Hypertensive heart disease was unlikely since the patient’s Grade I hypertension was well controlled by basal dose medication (irbesartan 0.15 g qd). Idiopathic dilated cardiomyopathy and alcoholic cardiomyopathy were also excluded based on history and previous tests. The cause of cardiac enlargement remained unclear. Anyway, since 24-hour Holter monitoring presented frequent atrial premature beats and paroxysmal atrial fibrillation, we performed standard treatment, focusing on promoting heart function and controlling arrhythmia. Following a week of treatment, symptoms improved significantly, and the proportion of atrial premature beats on 24-hour Holter monitoring decreased from 25.01% to 13.18%. The patient was discharged on January 27th, 2022. Before discharge, the patient was prescribed Edoxaban Tosilate Tablets (30 mg qd), Rosuvastatin Calcium Tablets (10 mg qn), Amiodarone Hydrochloride Tablets (0.2 g qd), Sacubitril Valsartan Sodium Tablets (50 mg bid), Furosemide Tablets (20 mg qd), and Spironolactone Tablets (20 mg qd). The patient diligently followed this regimen until their subsequent admission.\n\nOn February 19th, 2022, the patient was readmitted due to weakness and fatigue. This time, orthopnoea and more severe peripheral edema were observed, along with an increase in NT-proBNP levels to 14,396 ng/L. The LV size had increased to 71.2 mm with minimal 24-hour atrial premature beats (1,631; 1.30%) and no atrial fibrillation detected, indicating arrhythmia was not the cause of the cardiac enlargement. Heart failure symptoms improved with timely guideline-directed medical therapy, but the underlying cause needed to be identified. Upon reviewing the patient’s medical history, it was noted that he had been receiving a regular anti-VEGF IVT for almost 10 years (2012.11-2018.01, Ranibizumab; 2018.02-2018.10, Conbercept; 2018.11-2021.10, Aflibercept) to manage PCV. Anti-VEGF agents inhibit angiogenesis and vascular leakage from newly formed vascular networks in the choriocapillaris, which contributes to the progression of PCV. However, it also poses risks for the circulatory system, including hypertension, cardiac insufficiency and myocardial ischemia. The patient was advised to discontinue anti-VEGF therapy. After a 2-month withdrawal period, there was a gradual improvement in LV and LVEF. The patient was discharged on May 27th, 2022, and has not experienced dyspnea or edema ever since.",
    "summary": "This case report describes an elderly patient with no prior history of heart disease who exhibited unexpected heart enlargement and dysfunction. Throughout the patient’s hospital stay, various potential causes were investigated, leading to the hypothesis that a 10-year history of intravitreal injections of anti-vascular endothelial growth factor could be related to the observed clinical manifestations. The patient was advised to discontinue this treatment, and after a 2-month follow-up period, there was a gradual improvement in the patient’s cardiac structure and function."
  },
  {
    "id": "multiclinsum_gs_en_584.txt",
    "fulltext": "30-year-old male patient with a localized dermatosis in the face affecting the left corner of the mouth, characterized by a 1 cm diameter ulcer with a base covered in fibrin and granulating tissue, irregular and ill-defined borders, and painful for 20 days. The patient has a history of HIV/AIDS. He reported risky sexual practices in the previous weeks. A punch biopsy of the dermatosis was performed, and the histopathological report was compatible with syphilitic chancre; in addition, a VDRL (Venereal Disease Research Laboratory) was requested with a negative result. Based on the clinical-pathological correlation, the diagnosis of syphilitic chancre was made, which was managed with 2,400,000 U of intramuscular benzathine penicillin G, after which the patient showed improvement.\n",
    "summary": "A 30-year-old man presented with a localized dermatosis at the left labial commissure, characterized by a non-painful ulcer 1 cm in diameter, which had been present for 20 days. The patient had a history of HIV/AIDS. A punch biopsy of the dermatosis was performed, and the histopathological report was compatible with syphilitic chancre and a negative VDRL result. He was treated with benzatin penicillin G, which led to improvement.\n"
  },
  {
    "id": "multiclinsum_gs_en_309.txt",
    "fulltext": "A healthy 18 kg 4-year-old girl of Northern European descent [American Society of Anesthesiologists (ASA) Physical Status Classification I] presented for laser tonsillotomy, adenoidectomy, and tympanocentesis. Premedication included oral midazolam (0.1 mg/kg) and ibuprofen (10 mg/kg). Following attachment of standard monitoring devices [electrocardiogram (ECG), non-invasive blood pressure, pulse oximetry], anesthesia was induced with intravenous fentanyl 20 µg, propofol 70 mg, and mivacurium 6 mg. Dexamethasone 2.5 mg and ondansetrone 2 mg were given for prophylaxis of post-operative nausea and vomiting. General anesthesia was maintained with remifentanil (0.5 µg/kg/minute) and propofol (10 mg/kg/hour) under continuous processed electroencephalogram (EEG) monitoring (Narcotrend, Narcotrend-Group, Hannover, Germany; target range 40–60).\n\nThe immediate postoperative course was notable for a lack of spontaneous ventilation and delayed emergence, despite Narcotrend indices of B1–B2 (80–89)—indicating light residual sedation—approximately 25 minutes after discontinuation of anesthetics. Interestingly, Narcotrend indices subsequently decreased again, providing readings of C1–C2 (70–79) over the following 40 minutes. A sudden spike to A (94), despite sustained apnea, prompted evaluation of her neuromuscular status and immediate re-initiation of sedation [remifentanil (0.2 µg/kg/minute) and propofol (4 mg/kg/hour)].\n\nRecovery from neuromuscular blockade was evaluated using a peripheral nerve stimulator. Train-of-four testing (TOF, 2 Hz) did not elicit a response (TOF 0/4), indicating residual paralysis. A clinical diagnosis of suspected pseudocholinesterase deficiency was made after brief consideration of possible—but less likely—differential diagnoses (that is, narcotic overdose and central anticholinergic syndrome). Transfer to our pediatric intensive care unit was arranged for continued mechanical ventilation and monitoring.\n\nThe subsequent postoperative course was unremarkable. The patient could be safely extubated 8 hours after the administration of mivacurium (TOF 4/4), and was transferred back to the department of otorhinolaryngology. She was issued a medical alert card and discharged home after 2 days of observation.\n\nThe clinical diagnosis was confirmed using laboratory tests. Serum pseudocholinesterase activity was 940 kU/L (normal range 3200–6600 IU/L). Genetic testing identified compound heterozygosity in the BChE gene, and a diagnosis of autosomal recessive hereditary pseudocholinesterase deficiency was made. Compound heterozygosity is characterized by the presence of two different pathogenic alleles of a particular gene. Indeed, her non-consanguineous, phenotypically unremarkable parents were both found to be heterozygous carriers of different pathogenic variants of the BChE gene. Specifically, DNA sequencing identified a complex allele carrying the K and A variant of the BChE gene in the father (NM_000055.2: c. [293A > G; 1699G > A] p. (Asp98Gly; Ala567Thr); previously p. (Asp7OGIv:Ala539Thr)), while the mother was found to have the following variant: NM_000055.2:c. [428G > A; 1685-14 T > C] p. (Gly143Asp); previously p. (Gly115Asp) in).",
    "summary": "A healthy 4-year-old girl of Northern European descent underwent general anesthesia for tonsillotomy, adenoidectomy, and bilateral tympanocentesis. Previously unknown pseudocholinesterase deficiency presented as delayed emergence with sustained apnea and paralysis following administration of mivacurium, necessitating transfer to the pediatric intensive care unit for prolonged post-operative ventilatory support and monitoring. Extubation was safely performed 8 hours later. No long-term sequelae were noted. Genetic testing identified compound heterozygosity in the butyrylcholinesterase gene. Thus, a diagnosis of autosomal recessive hereditary pseudocholinesterase deficiency was made."
  },
  {
    "id": "multiclinsum_gs_en_385.txt",
    "fulltext": "61-year-old woman with a history of FIGO IIB stage cervical squamous cell carcinoma, diagnosed in February 2019, treated in a private hospital of fourth level of care, where outpatient and inpatient care is offered for patients with complex oncological and non-oncological conditions. At the time of diagnosis, radical hysterectomy with pelvic lymphadenectomy was performed, which ruled out nodal involvement. The first-line adjuvant treatment included six cycles of chemotherapy with cisplatin, and brachytherapy and radiotherapy, achieving a complete tumour response. In 2021, after an isolated relapse was detected in the iliac region by tomography, cisplatin and 30 sessions of radiotherapy were administered, achieving a new complete response. In September 2022, a tomography revealed another relapse with left parametrium, ureter and ipsilateral iliac chain involvement, so first-line treatment for recurrent disease with carboplatin, paclitaxel and pembrolizumab was decided. During this regime, the patient presented hypersensitivity to platinum in the fifth cycle, managed with a desensitization protocol, continuing with pembrolizumab. In September 2023, in the face of a progression in images of a single retroperitoneal mass, due to the lack of optimal response, gemcitabine was initiated, according to management guidelines, second-line treatment for recurrent disease, receiving a cumulative dose of 8,544 mg/m2 until January 2024. However, she developed symptoms of digital ischemia in hands, so treatment was suspended after the second dose of the third cycle, accumulating 11,744 mg/m2 of gemcitabine.\n\nIn February 2024, the patient presented to the emergency department of the same hospital where she was being seen on an outpatient basis, referred by oncology due to progression of symptoms in her extremities. The patient reported lancinating pain and blue discoloration in fingers of hands; physical examination revealed necrosis in the second finger of the right hand, ochre discoloration and Raynaud's phenomenon in the fingers of the left hand. The lower extremities showed grade II edema in the left lower limb and pulses present. Studies for autoimmunity and vasculitis were negative, including anti-neutrophil cytoplasmic antibodies (ANCAS), antinuclear antibodies (ANAS), anti-deoxyribonucleic antibodies (anti-DNA), cardiolipins, confirmatory test for lupus anticoagulant, extractable nuclear antigen (ENAS) antibody profile, anti-proteinase 3 antibodies, anti-myeloperoxidase antibodies and anti-DNA topoisomerase I antibodies (anti-SCL). In addition, rheumatoid factor and complement levels 3 (C3) and complement 4 (C4) were also normal. Serologic test for syphilis (VDRL - Venereal Disease Research Laboratory) negative, transthoracic echocardiogram without findings of a cardioembolic focus.\n\nAnticoagulation with low molecular weight heparin was initiated, along with acetylsalicylic acid, a statin, and a calcium antagonist. The hand surgery team amputated the second finger of the right hand, confirming liquefactive necrosis in the histopathological study.\n\nPostoperatively, sildenafil was added to the treatment, achieving a progressive improvement in the ischemia signs of the remaining fingers. During hospitalization, the patient presented a complication of massive vaginal bleeding, requiring uterine artery embolization.\n\nThe rheumatology department used the Naranjo causality scale to determine the role of gemcitabine in the vasculitis, with a score of 8 indicating that the drug was likely the cause of the necrosis.\n\n20 days later, she developed neurological impairment without significant findings on a skull scan. She was evaluated by palliative care and her functional status was rated 0/30 on the Barthel scale, 4 on the ECOG scale, and 10% on the Karnofsky scale, with a life expectancy of less than three weeks according to the Patient Prognostic Index (PPI: + 6 points). In agreement with the family, further studies were discontinued and comprehensive palliative management was implemented. The patient died after discharge from the hospital.\n",
    "summary": "A 61-year-old woman treated with gemcitabine (11,744 mg/m2 cumulative) for metastatic disease in a private, non-oncological, fourth-level general hospital, where she was being managed on an outpatient basis. She presented with distal necrosis of the second finger of the right hand, so treatment was discontinued and amputation of this finger was required. A search was performed in Embase, Medline and Lilacs. Studies of reports and case series on distal necrosis induced by gemcitabine were searched. Dose, diagnosis and treatment data were extracted.\n"
  },
  {
    "id": "multiclinsum_gs_en_203.txt",
    "fulltext": "A 69-year-old male patient suffered from sick sinus syndrome (SSS) with a heart rate ranging from 40 to 50 beats per minute, hypertension, moderate mitral regurgitation, dilated left ventricle, diabetes, chronic kidney disease (on hemodialysis), and NYHA III heart failure. On a follow-up day, he reported fatigue, mild dyspnea, and inability to walk independently. Examination showed a pulse of 40 bpm, blood pressure of 132/51 mmHg (on antihypertensives), pale skin, no edema or fever, normal lung sounds, and non-palpable liver/spleen. Muscle strength was 4/5 bilaterally.\n\nLaboratory tests revealed mild anemia (Hb 98 g/L), glucose 7.7 mmol/L, HbA1c 7.3%, eGFR <5 mL/min, potassium 4.1 mmol/L, and normal thyroid function. Brain MRI was normal. ECG showed sinus bradycardia (49 bpm), and 24-hour Holter monitoring confirmed persistent bradycardia (HR: avg 45 bpm, min 36 bpm, max 77 bpm) with bradycardia present 86% of the time, along with occasional premature ventricular contractions classified as Lown Class IVA.\n\nEchocardiogram showed left ventricular dilation (Dd: 60mm; Ds: 36mm), concentric hypertrophy, moderate mitral regurgitation, mild tricuspid regurgitation, moderate pulmonary hypertension (PAPs 46 mmHg), normal left ventricular ejection fraction (EF 70%) and dilated coronary sinus measuring 20.9×24.8 mm. A coronary angiogram revealed 20% stenosis in the mid-left anterior descending artery. The patient consented to permanent dual-chamber pacemaker implantation after a thorough explanation, with all documentation completed.\n\nPreoperative Preparations\nThe pacemaker was implanted a day after the patient’s last hemodialysis session. Due to a right forearm AVF, the pacemaker was placed on the left side. The patient fasted for 6 hours, and 2 g of cefotaxime was administered prophylactically. A Biotronik Evity 6 DR-T dual-chamber pacemaker with active fixation leads Solia S 60, and S 53 leads were used.\n\nImplantation Procedure\nA 7 cm incision was made below the left deltopectoral groove to create the pacemaker pocket. Venography revealed a dilated PLSVC draining into the right atrium via the coronary sinus. Two access points were established in the left axillary vein under fluoroscopic guidance. The right ventricular lead was implanted first, followed by the right atrial lead.\n\nRight Ventricular Lead Implantation\nFirstly, using a straight stylet, advance the lead into the right atrium as far as possible, visualized in an antero-posterior (AP) view. Secondly, replace the straight stylet with a “C”-shaped stylet. Gently push the entire system (lead with “C” shaped stylet) into the lateral right atrial wall and rotate the stylet counterclockwise so the lead tip points towards the tricuspid valve annulus. Thirdly, the crucial step of guiding the lead through the tricuspid valve is performed. At this position, gently withdraw the stylet 2–3 cm while simultaneously pushing the lead forward. This should allow the lead to pass smoothly through the tricuspid valve into the right ventricle. This step may need to be repeated 2–3 times for success. Fourthly, navigate and fix the lead to an appropriate position in the right ventricle. Continue gently pushing the lead and fixing the stylet to allow contact with the right ventricular outflow tract or interventricular septum. For apical positioning, gently rotate the stylet clockwise and advance the lead towards the apex. Finally, the lead secured with 7–10 turns. Pacing parameters were checked, and the “C” shaped stylet was gently withdrawn and the lead slightly pushed to test stability. Replace the “C” shaped stylet with a straight one, advancing it to the coronary sinus ostium or partially into the right atrium to recheck lead stability. If stable with good pacing parameters, suture the lead in place. Fluoroscopic views (RAO 30°, LAO 30°, and AP) were used for guidance.\n\n\nRight atrial lead implantation: The lead was advanced into the right atrium using a straight stylet, then replaced with a “C” stylet. Due to the curved path and angle, placing the atrial lead in the right atrial appendage was challenging, so we navigated and fixed the lead to the high lateral right atrial wall. Fixation and good pacing threshold. Secure the atrial lead.\n\nPacing parameters: Right ventricular lead: 0.5V at 0.4ms; impedance 700 Ohm; sensing 10.7 mV. Right atrial lead: 0.8V at 0.5ms; impedance 450 Ohm; sensing 1.8 mV. Total procedure time: 115 minutes, fluoroscopy time: 17.5 minutes.\n\nResults and Follow-Up\nPost-implantation, the patient continued antibiotic therapy and inpatient treatment for 7 days before discharge. Follow-up at 1, 3, and 4 months showed clinical improvement, including reduced fatigue, better mobility, and improved self-care. The device pocket healed well, and pacemaker parameters remained stable with 100% atrial pacing, <1.0% ventricular pacing, and minimal pacing thresholds, sensing, and impedance changes. The chest X-ray film confirmed proper device and lead positioning, and echocardiography parameters showed no significant changes in valves, left ventricular size, or LVEF.",
    "summary": "A 69-year-old male patient with sick sinus syndrome (SSS), hypertension, moderate mitral regurgitation, dilated left ventricle, diabetes, chronic kidney disease (on hemodialysis), and NYHA III heart failure underwent dual-chamber pacemaker implantation via the left axillary vein. Venography revealed a persistent left superior vena cava, a challenge for the placement of leads. The ventricular lead was positioned in the right ventricular outflow tract using a Biotronik active fixation lead with a “C” shaped stylet, and the atrial lead was placed in the right atrial lateral wall. The procedure took 115 minutes with 17.5 minutes of fluoroscopy. After 4 months, the patient showed symptom improvement and stable pacing parameters."
  },
  {
    "id": "multiclinsum_gs_en_486.txt",
    "fulltext": "A 10-year-old African American female presented with bilateral lower extremity edema, abdominal distension, malaise, loss of appetite, nausea, and weight gain for two weeks. There was no history of fever, gross blood in urine or joint pains. Past medical history was significant for absence seizures, and she was started on ethosuximide 250 mg daily three months prior to presentation. The staring spells decreased from 8–10 episodes per day to 5–6 episodes per week after initiation of ethosuximide. Four weeks prior to presentation, she developed submental swelling following a dental extraction and received a seven-day course of amoxicillin. The patient had no history of prior allergic reactions with amoxicillin. There was no history of recent usage of non-steroidal anti-inflammatory drugs (NSAID), over the counter medications or proton pump inhibitors. There was no recent viral upper respiratory or gastrointestinal illness, streptococcal throat or skin infection and skin rash. Family history was not suggestive of systemic lupus, NS, other autoimmune diseases, renal failure, dialysis, kidney transplantation, or sickle cell disease. Her immunization was up to date and she had normal growth and development.\n\nOn examination, the vital signs showed an afebrile child with a heart rate of 74 beats per minute, respiratory rate 20 per minute, blood pressure 122/86 mm Hg (>95th percentile for age, gender, and height), and oxygen saturation of 96% on room air. Her current weight was 49.4 kg (95th percentile) and the baseline weight prior to presentation was 41 kg. Physical examination showed puffiness of eyes and face, abdominal distension, and 1+ bilateral pitting edema of the lower extremities. There were no oral ulcers, joint swelling, tenderness or erythema. Skin examination showed some non-itchy and non-painful excoriated pustules on the frontal hairline and upper thighs posteriorly. There was no malar or discoid rash. Eye examination showed no redness; a formal ophthalmology examination showed no uveitis. Mental status was normal without seizures.\n\nPrior renal function test was unknown. Differential blood count showed no eosinophilia. Liver enzymes were normal. Serum creatinine kinase was normal. Urinalysis showed specific gravity ≥1.030, pH 6.0, ≥500 protein, one red cell per high power field, two white cells per high power field, negative nitrite, and leukocytes. Urine eosinophil was not obtained. Random urine protein to creatinine ratio was 5.4 mg/mg (normal < 0.2 mg/mg). Urine culture was negative. Subsequent blood count showed drop in hemoglobin to 10.2 gm/dL with stable white cell count and platelet count. There was Coombs’ positive autoimmune hemolytic anemia. Anti-nuclear antibody (ANA), anti-double-stranded (ds) DNA antibody and anti-histone antibodies (8.5 units, normal range: 0–1 unit, 1–1.5: weak positive, 1.6–2.5: moderate positive, 2.6 units or greater: strong positive) were all strongly positive. Anti-smith antibody was negative (5 AU/mL, normal range: 0–40 AU/mL). Ribonucleic protein, SCL-70 antibody, SS-A and SS-B were all negative. Serum immunoglobulin E (IgE) was elevated at 5811 KU/L (normal ≤ 696 KU/L) but there was normal serum IgG and IgA. Nasopharyngeal SARS-CoV-2 polymerase chain reaction (PCR) was negative. Varicella zoster DNA PCR and Epstein–Barr virus DNA PCR were negative.\n\nChest X-ray revealed no pleural effusion, pneumothorax, consolidation, or acute abnormalities. Renal sonogram demonstrated bilateral echogenic kidneys with right kidney measuring 11 cm in length and left kidney measuring 11.2 cm in length without hydronephrosis. A percutaneous sonogram-guided renal biopsy which was obtained three days after the onset of current signs and symptoms showed two portions of renal cortical tissue with ten glomeruli. Light microscopy showed a segmental mild increase in mesangial cellularity with moderate increase in the mesangial matrix. There was no segmental sclerosis, cellular crescent, nor area of segmental necrosis. The tubular atrophy and interstitial fibrosis were mild. There was moderate to severe interstitial inflammation, comprised of lymphocytes/mononuclear cells, plasma cells, eosinophils, and rare neutrophils, associated with severe tubulitis and tubular damage. No granulomas were seen. There was no active arteritis. The immunofluorescence study was negative for IgA, IgG, IgM, C3, C1q, kappa, and lambda light chains. Electron microscopy showed a normal glomerular basement membrane without immune deposits nor tubular-reticular inclusions. There was partial podocyte foot processes effacement. These findings were most consistent with acute TIN with podocyte injury.\n\nThe patient was treated with albumin/diuretic infusions for the symptomatic relief of edema and the weight trended down to near her baseline at discharge. Due to severe TIN and NS, a course of steroids, prednisone 60 mg daily, was started with gradual tapering over six weeks. Serum creatinine trended down to 1.13 mg/dL at discharge. Due to concerns of DIL, ethosuximide was changed to zonisamide after consultation with neurology and switched again after three weeks to sodium valproate for better seizure control. Rheumatology consultation was carried out, who agreed with the diagnosis of ethosuximide-induced DIL. Mild anemia persisted with serum hemoglobin of 10.8 gm/dL at the time of discharge.\n\nThe edema resolved within two weeks and her weight returned to the baseline. Hypertension, which was thought to be secondary to fluid overload and steroid usage, was managed with amlodipine. Blood pressure normalized and hence amlodipine was discontinued after completion of steroid therapy. At two weeks follow-up, the serum creatinine was 0.6 mg/dL (schwartz eGFR 90 mL/min/1.73 m2), serum albumin improved to 3.4 g/dL from 2.2 g/dL at discharge, urinalysis was negative for blood and protein, with normal spot urine protein creatinine ratio of 0.12 mg/mg. Serum 25 hydroxy-vitamin D and IgE improved. At two months follow-up, ANA was weakly positive with titer of 1:160 (homogenous pattern), dsDNA antibody was 10 IU (normal range 0–24 IU, IgG ELISA, ARUP laboratories, Salt Lake City, UT, USA), and anti-histone antibody was 1.0 unit.",
    "summary": "Here we describe a 10-year-old female with absence seizures who developed a lupus-like syndrome after being on ethosuximide for three months. She presented with nephrotic syndrome (NS) and acute kidney injury. Four weeks prior to presentation, she had been prescribed a seven-day course of oral amoxicillin for submental swelling after dental extraction. Investigations showed high titer of antinuclear antibody (ANA) and anti-double stranded DNA, elevated serum IgE level, and positive Coombs' test, along with positive anti-histone antibodies. Renal biopsy showed features of acute tubulointerstitial nephritis (TIN) and partial podocyte foot process effacement without evidence of lupus nephritis. The patient had an excellent response to the steroid therapy with remission within two weeks. The patient remained in remission for two months as evaluated during the most recent follow-up; the autoimmune antibodies and immunoglobulin E trended down. Ethosuximide has been reported to cause DIL, however its possible association with TIN has not been reported. Although amoxicillin could have caused the TIN and NS in this patient, a possible novel association of ethosuximide with this nephrotic-nephritic presentation (NNP) cannot be ruled out."
  },
  {
    "id": "multiclinsum_gs_en_442.txt",
    "fulltext": "44-year-old male with a history of bilateral carpal tunnel surgery and no other relevant history. He consulted for progressive dyspnoea up to functional class III for months, with oedema in the lower limbs, weight gain and episodes of dizziness with a single syncope. On physical examination, he presented a tendency to hypotension (90/60 mmHg), with the rest of the vital signs preserved, good mechanical ventilation with crepitant rales in both pulmonary bases, oedema in the lower limbs 3/6 with a positive Godet, and a marked decrease in the ability to open the mouth. The electrocardiogram showed a sinus rhythm of 75 beats per minute with an electrical axis deviated to the left, the presence of a right bundle branch block with microvoltage in the derivations of the limbs. The chest X-ray showed a cardiothoracic index at the upper limit of normal with signs of redistribution of flow to the upper pulmonary fields and the presence of a moderate right pleural effusion. In the laboratory, a normal creatinine value of 1 mg/dl was observed, and N-terminal pro-B-type natriuretic peptide (pro BNP) of 3500 pg/ml (for a normal value adjusted to age of up to 210 pg/ml). A Doppler echocardiogram was performed, where a diffuse increase in the thickness of the parietal walls (septal thickness 1.93 cm, posterior wall 1.7 cm) and of the ventricular mass was observed, with hypokinesia of the basal and middle ventricular segments with mild impairment of the ejection fraction (51.7%). The global longitudinal strain technique, which measures the strain in the direction of the base-tip of the ventricular cavity and is considered more sensitive than the ejection fraction, was -10.5% (normal value considered between -18 and -22%; lower values suggest poor myocardial deformation). In addition, a marked apical-basal gradient was observed, a characteristic pattern of cardiac amyloidosis. He did not have significant left-sided valvular pathologies. In the right ventricle, a slight deterioration of the function of the systolic function was observed, with an increase in the thickness of the free wall, without signs of pulmonary hypertension. The picture was interpreted as IC and good initial response to diuretics was indicated. With the suspicion of infiltrative disease, a bone scan with pyrophosphate and free light chains in serum was requested. The bone scan had a visual Perugini score of 1, not suggestive of transretin amyloidosis. The free light chains were 163 mg/dl (normal range between 5.7 and 26.3 mg/dl) and the kappa free chains were 8 mg/dl (normal range between 3.3 and 19.4 mg/dl) with a kappa/lambda ratio of less than 0.26, for values considered normal between 0.26 and 1.65. In serum immunoelectrophoresis, a monoclonal component of the lambda type was found. A bone scan with contrast was also performed, where a similar ejection fraction to the echocardiogram was observed, with late gadolinium enhancement of the subendocardium diffused, with cancellation of the blood pool. With these results, a gum biopsy was performed, which confirmed the diagnosis of AL amyloidosis. After the confirmation of the diagnosis, treatment with cyclophosphamide, bortezomib and dexamethasone (CYBORD scheme) and Daratumumab was immediately started. After the third cycle, he had a similar ejection fraction to the previous one. After a complex multidisciplinary evaluation, he was admitted to the emergency cardiac transplant list. One month after the diagnosis of the disease, he had the possibility of receiving the same with good evolution. This allowed him to restart a suppressive chemotherapy with good tolerance after 3 months of receiving the transplant, with a requirement for intravenous infusion of continuous and inotropic drugs. The echocardiogram was repeated, showing a similar ejection fraction to the previous one. After a complex multidisciplinary evaluation, he was admitted to the emergency cardiac transplant list. He had a good evolution without new admissions.\n",
    "summary": "A 44-year-old man presented with signs and symptoms of heart failure (HF) with elevated cardiac biomarkers. A transthoracic echocardiogram was performed, which showed increased wall thickness with global hypokinesia and mildly impaired ejection fraction (50%). The patient was admitted to the coronary unit for a negative balance and for an etiological study of the condition. Given the suspicion of infiltrative disease, a bone scintigraphy with pyrophosphate and free light chains in serum was requested. The bone scintigraphy was not suggestive of transthyretin amyloidosis and the free light chains showed a ratio of less than 0.26 with a predominance of lambda. A gingival biopsy was performed, which confirmed the diagnosis of AL amyloidosis. Following the diagnosis, specific chemotherapy treatment was initiated with cyclophosphamide, bortezomib and dexamethasone (CYBORD regimen) and daratumumab. The patient progressed with refractory HF, so he was placed on the cardiac transplant list, receiving a transplant shortly after with good results. This allowed the chemotherapy regimen to be restarted and, secondly, he received an MLT, with good results.\n"
  },
  {
    "id": "multiclinsum_gs_en_485.txt",
    "fulltext": "Case Presentation\nA 35-year-old woman, gravida 9, para 8, presented to the hospital on the 13th postpartum day following an uncomplicated spontaneous vaginal delivery at home, attended by a traditional birth attendant. The patient exhibited a 5-day history of right-sided weakness and generalized tonic-clonic seizures. Notably, her family history was significant for the sudden deaths of two brothers and one sister, all of whom exhibited similar neurological symptoms.\n\nPrior to the onset of her neurological manifestations, the patient experienced an abrupt, severe generalized headache accompanied by blurred vision and visual field deficits. Additionally, she reported rapid mood fluctuations and initially sought care at a local clinic, where she received unspecified oral medication without any improvement, but was unable to provide further details regarding the type or composition of the medication. She denied knowingly taking any other traditional or herbal medications during or before her pregnancy. Due to cultural practices and potential stigma, it remains possible that she may have used undisclosed herbal remedies.\n\nThe patient reported receiving unspecified oral medication from a local clinic prior to admission, but was unable to provide further details regarding the type or composition of the medication. She denied knowingly taking any other traditional or herbal medications during or before her pregnancy. Due to cultural practices and potential stigma, it remains possible that she may have used undisclosed herbal remedies.\n\nConsidering the patient’s multiparity (G9, P8), a thorough exploration of her obstetric history was undertaken to identify any previous complications associated with childbirth, particularly venous thromboembolism (VTE) or indications for thrombophilia screening. The patient denied any prior history of postpartum complications or VTE, and her medical records revealed no documentation of thrombophilia screening. This absence of previous events may have contributed to the initial oversight of her symptoms during the current postpartum period.\n\nUpon admission to the gynecology ward of a regional hospital in Borama, the patient was administered haloperidol and diazepam; however, her level of consciousness subsequently declined. The patient’s past medical history was unremarkable, with no known hypertension, diabetes, epilepsy, or history of oral contraceptive use. She denied any known drug or food allergies. The patient was married, had eight children, resided in traditional housing, and reported no history of substance abuse.\n\nPhysical Examination\nOn admission, the patient exhibited a reduced level of consciousness with a Glasgow Coma Scale (GCS) score of 9/15. She appeared restless and agitated, was normocephalic without facial asymmetry, but exhibited neck stiffness. Vital signs included blood pressure of 130/90 mmHg, heart rate of 100 bpm, respiratory rate of 20/min, oxygen saturation of 96% on room air, and temperature of 36.9°C. Neurological examination revealed vigorous movements of the left limbs, right-sided hypotonia, and an equivocal plantar response.\n\nMethods (Differential Diagnosis, Investigations, and Treatment)\nInvestigations\nComplete Blood Count (CBC): Total WBC 11,100 cells/µL (Neutrophils 9500 cells/µL), hemoglobin 7.5 g/dL, MCV 61.2%, platelets 455,000 cells/µL. Renal Function Tests (RFT): Urea 17 mg/dL, creatinine 0.6 mg/dL. Liver Function Tests (LFT): GOT 17 IU/L, GPT 21 IU/L, total bilirubin 0.8 mg/dL. Blood Group: O positive. Urine Analysis: pH 5, protein 2+, WBCs 1–5/HPF. Following five days of management for presumed eclampsia and postpartum psychosis, a brain CT scan was performed, revealing an irregularly shaped hyperdense hemorrhage in the left parieto-occipital lobe at the gray-white matter junction, accompanied by surrounding hypodense edema and effacement of the ipsilateral lateral ventricle, indicating mild midline shift to the right. The findings suggested a large venous hemorrhagic infarction secondary to superior sagittal sinus thrombosis, complicated by mild subarachnoid hemorrhage, brain edema, and mild subfalcine herniation to the right. A subsequent MRI/MRV confirmed subacute hemorrhagic ischemia in the left temporo-parieto-occipital region with signs of left sigmoid venous sinus thrombosis.\n\nDifferential Diagnosis\nOur initial differential diagnoses included: Postpartum Eclampsia: Given the patient’s recent delivery and presentation of headache, visual disturbances, and seizures. Pseudotumor Cerebri: Due to signs of increased intracranial pressure such as headache and visual changes. Other Cerebrovascular Accidents: Due to the sudden onset of neurological deficits. Postpartum psychosis: As a possible contributing factor.\n\nTreatment\nThe patient was transferred to the intensive care unit (ICU) and treated as follows: Intracranial Pressure Management: Mannitol infusion (350 mL IV loading dose, followed by 200 mL IV TID for 3 days). Seizure Prophylaxis: Phenytoin 100 mg PO TID. Anticoagulation: Unfractionated heparin (UFH) 5000 IU IV loading dose, followed by 17,500 IU SC BID, and warfarin 5mg PO /day (target INR 2.0–3.0). Acetazolamide 500mg PO TID. Other: Paracetamol 300 mg IV as needed, intravenous normal saline 1000mL BID, and bromocriptine 2.5 mg PO BID.\n\nClinical Course and Follow Up\nBy day 3 of admission, the patient regained full consciousness with no cranial nerve deficits but presented with dense spastic right-sided hemiplegia and intact sensory function. Coagulation studies indicated a prothrombin time (PT) of 24 seconds, partial thromboplastin time (PTT) of 27.5 seconds, and an INR of 2.4. On day 9, her GCS improved to 15/15, although she retained right spastic hemiplegia (power 0/5) and exaggerated deep tendon reflexes. The INR was noted to be 3. She was discharged on day 16 with residual word-finding difficulties and flickering movements in her right hand. Warfarin therapy was continued at 2.5 mg daily. At a one-month follow-up, the patient was able to walk with slight support, exhibiting power of 4/5 and continued word-finding difficulties, along with sleep disturbances.",
    "summary": "We report the case of a 35-year-old woman, gravida 9, para 8, who presented on the 13th postpartum day with right-sided weakness, seizures, and severe headache. Initially misdiagnosed as impending eclampsia due to the absence of hypertension and proteinuria, she underwent CT and MRI scans, revealing a significant superior sagittal sinus thrombosis with hemorrhagic infarction. The patient was treated in the ICU with increased intracranial pressure management, seizure prophylaxis, and anticoagulation therapy, resulting in substantial clinical improvement."
  },
  {
    "id": "multiclinsum_gs_en_128.txt",
    "fulltext": "46-year-old man presented with visual impairment of three years' evolution, associated with occasional headaches, asthenia, severe adynamia, erectile dysfunction and loss of libido. Personal history of primary hypothyroidism and NF1 with multiple lesions consistent with neurofibromas with confirmed diagnosis in 2014. Family history includes a daughter with a diagnosis of NF1 who underwent surgery for a brain astrocytoma at the age of 11 years. On physical examination, he presented with multiple lesions consistent with neurofibromas, brown-milky spots on the back and abdomen, preserved higher mental functions, isochoric and reactive pupils, bitemporal hemianopsia, no cranial nerve impairment, motor or sensory deficits. In contrast-enhanced magnetic resonance imaging (MRI) of the brain, a 24x24x39 mm-diameter, bilobed, suprasellar lesion was observed, which generated compression of the optic chiasm, corresponding to a lesion type KNOSP II - Hardy C. It was hypointense in T1 and slightly hyperintense in T2, with homogeneous enhancement after contrast administration, which may correspond to a pituitary macroadenoma.\n\nHe was referred to the Endocrinology Service where laboratory tests were performed and a hypopituitary syndrome with secondary hypervitaminosis D and mixed dyslipidaemia was detected. The serum ionogram and urinary density were normal, ruling out diabetes insipidus. The urinary catecholamine and mandelic acid were normal. A classic transnasal endoscopic resection was performed. A pale, capsulated, hypovascularised, hard-elastic tumour was detected and resected in a block. A 12 hour postoperative imaging scan was performed with intravenous contrast and the lesion was completely removed. The patient developed diabetes insipidus in the first postoperative days, responding to the administration of desmopressin. There was no evidence of cerebrospinal fluid fistula. He was discharged with a diagnosis of partial diabetes insipidus, with treatment with carbamazepine 100 mg every 12 hours, hydrocortisone 30 mg daily, levotiroxina 150 micrograms daily, with a good response. The pathological anatomy report described a compact fusocellular proliferation, arranged in a stellate pattern with very little interstitial stroma. The cellular elements were spindle-shaped with eosinophilic cytoplasm and slightly uneven nuclei. There was no evidence of mitotic activity, necrosis or residual brain parenchyma. The scarce interstitial stroma was highlighted with CD34 positive vascular elements. The reticular network was preserved. Immunohistochemistry was performed and the patient was positive for vimentin and nuclear transcription factor 1 (TTF1) with a diffuse and intense staining. It was also focal for VCL2 and S100. It was also negative for synaptophysin, EMA, GFAP and STAT6. KI67 6%. The final diagnosis was low-grade fusocellular lesion compatible with pituitary gland tumour.\n",
    "summary": "The case of a 46-year-old man who presented visual field defects and symptoms of panhypopituitarism of 3 years evolution is described. As personal background he presented neurofibromatosis type 1, and his daughter, with the same disease, was operated for cerebral astrocytoma. In the ophthalmologic examination the patient presented bitemporal hemianopsia and the hormonal evaluation confirmed hypopituitarism. The pituitary magnetic resonance evidenced a selar mass with supraselar extension with homogeneous post contrast enhancement, which generated displacement of the optic chiasm. A transnasal transsphenoidal resection was performed. After the surgery, he developed diabetes insipidus. The histopathology showed patterns compatible with pituiticoma confirmed by immunohistochemistry. The total resection continues to be the objective of the treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_472.txt",
    "fulltext": "Patient information: This is Mr. RL, 27 years old, a welder by profession, single, of low socioeconomic level and with no particular medical history.\n\nClinical findings: the patient was confused (Glasgow Coma Scale (GCS) 13/15th), agitated pupils in mydriasis, had tremors with tachypnea and tachycardia, a hyperreflexia associated with spontaneous myoclonies more marked at the level of the lower limbs with a hypersudation and chills.\n\nTimeline: the history of the disease goes back to a week before his consultation with a neurologist in the private sector, by the installation of persecution delusions, denial of filiation, a bizarre behaviour and hallucinatory attitudes and the picture was complicated by psychomotor agitation and an initial diagnosis of an acute psychotic episode was retained and the patient was put on haloperidol 5 mg daily.\n\nTwo months later, the evolution was marked by a bad compliance with the therapy with persistence of the psychotic symptomatology associated with negative symptoms such as loss of pleasure, isolation and abolition with a disturbed sleep, motivating the patient to make another appointment with the same treating doctor who added paroxetine 20 mg per day and amitriptyline 25 mg per day.\n\nSeveral hours (6 to 8 hours) after taking the two antidepressants, the patient presented with a loss of consciousness and psychomotor agitation, which required admission to the intensive care unit.\n\nDiagnostic approach: the patient underwent a complete biochemical evaluation, which showed electrolyte imbalances with metabolic acidosis and creatine phosphokinase (CPK) levels of 100 IU/L. The cytobacteriological examination of urine, the study of cerebrospinal fluid and blood cultures were negative. The plasma concentration of C-reactive protein (CRP) and the blood count were normal.\n\nThe electrocardiogram (ECG) showed an arrhythmia of atrial fibrillation, and the chest radiograph and magnetic resonance imaging (MRI) of the brain were unremarkable. The diagnosis of serotonergic syndrome was made after the infectious, metabolic or neurological etiology was ruled out.\n\nTherapeutic intervention: the patient was placed on mechanical ventilation, gavage 500cc/8H, rehydration with plain water 500cc/8H, basic ration SG 5% + 2g Nacl + 2g Kcl +1g ca 2+ / 8h, and SS 0.9% 500cc/4H, sedation with midazolam 8mg/H, IPP 40mg/j, with an anticoagulant for preventive purposes and insulin according to dextro.\n\nFollow-up and results: the patient's clinical, haemodynamic and neurological condition stabilised after 24 hours, after which he was transferred to the psychiatric department where the treating doctor found a patient who was calm in terms of motor function, well oriented in time and space, who had had a mystical religious and persecution delirium, some inappropriate responses, a disturbed judgement without the presence of a depressive, manic or confused syndrome. The evolution of the psychiatric symptomatology was marked by a good improvement with a good return to the pre-morbid condition, stabilised under atypical neuroleptic type olanzapine with an initial dose of 5 mg per day.\n",
    "summary": "We report the clinical case of a patient who presented a state of confusion with psychomotor agitation and hyperreflexia and spontaneous myoclonus following the concomitant intake of paroxetine and amitriptyline. The diagnosis of serotonergic syndrome was retained after ruling out other possible diagnoses, requiring hospital admission to an intensive care unit.\n"
  },
  {
    "id": "multiclinsum_gs_en_357.txt",
    "fulltext": "An 86-yr-old man was referred for transfemoral aortic valve implantation.\n\nSignificant history included smoking 40 pack-yr (until the late 1980s) and paroxysmal atrial fibrillation requiring Coumadin anticoagulation since 1999, soon followed by the implantation of a ventricular pacemaker because of bradycardia. He was admitted for syncope in May 2011, and a severe calcified aortic stenosis was diagnosed. He was eupneic and showed no sign of heart failure or fluid retention. Transthoracic echocardiography revealed a severe aortic stenosis (mean gradient: 58 mmHg, aortic valve area: 0.4 cm2) with left ventricular hypertrophy, impaired left ventricular ejection fraction (29%), inferoapical akinesia, and subvalvular septal obstruction (septum: 18 mm) with biauricular dilatation and pulmonary hypertension with vena cava dilatation.\n\nCoronary angiogram showed a 75% stenosis of the left anterior descending artery. Echo-Doppler examination found normal neck vessels. Aspirin 80 mg daily was added to his treatment; the patient was scheduled for aortic valve replacement but did not arrive until August, when he was readmitted in emergency for acute dyspnea and confusion. He had gained 6 kg weight, with leg edemas and clinical signs of pleural effusion. At this time, his SpO2 was 92% and B-natriuretic protein was elevated at 2,336 pg·mL−1 (normal < 100 pg·mL−1).\n\nAfter diuretic therapy and removing 850 mL pleural effusion, an emergent aortic percutaneous balloon valvuloplasty (Cristal Balloon, 23 mm) was performed and was immediately followed by left anterior descending balloon angioplasty with bare-metal stent implantation (Biotronik-Pro-Kinetic 2.74 × 10.0). Transvalvular mean gradient decreased from 59 to 38 mmHg. A few runs of torsades de pointe were observed on day 6 postintervention, disappearing when the lower rate of the pacemaker was accelerated to 80 beats/min. His condition improved dramatically, and he was discharged on furosemide, aldactazine, and clopidogrel. After careful review of the patient’s file by the heart team, the risk of a valve surgery was judged too high (logistic Euroscore: 51%), and the patient was proposed for a transfemoral aortic valve implantation.\n\nNurses’ notes mention nocturnal hyperventilation and anxiety crises. The patient was semiautonomous and lived with his daughter.\n\nTransfemoral aortic valve implantation was scheduled in October 2011. On admission, 2 days before the procedure, the patient was described “anxious and hyperventilating”; his weight was 67 kg for 168 cm height; forced expiratory volume in 1 s (FEV1) was 1.1 L (50% of predicted) and forced vital capacity 1.7 L (55%); systemic arterial blood pressure was 120/60 mmHg; hemoglobin concentration was 167 g·L−1; creatinine was 12.7 g·L−1; glomerular filtration rate was calculated at 54 mL.min−1·m−2; potassium was 3.7 mEq·L−1; sodium was 141 mEq·L−1; bicarbonate was 22 mEq·L−1; and B-natriuretic protein was 2,073 pg·mL−1. Echography described an aortic valve surface area of 0.5 cm2 with a mean aortic gradient 55 mmHg and inferoapical akinesia in the left ventricle. Ejection fraction was measured at 27% by Simpson biplane method with moderate mitral regurgitation with biauricular dilation and estimated the systolic pulmonary pressure at >69 mmHg. Chest X-ray showed no significant pleural effusion. The patient was totally pacemaker dependent.\n\nTwo hours before intervention, the patient received 1 g acetaminophen by mouth. On arrival in the operating room, the patient, fully conscious, was noted to have periodic Cheyne–Stokes respiration; each cycle lasted ~85 s, with apneas lasting between 15 and 20 s with large SpO2 oscillations between 88% and 99%. He was equipped with two peripheral intravenous catheters and one arterial catheter. The arterial tracing also showed also 85 s oscillations and systolic pressure varying from 130 to 150 mmHg. A nonocclusive Venturi facial 40% oxygen mask was applied, and SpO2 reached a more stable range (92%-99%). Ten minutes later, blood gas analyses showed pH 7.39, Pao2 108 mmHg, Paco2 40 mmHg, SaO2 97%, and lactate levels 1.2 mEq·L−1. A capnograph sampling line was installed inside the face mask to monitor respiratory frequency (Carescape Monitor B650, GE Healthcare, Helsinki, Finland). Monitoring also included a 12-lead ECG, pulse-oximetry, and regional cerebral oximetry (rSO2) by frontal near-infrared spectroscopy (INVOS, Somanetics). Capnography revealed that arterial pressure oscillations were synchronous with the rhythm of respiration and pressure decreasing during apneic-hypopneic spells and increasing during hyperventilation; rSO2 followed the same pattern, despite finger SpO2 remaining at a constant 99%. A very low-dose propofol infusion was started with a target concentration of 0.2 µg·mL−1; sufentanil 2.5 µg was given before operators infiltrated each groin with 200 mg mepivacaine; the patient dozed off but remained arousable at the slightest contact of his face or when his name was whispered to his ears; another 2.5 µg sufentanil was given before femoral artery dilatation, a procedure required before the valve replacement. Ventilation cycles slowed to a maximum of 120 s with 24 s central apneas. When angiography and operating catheters were in place in the ascending aorta and a temporary pacemaker lead was introduced in the right ventricle, rapid pacing was induced at a rate of 200 beats/min to allow a new balloon-dilatation of the calcified valve. This procedure lasted <25 s, during which the patient remained conscious and continued to breathe in his usual fashion, the pacing having been induced just after the end of an apneic spell. A 26-mm valve (SAPIEN, Edwards Lifesciences) was then prepared and introduced into the aortic orifice. A signal was given to the operators once breathing resumed at the end of an apneic period, rapid ventricular pacing was started leading to asystole at a mean arterial pressure of 45 mmHg, and the valve was balloon expanded, and angiography confirmed the absence of paravalvular leak. The balloon was deflated just before rapid pacing was stopped, and the heart resumed beating at 80 beats/min under the stimulation of the implanted pacemaker. The whole sequence was filmed; it lasted 31 s, during which the patient kept breathing regularly (8 times during circulatory arrest, i.e., a rate of 16 times per minute) and did not wake up. Blood ejections resumed immediately after balloon deflation, with a systolic pressure of 80 mmHg. After a few deep breaths, respiration became regular; no further apneic spells occurred nor blood pressure or rSO2 oscillations. Systemic hypertension developed rapidly, culminating after 1 min at 190 mmHg and controlled with 40 mg of intravenous urapidil given over the next 15 min. Transthoracic echography measured the valvular area at 1.6 cm2 and peak transvalvular gradient at 15 mmHg. Pulmonary artery pressure estimation by transthoracic echography showed a peak systolic right ventricular-right atrial pressure gradient of 69 mmHg 1 day before the procedure and 45 mmHg 2 days after. One month later, it was 28 mmHg. Further evolution was uneventful, and the patient was discharged home 72 h later without having reverted to periodic breathing.",
    "summary": "A 86-yr-old man was referred for transfemoral aortic valve implantation. Transthoracic echocardiography revealed a severe stenosis (mean gradient: 58 mmHg, aortic valve area: 0.4 cm2), and after multidisciplinary discussion, the risk of surgery was judged too high (logistic Euroscore: 51%), and the patient was proposed for a transfemoral aortic valve implantation (TAVI). On arrival in the operating room, the patient, fully conscious, was noted to have Cheyne–Stokes breathing (CSB), which persisted after 40% oxygen administration. TAVI procedure was successful, and the CSB pattern was interrupted within 8 s."
  },
  {
    "id": "multiclinsum_gs_en_394.txt",
    "fulltext": "A 50-year-old male patient with a known medical history of diabetes mellitus (DM) and hypertension (HTN), managed irregularly, presented to our hospital in Sana’a City, Yemen, on 25 May 2022, at 5:30 pm. The patient was referred to another hospital and reported severe abdominal pain that lasted for one week before admission. The pain was localized in the epigastric region, of sudden onset, progressively worsening, and radiating to the back. In addition, the patient experienced generalized abdominal distension, nausea, vomiting, and significant fatigue. A history of melena and food-related vomiting was also reported over the past month. Two days before admission, the patient had received a blood transfusion of 2 units. There was no history of previous surgeries or a family history of malignancy.\n\nUpon examination, the patient was conscious and alert but exhibited severe pallor. Blood pressure was recorded as 90/60 mmHg and the pulse rate was 120 beats per minute. Generalized abdominal distension, particularly prominent in the supraumbilical region with downward displacement of the umbilicus, was observed. Mild tenderness was present in the epigastric area, along with positive bowel sounds, digital rectal examination revealed a normal anal sphincter tone and no palpable mass.\n\nHematological and biochemical investigations revealed hypochromic microcytic anemia with a hemoglobin level of 6 g/dL (normal range: 12–15.5 g/dL), a white blood cell count of 16,000 (normal range: 4–10,000), and a platelet count of 303. The blood urea nitrogen level was 7 mg/dL (normal range: 10–20 mg/dL), creatinine was 0.49 mg/dL (normal range: 0.7–1.5% / dL), the international normalized ratio was 1.34 (normal range: 0.62–1.3), the prothrombin time (PT) was 16.9, the partial thromboplastin time (PTT) was 30, calcium was 8.0 mg/dL (normal range: 8.5–10.1 mg / dL) and lactic acid was 1.9 mmol/L (normal range: 0.5–2.2% / L). Liver enzymes and amylase levels were within normal limits.\n\nDiagnostic imaging studies were conducted, including erect chest radiograph and abdominal ultrasound. The chest radiograph did not reveal any subdiaphragmatic air, but an elevation was observed in the left diaphragm. Abdominal ultrasound demonstrated the presence of an intra-abdominal fluid collection. Subsequently, an abdominal CT angiography was performed, which revealed a hematoma measuring approximately 14.3×8.8 cm in the paraumbilical region. Within the hematoma, a 3.4×2.2 cm arterial aneurysm was identified connected to the gastroduodenal artery, accompanied by surrounding edematous changes. These findings were suggestive of a large, thrombosed aneurysm in the gastroduodenal artery. Furthermore, eventration of the left diaphragm, which contains the spleen and part of the stomach, was observed, along with mild to moderate intraperitoneal fluid collection. No evidence of an aortic aneurysm was detected.\n\nTo stabilize the patient, resuscitation was initiated with 1000 ml of Ringer lactate and three units of fresh blood were transfused. Informed consent for the high-risk intervention was obtained and the patient was immediately taken to the operating room. Under general anesthesia, in the supine position and with strict adhesion to aseptic techniques, a midline laparotomy incision was made. When the peritoneum was opened, approximately 2000 ml of blood was evacuated, revealing an occluded, pulsating mass in the duodenum. Adequate exposure was achieved using a self-reinforcement retractor. The flexure of the liver and the transverse colon were mobilized inferiorly from the head of the pancreas and clotted blood was removed from the lesser momentum. Meticulous dissection was performed over the large pulsatile occluded aneurysm in the gastroduodenal artery by opening the gastrohepatic ligament. Mobilization of the pylorus and duodenum away from the head of the pancreas exposed a fistula that connected the duodenum and the aneurysm, without digestive content. Following heparinization, proximal and distal clamping of the gastroduodenal artery was performed. Subsequently, the pseudoaneurysm was opened and a significant amount of thrombus was evacuated. Aneurysmorrhaphy was performed using proline 7.0 sutures. The perforation in the first part of the duodenum was repaired in two layers and a nasogastric tube (NGT) was inserted beyond the perforation. Thorough irrigation with normal saline and meticulous hemostasis were achieved. An abdominal drain was placed, and the abdominal incision was closed in layers. The patient was then transferred to the intensive care unit (ICU) for close monitoring and observation.\n\nDuring the postoperative period, the abdominal drain collected approximately 100 ml of serous fluid, which was removed the third day after the operation. The patient’s recovery progressed without complications. After ten days after surgery, the patient was discharged home in favorable condition. Follow-up appointments were scheduled in the outpatient department and regular communication was maintained by telephone, with the patient’s condition reported as satisfactory.",
    "summary": "A 50-year-old male presented with severe abdominal pain, anemia, and signs of hemodynamic instability. Diagnostic imaging including CTA revealed a large, thrombosed gastroduodenal artery aneurysm with evidence of rupture. The patient underwent open surgical exploration and repair to address both the aneurysm and the duodenal perforation. The patient’s recovery was satisfactory and was discharged home in stable condition."
  },
  {
    "id": "multiclinsum_gs_en_398.txt",
    "fulltext": "We present a case of 2-year-old white girl with chronic crackles admitted to our Pediatric and Allergy Clinic. The pregnancy was unremarkable and after birth the child was healthy until the seventh month of life, when she developed RSV infection. From then on she had a LRTI every month treated with antibiotics, mainly macrolides for presumed bacterial pneumonia; symptoms persisted daily. She had been under the care of pulmonologists from a different department, who suspected childhood interstitial lung disease (chILD) and prescribed systemic and inhaled steroids, short-acting β2-mimetics, and antileukotriene. This treatment, however, did not lead to any clinical improvement; symptoms of crackles were present at all times. She was hospitalized eight times due to exacerbation of symptoms such as dyspnea, cough, and persistent crackles during physical examination. At the age of 11 months she had high resolution computed tomography (HRCT) which revealed lung areas of uneven aeration in the middle lobe of her right lung and small areas of densities which indicated postinflammatory changes. Due to suspected Pneumocystis jirovecii (carinii) infection, she was unsuccessfully treated with sulfamethoxazole and trimethoprim.\n\nShe was admitted to our clinic at 23 months of age with intense cough, dyspnea, and chronic crackles. A chest X-ray showed areas of density due to parenchymal and interstitial inflammatory changes. Autoimmune disease and atypical inflammatory infections (Mycoplasma pneumoniae, Chlamydia pneumoniae, and Bordetella pertussis) were excluded by use of a multiplex assay; immunodeficiency was also excluded. An echocardiogram revealed no abnormalities. Next, she was referred to the Pneumonology and Cystic Fibrosis Department in Rabka for bronchoscopy with bronchoalveolar lavage (BAL). The result showed: copious purulent secretions in her lower throat; mucosal edema of the larynx, trachea, and bronchial tree; and retention of the purulent mucus in bronchi with normal movement of bronchial cilia (high frequency video microscopy). Microbiological testing with growth on blood/chocolate agar isolated high colony count of Moraxella catarrhalis in the BAL fluid. It was beta-lactamase producer sensitive to amoxicillin-clavulanate. The BAL also showed epithelial cells, macrophages, and neutrophils under high power field. She was administered amoxicillin-clavulanate for 14 days with good clinical improvement in respiratory rate, labored breathing, and cough and she was discharged. She was observed for 2 months after discharge from the hospital and showed no signs of recurrence. Then, she had a few more respiratory tract infections (usually every other month) treated with antibiotics (crackles were present at each time during infection); between infections she remained healthy, without any crackles or wheezing.",
    "summary": "A 2-year-old white girl presented to our Pediatric Allergy Clinic with recurrent crackles in addition to cough, fevers, and labored breathing since her first respiratory syncytial virus infection at the age of 7 months. She had been under the care of pulmonologists, who suspected childhood interstitial lung disease. She was hospitalized eight times due to exacerbation of symptoms and prescribed systemic and inhaled steroids, short-acting β2-mimetics, and antileukotriene. There was no short-term clinical improvement at that time between hospitalizations.\n\nDuring her hospital stay at the Pneumonology and Cystic Fibrosis Department in Rabka a bronchoscopy with bronchoalveolar lavage was performed. Laboratory bacteriological tests found high colony count of Moraxella catarrhalis (β-lactamase positive), sensitive to amoxicillin-clavulanate, in bronchial secretions and swabs from her nose. After this, infections were treated with antibiotics; she remained in good condition without symptoms. Crackles and wheezing recurred only during symptoms of infections. Therefore, we hypothesize that respiratory syncytial virus infection at an early age might cause severe damage of the lung epithelium and prolonged clinical symptoms, mainly crackles and wheezing, each time the child has a respiratory infection."
  },
  {
    "id": "multiclinsum_gs_en_388.txt",
    "fulltext": "72-year-old man with a history of type 2 diabetes mellitus, benign prostatic hyperplasia, who was admitted to the ICU for dengue (NS1 antigen positive), with severe thrombocytopenia (platelets 15,000/mm3) and signs of dehydration. He was given 500 ml of physiological solution in one hour, then he reported respiratory discomfort. He was auscultated with bibasilar pulmonary wheezing. A pulmonary ultrasound was performed, where bilateral B lines were observed with a B7 pattern compatible with interstitial syndrome and pulmonary oedema. Blood and urine cultures were taken, where Klebsiella pneumoniae was found in the latter. He began treatment with ceftriaxone. A transthoracic ultrasound was performed, where basal hyperkinesia, medial and apical hypokinesia with a picture compatible with apical ballooning was observed. The ECG showed a complete right bundle branch block. Chagas serology was negative. Quantitative troponin I: 1243 ng/L (normal value up to 25 ng/L). Takotsubo syndrome was suspected versus coronary artery disease, an interconsultation with cardiology was performed, which suggested not to perform CCG for the time being due to thrombocytopenia and haemodynamic instability. He began treatment with intravenous furosemide and carvedilol. The patient evolved favourably with normalisation of platelet count and the control echocardiogram showed an improvement in the motility of the middle and apical segments. In the follow-up outpatient appointment after discharge, the motility was normalised in the echocardiogram. The patient signed the informed consent for publication.\n",
    "summary": "A 72-year-old man admitted to the ICU for dengue with platelet count of 15,000 cells/mm3 and dehydration was presented. After fluid administration, he reported respiratory discomfort and wheezy breathing. A pulmonary ultrasound was performed and bilateral B lines with a B7 pattern compatible with interstitial syndrome and pulmonary edema were observed. A transthoracic echocardiogram showed basal hyperkinesia, medial and apical hypokinesia with a picture compatible with apical ballooning. A right bundle branch block was detected on the electrocardiogram. Chagas serology was negative and a quantitative troponin I was detected with increased levels. Takotsubo syndrome was diagnosed in the context of severe dengue. The patient recovered well. After discharge, cardiac motility was normalized in the ultrasound images.\n"
  },
  {
    "id": "multiclinsum_gs_en_457.txt",
    "fulltext": "A Venezuelan male, 62 years of age. Medical history included diabetes mellitus type 2, arterial hypertension, and chronic heart failure of possible ischemic necrotic etiology, with his usual medication of enalapril, bisoprolol, and metformin. His left leg had been amputated due to peripheral arterial vascular disease. He presented to the emergency department for persistent hiccups for five days, which began suddenly, was constant in its evolution, and did not affect his daily activities. At 48 hours of the onset of hiccups, the patient began to have a progressive dry cough. At 96 hours from the onset of hiccups, he experienced asthenia and, the next day, developed a sudden dyspnea of functional class II according to the New York Heart Association classification, which led to the corresponding consultation. On physical examination, he was lucid and had stable hemodynamic. On respiratory examination, he had an elastic chest without alterations in percussion and good bilateral air entry. He used the intercostal musculature minimally, especially when the hiccups were accentuated. On auscultation, there were isolated crepitant rales with predominance of the left side. His vital signs were as follows: axillary temperature 36.7 °C, respiratory rate of 20 cycles/minute, heart rate of 80 beats/minute, blood pressure of 130/80 mmHg, and oxygen saturation measured by oximetry of 94%. The chest X-ray showed cardiomegaly, without significant lesions in pulmonary fields. No radioscopy was performed. A nasopharyngeal swab was taken for diagnosis of SARS-CoV-2 infection (search for antigen by immunochromatography), which was positive. The values of the complementary laboratory studies were as follows: Ht 34%, Hb 12.3 g/dl, leukocytes 5300/mm3 (84% neutrophils), platelets 252000/mm3, blood glucose 186 mg/dl, urea 68 mg/dl, creatinine 1.22 mg/dl, aspartate aminotransferase 27 IU/l, alanine aminotransferase 13 IU/l, total bilirubin 0.65 mg/dl, sodium 131 mmol/l, potassium 5 mmol/l, chloride 96 mmol/l, CK total 236 IU/l, CK MB 23 IU/l, LDH 872 IU/l, ferritin 1750 ng/ml, C reactive protein 9 mg/l, dimer D 2225 ng/ml, and ProBNP 12215 pg/ml (normal value 50-75 years: 900 pg/ml). The oxygenation of the blood gas showed the following results: pH: 7.318, pCO2: 46.8 mmHg, pO2: 74 mmHg, HCO3: 23.5 mmol/l, and EB -2.7. The electrocardiogram showed pathological Q waves in the anterior face.\n\nThe clinical severity scale CURB-65 was 1. He was admitted to the general ward. The treatment was started with antibiotics (clarithromycin and sulbactam ampicillin, which were discontinued immediately), unfractionated heparin in a daily subcutaneous dose of 5000 IU every 12 hours, as antithrombotic prophylaxis, nasal cannula oxygen therapy (5 liters/minute, 40% FiO2) and adjustment of the hydration to treat mild hyponatraemia. The symptomatic treatment of hiccups was performed with metoclopramide (dopaminergic antagonist), at a daily intravenous dose of 10 mg every 8 hours, showing a partial improvement. The patient evolved with symptomatic improvement, requiring correction of glycaemia with normal insulin. The hiccups subsided gradually and disappeared around the sixth day of admission. The results of the control studies were as follows: Ht 36%, Hb 12.1 g/dl, leukocytes 9100/mm3 (70% neutrophils), glycaemia 179 mg/dl, urea 51 mg/dl, creatinine 1.08 mg/dl, aspartate aminotransferase 18 IU/l, alanine aminotransferase 16 IU/l, total bilirubin 0.3 mg/dl, sodium 136 mmol/l, potassium 5.6 mmol/l, chloride 101 mmol/l. It was decided to discharge the patient 14 days after admission. During the ambulatory follow-up, the absence of the symptoms presented previously was maintained.\n",
    "summary": "A 62-year-old man with a history of hypertension, diabetes and heart failure was described as having persistent hiccups as the first symptom of COVID-19, followed by respiratory symptoms. After the diagnosis of SARS-CoV-2 infection was made, the patient was hospitalized and received the corresponding treatment. The hiccups partially improved with the use of anti-dopaminergic drugs (metoclopramide) and disappeared on the sixth day of hospitalization. Correction of glycemia with current insulin was required. He had a favorable evolution and was discharged after 14 days of hospitalization.\n"
  },
  {
    "id": "multiclinsum_gs_en_392.txt",
    "fulltext": "A 23-year-old female presented to the emergency department with loss of consciousness and excess oral secretions 2 hours after ingestion of an unspecified poison. She had no abnormal body movement, fever, diarrhea, vomiting, or sweating. She had been initially been taken to a nearby primary hospital, where she was treated for possible OP poisoning with atropine and cimetidine for 3 days, before she was transferred to Saint Peter’s hospital. After thorough questioning, it was found that the patient had consumed about 30 mL of 2,4-D in a suicide attempt, precipitated by financial problems. She did not have any known history of psychiatric illness, suicidal attempts, depressive episodes, or substance abuse. No prior cardiac, renal, or metabolic disorders were noted.\n\nOn arrival at the emergency department, the patient was unconscious. Her vitals were PR 110/min, BP 120/70 mmHg, RR 21/min, and SPO2 96% on room air. Physical examination results were remarkable: a GCS of 6 out of 15, dilated and reactive pupils, hypertonic and hyperreflexic lower extremities, and upgoing plantar reflex. Upon initial investigation, complete blood-cell count, renal function test, liver-function test, and random blood glucose were normal. Her electrocardiogram showed sinus tachycardia, while chest X-ray was unremarkable. Arterial blood-gas analysis and serum level of the toxin could not be determined, as neither means of testing was available at the hospital.\n\nThe patient was transferred to the intensive care unit (ICU), intubated for airway protection, and started immediately on forced alkaline diuresis. Her ICU course was remarkable for the development of renal failure (creatinine 3.1 mL/dL [reference range 0.5–1.2 mg/dL], BUN 133 mg/dL [reference range 16.6–48.5 mg/dL], urinalysis 3+ hemoglobin, and many red blood cells), due to toxin-induced rhabdomyolysis (creatine phosphokinase level of 1,330 µg/L). Subsequently, the patient became hypotensive, and vasopressor support was started. Echocardiography and abdominal ultrasonography were both unremarkable. Despite these efforts, she died of circulatory collapse on the third ICU day.",
    "summary": "We herein report a case of a young female farmer from rural Ethiopia who was admitted to a local hospital after presenting with loss of consciousness and excess oral secretions 2 hours after a suicidal ingestion of an unknown toxic agent. She was originally treated for organophosphate poisoning, and then transferred to Saint Peter's Hospital in Addis Ababa for more intensive care. There, ingestion of 2,4-D was confirmed, and she received supportive care, mechanical ventilation, and forced alkaline diuresis. Despite these interventions, she died several days later."
  },
  {
    "id": "multiclinsum_gs_en_348.txt",
    "fulltext": "Thirty years-old Para two Gravida three gestational ages of 39 weeks and 4-day pregnant mother currently presents with chronic rheumatic heart disease, severe mitral regurgitation, moderate pulmonary hypertension, severe left atrial dilatation, mild aortic regurgitation, and mild tricuspid regurgitation scheduled for elective caesarean section. She had one previous caesarean section four years ago with an indication of fetal macrosomia. Her cardiac condition, however, was moderate mitral regurgitation, mild left atrial dilatation, mild pulmonary hypertension, and no tricuspid or aortic regurgitation. The patient had continuous follow-up after diagnosis until now but has not taken any medication since 8 years ago.\n\nOn the preoperative assessment, the mothers had shortness of breath during exercise, exercise intolerance after 1 year, an intermittent productive cough, and a history of anaesthesia. Otherwise, she had no history of hypertension, diabetes mellitus, asthma, or a central nervous system disorder. Her vital signs were 110/70 mmHg non-invasive blood pressure, 90 beats per minute heart rate, 20 breaths per minute respiratory rate, and 36.7 °C temperature. On her entire preoperative follow-up, her blood pressure was in the lower border and maximum of 110/70 and the remaining blood pressure was less than this value. She appeared healthy, with adequate mouth opening and Mallampati class 1. Her atlantoccipital and temporomandibular joints were functional, had no tenderness, could move freely in all directions, and could bite her upper lip without difficulty. The spine examination was normal. Graham Steele heard a murmur in the left upper lobe during chest auscultation, and the third heart sound (a holosystolic (pansystolic) murmur) was heard at the apex via the diaphragm of the stethoscope in the left lateral decubitus position.\n\nThe patient’s CBC was 12.8 g/dl, Hct was 38%, and Plt was 176 x 103/l, according to the laboratory results. WBC was 6.3 x 103/l, RBC was 4.36 x 106/l, BG-O +ve organ function test Cr 0.4 mg/dl, SGPT 13.6 u/l, SGOT 20.5 u/l, and electrolytes were normal. ECG results showed a left atrial abnormality. Echocardiography presented chronic rheumatic heart disease: severe left atrial dilatation (68 mm), severe mitral regurgitation, mild aortic regurgitation, mild tricuspid regurgitation, moderate pulmonary hypertension, and an ejection fraction of 65%.\n\nWhen the patient had been fully informed of the advantages and disadvantages of anaesthesia and surgery, she accepted her ASA Class III status before having her formal informed consent obtained. She transferred to the operating room after obtaining bilateral large-bore IV access. Apart for capnography, the patient was being monitored per usual procedure.\n\nThe patient’s vital signs at baseline were 102/61 mmHg BP, 90 bpm HR, 36.5 oC Toc from axilla, and 97% oxygen saturation. We intend to administer lower-dose local anaesthesia with opioid spinal anaesthesia along with trans-abdominal (TAP) block because we are a developing nation and do not currently have an epidural anaesthesia kit or an IV anaesthesia agent on hand to maintain the anaesthesia goal for mitral regurgitation and moderate pulmonary hypertension.\n\nAfter assessing the location of the needle insertion and performing local infiltration with 2% plain lidocaine while seated, spinal anaesthesia was administered using a rigorously aseptic procedure. After a free flow of CSF and negative blood aspiration, 7.5 mg of heavy bupivacaine + 0.1 mg of morphine were administered via a 24G spinal needle as spinal anaesthesia between the L4 and L5 interspaces. The patient was placed in the supine position, and before making the skin incision, a TAP block with a 0.125% solution (40 mL of bupivacaine) was administered bilaterally. The level of T6 was reached with the spinal blockade. 2 L/min of supplemental oxygen was given through a nasal catheter immediately after spinal anesthesia and supine position.\n\nSurgery started after 15 minutes of spinal anesthesia. Following the delivery of the baby, 10 IU of oxytocin IM were administered as uterogenic drugs. The uterus was remained relaxed after 10 IU of oxytocin, therefore the gynaecologist requested more oxytocin, but the patient’s blood pressure was borderline low. Misoprostol 600 mg sublingually was used to prevent hypotension brought on by oxytocin and to promote uterine contraction. Furosemide was given intraoperatively to prevent further exacerbation of pulmonary hypertension.11 In the first five minutes of delivery, the neonatal Apgar score was 9–10/10. It took 45 minutes to complete the procedure.\n\nTotal amounts of fluid, blood loss, and urine output were 1500 mL, 400 mL, and 300 mL, respectively. Throughout, we have not encountered any complications associated with spinal anaesthesia. The intraoperative time was mostly uneventful with the exception of a slight tachycardia relative to her baseline heart rate for the first 4 minute.\n\nPost operatively; SpO2, NIBP, and ECG monitoring were used in the post-anesthesia care unit (PACU), along with oxygen supplementation delivered through a nasal catheter. She remained stable throughout the entire postoperative period. After spending an hour in the PACU, she was moved to the gynecology/obstetrics ward. Her initial analgesic need was not met until 18 hours later, when she received 50 mg of pethidine IV. She had a smooth hospital stay and was released after four days.",
    "summary": "A 30-year-old Para two Gravid three pregnant mother presented with chronic rheumatic heart disease, severe mitral regurgitation, moderate pulmonary hypertension, severe left atrial dilatation, mild aortic regurgitation, and mild tricuspid regurgitation scheduled for elective cesarean section. She had one previous cesarean section four years ago with an indication of fetal macrosomia. Her cardiac condition, however, was moderate mitral regurgitation, mild left atrial dilatation, mild pulmonary hypertension, and no tricuspid or aortic regurgitation. She had continuous follow-ups after diagnosis until now but has not taken any medication."
  },
  {
    "id": "multiclinsum_gs_en_568.txt",
    "fulltext": "18-year-old male patient with a clinical diagnosis of neurofibromatosis type 1 since the first year of life. His background includes a complete education, his parents are not consanguineous, and he has no family history of café au lait spots. From a neurological point of view, he developed a delay in fine and gross motor development, an expressive language disorder with phonological and semantic alteration of language during childhood, for which he was treated with speech therapy in a language school, as well as physical therapy and occupational therapy during childhood. During adolescence, he was diagnosed with attention deficit disorder and hyperactivity, which was treated with methylphenidate, maintaining regular school performance. He had normal pubertal development. Ophthalmologically, he presented Lisch nodules from the age of 4, euriblepharon and astigmatism. He was monitored annually in ophthalmology and neuropediatrics. His last brain MRI was performed 6 months prior to the dermatology consultation, with no pathological findings, and in the spinal MRI, L5-S1 discopathy and peripheral enhancement in T11-T12 and T12-L1 were evident. At 16 years of age, a genetic study was performed that demonstrated deletion of exons 5-47 of the NF1 gene.\n\nAt 18 years of age, he consulted the Dermatology service of the Reference Health Center of Peñalolén Cordillera Oriente for the appearance of a new spot on his left thigh that had been there for a year, asymptomatic. He also reported the appearance of nodules on his right wrist, his right hand and scalp, that had been there for a few months, asymptomatic.\n\nThe physical examination revealed normal blood pressure, macrocephaly (head circumference 60 cm), and multiple generalized café au lait spots, ephelides in axillae, and right supraciliary, occipital, and right wrist oval subcutaneous nodules 0.5 cm in size, well-demarcated, mobile. In the left lateral thigh, there was a plaque 25 mm in size, somewhat pink, with loss of appendages, and soft consistency. Finally, in the lumbar and pectoral region, there were multiple small red-blue macules, less than 5 mm each, some slightly depressed.\n\nSkin biopsy of blue patches on the chest and thigh plaque were performed, both compatible with NF. An ultrasound of supraciliary and occipital nodules was performed, which was compatible with subcutaneous nodular NF.\n\nUsing the clinical classification of García-Martínez et al.1 the patient was diagnosed with superficial subcutaneous nodular NF in the right supraciliary, occipital and right wrist, superficial cutaneous pseudoatrophic NF in the lateral left thigh and superficial cutaneous red blue NF in the lumbar and pectoral areas.\n",
    "summary": "18-year-old male patient with a diagnosis of NF-1 since childhood who presented with multiple oval nodules on the face, occipital region and wrist, red-blue macules on the back and a pink atrophic plaque on the thigh. The ultrasound study of the nodules was compatible with neurofibromas and the histopathological study of the lesions on the back and thigh was compatible with cutaneous neurofibromas.\n"
  },
  {
    "id": "multiclinsum_gs_en_159.txt",
    "fulltext": "12-month-old male who presented to the paediatric neurology outpatient department due to developmental delay. He was a term newborn with an uncomplicated pregnancy, with healthy non-consanguineous parents and two healthy older siblings. He had a history of two lower respiratory viral infections since 6 months of age with two hospital admissions, without the need for ventilatory support, and was followed in the paediatric neurology outpatient department for recurrent wheezing. On physical examination, he presented with brachycephaly, mild hypotonia, normal tendon reflexes, and bilateral syndactyly of 2-3 fingers. His head circumference was between the 85th and 97th percentiles. His height and weight were above the 97th percentile. He did not have ptosis or ophthalmoplegia. At 12 months, he was able to sit without support but was unable to reach the sitting position. He appeared to understand simple commands but was unable to vocalize. The parents were also concerned about feeding; although they reported no problems with liquids, they reported apparent difficulty with chewing. Speech therapy, occupational therapy and physiotherapy were initiated with significant improvement. From birth to 4 years of age, he had slow but positive psychomotor development. He began walking independently at 18 months, while expressive language was significantly delayed with words starting at 3 years and sentences at 4 years. Social skills were always preserved; however, communication was affected. Developmental evaluation revealed a global developmental delay (global developmental delay 70) and a sensory processing disorder. He had no respiratory problems since 3 years and 6 months of age. Cardiological evaluation revealed no structural cardiac abnormalities. ENT examinations, including auditory evoked potentials, were normal. A brain MRI at 2 years of age revealed brachycephaly, normal brain parenchyma, myelination adequate for age, enlargement of the subarachnoid spaces in the frontal-parietal brain with reduction of the parenchymal volume, a wide posterior fossa with slight rotation of the vermis in the anti-clockwise direction, and an arachnoid cyst that compressed the left hemisphere of the cerebellum. A comparative genomic hybridisation array showed no relevant variants and metabolic testing was normal. Exome clinical sequencing identified the hemizygous c.722G>A p.(Arg241His) variant in exon 9 of the MTM1 gene (NM_000252.2) associated with myotubular myopathy. This variant was classified as probably pathogenic according to the American College of Medical Genetics and Genomics variant classification guidelines and, to the best of our knowledge, has never been reported before. The muscle biopsy revealed atrophic myofibres, some rounded myofibres with nuclei located internally and, although infrequent, localised central staining with oxidative stains, some with central nucleation, commonly associated with MTM1 gene myopathies. Genetic testing in the mother showed that she was a heterozygous carrier of the same MTM1 gene variant, which is not unexpected as only 10-20% of patients are de novo mutation carriers. In addition, we found that he had mild neuromuscular symptoms since young that were previously not appreciated.\n",
    "summary": "We report a 4-year-old boy with mild muscular hypotonia at 12 months, expressive language disorder, global developmental delay, and sensory processing disorder. Clinical exome sequencing identified the hemizygous c.722G>A p.(Arg241His) variant in exon 9 of the myotubularin 1 gene (NM_000252.2). The mother is a heterozygous carrier of the same variant. The diagnosis of a mild form of maternal X-linked myotubular myopathy was established. The boy had a significant improvement with speech, occupational, and physical therapies, without respiratory intercurrences or ventilator dependency.\n"
  },
  {
    "id": "multiclinsum_gs_en_155.txt",
    "fulltext": "A 62-year-old Thai woman presented with sudden bilateral visual loss and headache for 5 days. She denied a history of head trauma. Her medical history was significant for poorly controlled hypertension.\n\nVital signs were normal except for blood pressure of 200/105 mmHg. Visual acuity was no light perception (NLP) with fixed pupils in both eyes. The ocular motility of both eyes was limited in all directions. Both eyelids were difficult to open. Hertel exophthalmometer measurements were 16 mm in the right eye and 14 mm in the left eye. There were significant chemosis and episcleral corkscrew vessels in both eyes. Both corneas showed mild, diffuse stromal edema without any infiltration. The anterior chambers were deep and quiet in both eyes. Intraocular pressures were 45 mmHg and 48 mmHg in the right and left eyes, respectively. Gonioscopy revealed blood in Schlemm’s canal at the nasal angle of the right eye. Fundus examination showed slightly dilated and tortuous retinal veins with normal-appearing optic discs in both eyes. The cup-to-disc ratio was 0.3 bilaterally. Optical coherence tomography demonstrated normal thickness of the macula in each eye. There was no audible bruit. Other neurological examinations were unremarkable.\n\nMagnetic resonance imaging (MRI) with gadolinium of the brain and orbits demonstrated dilation of the bilateral superior ophthalmic veins (SOVs) and a marked degree of orbital and periorbital congestion bilaterally. However, neither compression nor stretching of the bilateral optic nerves was observed. Interestingly, diffusion restriction, with corresponding reduction of the apparent diffusion coefficient (ADC), in the entire orbital segment of the optic nerves bilaterally was revealed on diffusion-weighted imaging (DWI). That is consistent with bilateral PION. Magnetic resonance angiography (MRA) of the brain and orbits revealed arterialization of the bilateral cavernous sinuses and SOVs.\n\nCerebral angiography confirmed the diagnosis of bilateral anterior-drainage dural CCFs. The right dural CCF was fed by the dural branches of the ICA (right meningohypophyseal trunk). The left dural CCF was fed by the dural branches of the ECA (left-middle meningeal artery and the left artery of the foramen rotundum and the dural branches of the ICA (left meningohypophyseal trunk). Each side of the dural CCF contributed arterial blood flow into the bilateral SOVs (contralateral SOV through inter-cavernous communication). No cortical venous reflux of arterial blood flow was noted. Based on these findings, transvenous coil embolization was performed. The bilateral cavernous sinuses were embolized using coils to occlude the feeding vessels from the dural branches of both the ICA and ECA. Immediate post-embolization cerebral angiography showed complete closure of the fistulas.\n\nThree months after embolization, ophthalmic examination demonstrated progressive improvement of the aforementioned ophthalmic signs; however, the patient’s visual acuities remained NLP in both eyes.",
    "summary": "We report on a 62-year-old woman with a history of poorly controlled hypertension who presented with sudden bilateral visual loss and headache for 5 days. She denied a history of head trauma. On examination, her visual acuities were no light perception (NLP) with fixed pupils in both eyes. The ocular motility of both eyes was limited in all directions. Both eyelids were difficult to open. Anterior segment examination revealed bilateral chemosis and episcleral corkscrew vessels. Intraocular pressures were 45 and 48 mmHg in her right and left eyes, respectively. Gonioscopy revealed blood in Schlemm's canal at the nasal angle of the right eye. Fundus examination showed slightly dilated and tortuous retinal veins with normal-appearing optic discs in both eyes. The cup-to-disc ratios were 0.3 bilaterally. Other neurological examinations were unremarkable. Magnetic resonance imaging demonstrated dilation of the bilateral superior ophthalmic veins (SOVs), and marked orbital and periorbital congestion bilaterally. However, there was no compression or stretching of the bilateral optic nerves. Diffusion restriction on diffusion-weighted imaging, with corresponding reduced apparent diffusion coefficient, in the entire bilateral orbital segment of the optic nerves was revealed, consistent with bilateral PION. Magnetic resonance angiography revealed arterialization of the bilateral cavernous sinuses and SOVs. Cerebral angiography confirmed the diagnosis of bilateral anterior-drainage dural CCFs. Treatment with transvenous coil embolization was successful. Three months after embolization, ophthalmic examination demonstrated progressive improvement of aforementioned ophthalmic signs; however, her visual acuities remained NLP in both eyes."
  },
  {
    "id": "multiclinsum_gs_en_542.txt",
    "fulltext": "A 71-year-old man with diabetes and Chagas disease had recent significant weight loss (60 kg). The clinical investigation resulted in a diagnosis of megaesophagus associated with significant obstruction at the level of the cardia. Esophageal balloon dilatation was performed, successfully recovering digestive transit. In the meantime, during surgical risk assessment, the patient also presented chest pain on minimum exertion. Coronary computed tomography angiography performed three years earlier showed heavily calcified multivessel disease involving the left main (LM); no further investigation had been performed at that time. This time he was referred for us for cardiac catheterization.\nThe exam carried out on 16 February, 2016 showed: right coronary artery (RCA) with important calcification and a 50% lesion in the mid third; posterior descending artery (PDA) and right posterolateral artery (RPLA), with severe calcification and lesions of 80% and 70%, respectively; LM with 80% calcified lesions in the distal third; left anterior descending artery (LAD) with significant calcification and 90% lesion in the mid third; diagonal branches (DG1 and DG2) with calcified lesions of 70% and 80%, at the origin and in the proximal third, respectively; and left circumflex artery (LCx) occluded and calcified, receiving grade II collaterals of multiple origin. Left ventricular volume and contractility were preserved.\n\nWith this angiographic picture, Society of Thoracic Surgeons risk score 15.8% for morbidity or mortality, EuroSCORE II 4.67%, and significant frailty due to recent major weight loss, the heart team decided to perform percutaneous coronary intervention (PCI) of the LM, LAD, DG1 and DG2 initially and, in a second procedure after 30 days, PCI of the RCA branches. In both procedures, RA was also indicated due to significant calcification. The LCx would not be addressed since angiographically the vessel was not so severely involved and also considering the technical difficulty of recanalization, due to the length of the CTO and also heavily calcified walls (J-CTO score 4). The LCx was already receiving grade II collateral circulation.\nOn 19 February, 2016, after beginning dual antiplatelet therapy with aspirin and clopidogrel, the patient underwent RA of the LM, LAD and DG2 with a 1.5 mm burr followed by predilation with a 3.0 mm×20 mm balloon at 14 atm and implantation of drug-eluting stents (DES) in DG2 and LAD, using a mini-crush technique and a kissing balloon at the end. A kissing balloon was then performed at the LAD/DG1 bifurcation and finally the third DES was implanted from the origin of the LM to overlap with the LAD stent. Procedural success was achieved with TIMI flow 3 and without clinical or angiographic complications.\nOn 22 March, 2016, the patient returned for RCA PCI. The proposed strategy was RA in the PDA and RPLA with a 1.5 mm burr, followed by implantation of two DES. Through right femoral access and a 7F JR guide catheter we crossed the RotaWire extra support through the RPLA lesion, then conducted three successive 20-s passes at 170 000 rpm successfully and uneventfully. As there were no signs of dissection and TIMI 3 flow was maintained, the 0.009″ RotaWire was repositioned to cross the PDA lesion and debulking of the lesion was performed. After two attempts with short, gentle movements we succeeded in crossing the lesion, however entrapment of the burr ensued. The system was pulled back without success considering that the stretching of the system was causing wrinkles at the RCA and the 7F JR was penetrating deep into the artery, with risk of rupture. Attempts were then made to release the Rotablator, in both rotablation and dynaglide modes, by moving it forward and backward, but the burr did not even spin. Attempts were made to advance a parallel guidewire with 1.25 mm balloon but it did not progress within the 7F guide catheter. We therefore decided to puncture the left (contralateral) femoral artery and insert a 6F JR guide catheter to the RCA ostium, parallel to the first 7F guide catheter, and advance a PT2® guidewire (Boston Scientific) to the PDA branch with a 1.25 mm×8 mm balloon upstream to support this wire. We succeeded in arriving parallel to the Rotablator system until the proximal portion of the entrapment site. Attempts to cross the guidewire and balloon angioplasty tangentially to the burr were unsuccessful because the tip of the wire was not sufficiently stiff to cross it. When the PT2 was pushed with the back support of the balloon this forceful movement caused the tip of the wire to bend, and finally the guidewire was advanced with the ‘knuckle’ technique (used for recanalization of CTOs), taking advantage of the kinking of the distal portion of the PT2 guidewire, making a subintimal dissection. At this time we could not see if the wire had re-entered the true lumen, but the 1.5 mm balloon could then easily be crossed parallel to the burr and inflated to 16 atm to release the trapped burr. The burr was subsequently withdrawn maintaining the RotaWire in the initial position. After administration of 100 μg nitroglycerin, angiography confirmed that the PT2 guidewire had re-entered the true lumen and reached the most distal part of the PDA. The RotaWire was pulled out together with the whole 7F system. Through the 6F system and the same PT2 wire, PCI was finalized with implantation of the two programmed 2.75 mm×20 mm and 2.75 mm×16 mm DES at 12 atm in the PDA and RPLA, respectively, without any further predilation. We also noted the presence of a long and severe dissection in the mid third of the RCA, certainly caused by excessive handling and attempts to remove the burr, which caused deep penetration by the 7F guide catheter. This dissection was promptly corrected with implantation of a third 4.0 mm×32 mm DES, and final TIMI 3 flow was obtained without clinical or electrocardiographic complications. The two femoral puncture sites were occluded with 8F and 6F AngioSeal devices, respectively. The patient remained in the intensive care unit for 48 hours, the only abnormality being CK-MB elevation (twice the reference value). He was discharged on day 3 in excellent general condition. The control echocardiogram showed normal left ventricular contractility.",
    "summary": "A 71-year-old man with Chagas disease and stable angina on minimum exertion underwent coronary computed tomography angiography and cine angiography that revealed heavily calcified multivessel disease involving the left main artery (LM). Due to the degree of calcification, it was decided to perform rotablation. The first-stage percutaneous coronary intervention (PCI) with rotablation was performed on the LM, left anterior descending artery and second diagonal branch without complications. Almost 30 days later he returned for right coronary artery (RCA) PCI. The proposed strategy was rotational atherectomy in the posterior descending artery (PDA) and right posterolateral artery (RPLA) with a 1.5 mm burr, followed by implantation of two drug-eluting stents (DES). Through right femoral artery access the RPLA lesion was ablated with success. As there were no signs of dissection and TIMI 3 flow was maintained, the 0.009″ RotaWire was repositioned to cross the PDA lesion and debulking of the lesion was performed. After two attempts we succeeded in crossing the lesion with the 1.5 mm burr, however entrapment of the burr ensued. The system was pulled back until the guiding catheter penetrated deep into the RCA, and attempts were made to release the Rotablator by moving it forward and backward, but the burr did not even spin. The contralateral femoral artery was therefore punctured and a 6F JR guiding catheter was inserted, in order to move a guidewire and small angioplasty balloon tangentially to the burr, but without success. Finally we advanced the guidewire using the ‘knuckle’ technique, taking advantage of the kinking of the distal portion of the PT2 guidewire, performing a subintimal dissection and re-entry, and could then easily cross the balloon, inflate it and release the trapped burr. Through the 6F system, two programmed and one bailout DES were successfully implanted in the PDA, RPLA and RCA, obtaining final TIMI 3 flow without complications."
  },
  {
    "id": "multiclinsum_gs_en_528.txt",
    "fulltext": "We present five days old neonate admitted to the neonatal intensive care unit with a complaint of absence of anal orifice. The baby did not pass meconium for 48hrs since birth and later on, the families noticed that meconium passed through the urethral orifice together with urine. Following further evaluation, they found that there was no anal opening apart from a slight fossa on the area that was supposed to be an anal opening. In addition, the neonate had abdominal swelling which progressively increased since birth. Otherwise, the neonate had no fever, yellowish discoloration of skin and eyes, vomiting, and abnormal body movement.\n\nThe baby was born to a 32-year-old para-four mother who does not remember her last normal menstrual period but claimed to be amenorrheic for the past nine months. The mother had antenatal care at the nearby health center and it was uneventful. She gave birth at the nearby health center by Spontaneous vaginal delivery after laboring for 14 hours and the birth weight was 3.2kg. The neonate cried immediately after birth with APGAR scores of 7 and 10 at 1st and 10th minutes, respectively. The mother had no chronic medical illnesses like Hypertension and diabetes mellitus. Her prior children are all healthy and alive.\n\nOn physical examination, general appearance was alert, and vital signs were pulse rate = 152 beats per minute, respiratory rate = 46 breaths per minute, temperature 36°C, and venous oxygen saturation 97% at room air. On HEENT examination, head circumference was 42 cm and anterior fontanel size was 2cm. The pertinent positive physical findings were on abdomen and Genito-urinary system. The abdomen was grossly distended, and there was no anal opening other than just a dimple on sacrococcygeal area. On the genito-urinary system, external genitalia appears female on inspection with labia majora well developed and no fusion. However, upon palpation, the labia minora fused entirely to the base of the clitoris and there is no vaginal opening. The phallus measures about 0.8cm with a central opening through which loose stool leaks while crying. The urethral opening is a common pathway for the urinary tract, genital, and rectum. There are no gonads palpable at the labioscrotal folds and inguinal area.\n\nLaboratory tests and imaging were done to explore further findings. On complete blood count, white blood cell = 20,000, neutrophil = 53%, lymphocyte = 23%, red blood cell = 5*106, hemoglobin=15gm/dl, platelet = 272*103, the blood group was A+, and random blood sugar was 120gm/dl. Plain abdominal x-ray was taken and it showed absence of air shadow in the distal large bowel. The abdominopelvic sonography was done to reveal any Mullerian structures and distal bowel condition. However, it only showed that unilateral (left side) supernumerary kidney, one lying in renal fossa and the other lying caudally on the left psoas muscle both having distinct capsules and blood supply with a contralateral single normal kidney. The ultrasonography did not comment on the Mullerian structures due to collapsed bladder being unable to visualize the structures.\n\nThe patient was admitted with a diagnosis of term +Normal birth weight +Appropriate for gestational age +Cloacal anomaly +Ambiguous genitalia+ Supernumerary kidney+ Early onset neonatal sepsis. The neonate was managed with calculated maintenance fluid and intravenous antibiotics, ampicillin 150mg/kg/dose Iv twice daily (BID) and gentamicin 3mg/kg/dose iv daily. On the second day of admission, the baby was referred to black lion specialized hospital for better evaluation and management.",
    "summary": "We present five days old neonate admitted to the neonatal intensive care unit with a complaint of absence of anal orifice. The baby had not passed meconium within 48 hours after delivery, but the families later realized that meconium had been passing through the urethral orifice along with urine. The child was born to a 32-year-old para-four woman who claims to have been amenorrheic for the past nine months but could not recall her last regular period. On physical examination, the abdomen was grossly distended, and there was no anal opening other than just a dimple on the sacrococcygeal area, and the external genitalia appears female on inspection with labia majora well developed and no fusion."
  },
  {
    "id": "multiclinsum_gs_en_143.txt",
    "fulltext": "36-year-old woman who presented 6 years ago with asymmetrical progressive weakness of hands associated with cramping and muscle atrophy. Examination also showed right steppage but with normal sensation – Inflammatory Neuropathy Cause and Treatment (INCAT) disability scale total 4; and Medical Research Council Global Scale (MRC) total 58. Conduction block was identified in the left median nerve 8 cm proximal to the wrist and in the bilateral ulnar nerve distal to the elbow. Anti-GM1 antibody was positive.\n\nWith the diagnosis of NMM defined, the patient received intravenous Ig 2 g/kg/month (100 g) for two consecutive months. Her muscle strength improved (INCAT: 2) and she was switched to subcutaneous Ig 2 g/kg/month (100 g), and remained clinically stable. Each time the dose of subcutaneous Ig was attempted to be reduced, there was a worsening of muscle strength.\n\nDespite a stable dose of subcutaneous Ig, after five years of follow-up the patient deteriorated and developed severe weakness in both hands with no sensory symptoms, marked disability and complete dependency for activities of daily living such as dressing, bathing and feeding, unable to care for her daughter (INCAT: 5; MRC total: 40; Handgrip Martin Vigorimeter left: 0 kPa, and right: 0 kPa; Rasch-built Overall Disability Scale: 16). Treatment was again rotated to intravenous Ig at a dose of 2 g/kg/month for four months with no improvement. Subsequent treatments with prednisone at a dose of 1 mg/kg/weight for six weeks and rituximab at a dose of 375 mg/m2 for four consecutive weeks were also not effective.\n\nBased on a recent report, we decided to initiate ultra-high dose Ig treatment of 4 g/kg/month (200 g), followed by 5 g/kg/month for two months (250 g), divided into two cycles every 15 days. The patient's cardiovascular risk score (QRISK2) was low (6%), and the daily dose of intravenous Ig never exceeded 35 g/day. The patient presented progressive improvement (MRC: 54; left hand grip: 5 kPa, and right: 30 kPa; Rasch-built Overall Disability Scale: 41; and INCAT: 3).\n\nThe patient regained independence for daily living activities and was able to return to work. The only adverse event related to the use of ultra-high dose Ig was headache.\n",
    "summary": "36-year-old woman with a diagnosis of NMM who, after five years of clinical stability under treatment with subcutaneous Ig at a dose of 2 g/kg/month, developed severe weakness in both hands, so it was decided to change the treatment to intravenous Ig. However, she progressed to the point where she was unable to carry out basic activities of daily living. We initiated treatment with intravenous Ig at an ultra-high dose (5 g/kg/month) with a good response, achieving functional independence in activities of daily living and returning to work. The only adverse event related to intravenous Ig at an ultra-high dose was the presence of headaches during the infusion.\n"
  },
  {
    "id": "multiclinsum_gs_en_181.txt",
    "fulltext": "Our case is a 73-year-old man who presented with a 4-month-old, light brown, non-painful, nodular lesion on the foreskin. It was surgically removed by a general surgeon and presented to the laboratory as a 13 mm long, raised, nodular lesion on the skin. It was white in colour and had clear borders. The tumour tissue was fixed in 10% formaldehyde and was cut into 4 um sections that were stained with haematoxylin and eosin. Immunohistochemistry was performed with smooth muscle actin (SMA), muscle-specific actin (ASMA), CD34, p63 and S-100.\n\nRESULTS\nMicroscopically, there was a proliferation of neoplastic cells located in the papillary and reticular dermis, arranged in short, straight, intertwined bundles. The neoplasm was predominantly expansive in growth with atrophy and ulceration of the epidermis.\n\n\nThe cells, mostly fusiform, had elongated, blunt-ended nuclei, some with intracytoplasmic vacuoles and ill-defined cytoplasmic borders. Others had anisocaryosis with marked pleomorphism, bizarre nuclei and sparse cytoplasm. Nuclear grade and mitosis count were high (22x10 high-power fields). Although the borders were expansive, the surgical margins were compromised by diffuse tumour extension in the superficial dermis, at one end of the lozenge. Surgical margin expansion was recommended.\n\n\nImmunohistochemistry was performed to confirm the histogenesis of the neoplasm. It was found to be smooth muscle actin (+), muscle-specific actin (-), CD34 (-), p63 (-) and S-100 (-) positive. Chest radiograph and abdominal computed tomography did not show evidence of metastatic disease. The patient underwent radical circumcision and is disease-free 7 months after diagnosis.\n",
    "summary": "We present a case of a 73-year-old man with a 4-month-old leiomyosarcoma of the foreskin. An excisional biopsy of the lesion was performed for histopathological examination with HE and immunohistochemistry with actin of smooth muscle, muscle-specific actin, CD34, p63 and S-100 (-).\n\nResults: We observed a leiomyosarcoma with a high grade histological and mitotic count. It was positive for immunohistochemical actine of smooth muscle, while the other markers were negative. The surgical borders were compromised, so a reoperation with wide margins of healthy tissue was necessary.\n"
  },
  {
    "id": "multiclinsum_gs_en_554.txt",
    "fulltext": "A 38-year-old man was admitted to the hospital for blunt chest trauma. The patient was generally healthy and had no risk factors of coronary artery disease. He was hit in the chest by a high-speed screw that was of approximately 6-cm diameter while working in a factory. He flew approximately 4 m away because of the force and pressure of the high-speed screw. He lost consciousness at once, but regained consciousness several minutes later. He was then transferred to the emergency room of a local hospital immediately. His Glasgow Coma Scale score was 15. He complained of intense and persistent chest pain, tightness, and dyspnea. Chest computed tomography showed bilateral pleural effusion and sternal and rib fractures. Thus, a chest tube was inserted for several days. Then, he was discharged without undergoing electrocardiogram (ECG) or other cardiovascular examinations.\n\nThree months after hospital discharge, during a routine follow-up check-up, pleural effusion was still present with accompanying symptoms of chest tightness, shortness of breath after physical activities, and even dyspnea at night, which prompted his admission in our hospital. His vitals during admission were as follows: a regular heart rate of 98 beats/min, blood pressure of 110/70 mmHg, and respiratory rate of 20 breaths/min. Physical examination showed normal carotid and jugular venous pulsation. Bilateral thoracic respiratory movement and activity were normal, tactile language fibrillation of the right lung was abate, right lung percussion presented with dullness, and breath sounds were abate. There was no obvious rhonchus and moist rale during lung auscultation. There were no murmurs upon cardiac auscultation. Examinations of the abdomen and extremities revealed normal findings. The first ECG showed ST evaluation and T wave inversion in the I, avL, and V2-V5 leads and in the left anterior branch block. Troponin-I test was negative, and the NT-proBNP level was 706 pg/ml (normal range: 0–104 pg/ml), suggestive of an old anterior myocardial infarction. Transthoracic echocardiography showed a 26.4-mm left atrium, a 51.8-mm left ventricle, and a left ventricular (LV) ejection fraction (EF) of 32% (M mode). The anterior LV wall and interventricular septum showed thinning at 6.6 mm, with remarkably reduced movement echo.\n\nWhen examining the patient's carotid, intracranial, and lower extremity arteries, no obvious atherosclerotic plaques were found. All findings supported the diagnosis of old myocardial infarction (OMI), rather than arteriosclerosis. However, the patient was hemodynamically stable. After undergoing diuretic therapy, the patient was administered β-blockers, statins, and cardiac stimulants, which relieved his discomfort. Coronary computed tomography angiography showed moderate stenosis in the proximal LAD artery. To confirm the stenosis and examine the condition of the coronary intimal, CAG was performed at 3 months after the chest trauma, which showed approximately 70% narrowing of the lumen in the proximal LAD and the coronary segment had a curved lesion. The left circumflex artery (LCX) and right coronary artery (RCA) were normal. CAG results confirmed the diagnosis of OMI, but due to the cost burden, the patient refused IVUS examination. The patient underwent conservative therapy and was discharged from the hospital several days later.\n\nOne month later, on December 9th,2014, he returned to the hospital for percutaneous coronary intervention (PCI) therapy. After undergoing drug therapy, his conditions had improved slightly. Physical examination and ECG revealed almost normal findings. Transthoracic echocardiography showed improvement in LV systolic function and EF at 45%. He had full antiplatelet therapy with aspirin and clopidogrel. Then, he underwent another CAG at 4 months after the chest trauma, which showed a slight improvement of stenosis. There was approximately 60% narrowing of the lumen. IVUS was performed and revealed that the lesion severity was 55.9%, and the plaque of low echo appeared before thrombus formation after the subintimal tear. We completed the examination without further intervention because only 55.9% narrowing of the lumen was found and the patient had stable hemodynamics without evidence of constant myocardial ischemia. The patient was prescribed optimal medication, and his discomfort gradually alleviated. In July 17, 2018, 4 years after the trauma, follow-up evaluation revealed that the patient still experiences shortness of breath after working, but is relieved soon after taking a rest. Physical examination showed the following results: blood pressure of 114/80 mmHg, heart rate of 66 beats/min, absence of obvious abnormalities upon lung and heart auscultation; and absence of obvious edema in both lower extremities. Follow-up ECG revealed the following findings: rS in V2-V4 leads, T wave inversion in the I, avL, and V2-V5 leads and the left anterior branch block. Transthoracic echocardiography showed left heart enlargement with 39-mm left atrium, 54.7-mm left ventricle, and LV EF of 41% (Simpson's). Thinning of the LV anterior wall and interventricular septum was also noted, with the thinnest part being 4.7 mm; movement had almost disappeared and the echo was enhanced. However, the carotid, intracranial, and lower extremity arteries were still normal. Moreover, we found that the medications prescribed to treat heart failure was not religiously taken after the discharge; thus, we newly prescribed 23.75-mg metoprolol, 2.5-mg benazepril, and 20-mg spironolactone to be taken once daily, and coenzyme to be taken every 10 hours.",
    "summary": "Patient concerns:\nA 38-year-old, previously healthy, man was admitted to our hospital with a complaint of dyspnea. He had a history of being hit in the chest by a high-speed screw while working in a factory 3 months before he was admitted to the hospital.\n\nDiagnosis:\nAfter performing coronary angiography and echocardiography, he was finally diagnosed with myocardial infarction.\n\nInterventions:\nHe received optimized medications, including diuretics, β-blockers, and cardiac stimulants.\n\nOutcomes:\nAt the 4-year follow-up, the patient was diagnosed as having chronic heart failure with a reduced ejection fraction."
  },
  {
    "id": "multiclinsum_gs_en_147.txt",
    "fulltext": "A 30-year-old gravida 3, para 3 woman presented with decreased urination, left flank pain, and fever for 2 days after an emergency C-section for the first time, indicated due to fetal and maternal distress secondary to prolonged labor and prolonged vaginal bleeding in Al-Thora hospital, Ibb, Yemen. Despite resuscitative efforts, her newborn expired after 45 minutes. During the C-section, severe uterine adhesions were identified (As there were lesions of endometriosis, and adhesions between the posterior wall of the uterus and the sigmoid colon), and an estimated blood loss of 1500 cc, according to the gynecologist report. The patient did not receive any prenatal care during her pregnancy. She is a nonsmoker and denied chronic medical conditions, drug abuse, accidental poisoning, or previous surgical history.\n\nOn physical examination, the patient appeared pale, ill, and febrile during the initial evaluation, with an oral temperature of 38 °C, pulse rate of 80 beats per minute, and blood pressure of 95/70 mm Hg. The patient’s abdomen was mildly distended, with moderate tenderness, primarily in the left lower quadrant.\n\nThe laboratory data were as follows: White blood cell (WBC) count was 15.3 × 103/mL, with 90% polymorph neutrophils (Leukocytosis with neutrophilic predominance), hemoglobin was 7.5 g/dL, platelets count was 200×103/µL, blood urea nitrogen (BUN) was 23 mg/dl, and creatinine was 3.8 mg/dl. Other blood tests, such as liver function and coagulation tests, were within normal ranges. Ultrasonography (US) showed severe left hydronephrosis and moderate free fluid in the abdominal cavity. The abdominal tap aspiration was performed, and the spot creatinine was 52 mg/dL indicating that the fluid was urine.\n\nThe patient was resuscitated with packed red blood cells and broad antibiotic coverage. Thereafter, she urgently underwent a ureteroscopy that showed a total occlusion of the left ureter. Subsequently, a decision to surgical exploration was made, given the hemodynamic instability, lack of percutaneous nephrostomy equipment, and the evidence of intra-abdominal contamination. Intra-operatively, we found moderate free fluid in the abdominal cavity. The left ureter was crushed and ligated with a Vicryl suture (5 sticks) at around 5 cm of its distal part. After fluid evacuation, the injured segment of the ureter was excised and ureteroneocystostomy in a refluxing manner was performed after bladder distention with saline through the catheter. Additionally, we dissected the ureter, carefully, from the surrounding tissues in the cephalad direction, spatulated the distal ureteral end, and inserted a double j stent. The ureter was implanted in the posterior dome of the urinary bladder with tension-free anastomosis and sutured with 4–0 Vicryl through the full-thickness ureter, then the bladder mucosal and detrusor layer. A Jackson–Pratt (JP) drain near the anastomosis was inserted, and the abdominal wall was closed after evaluating the intraperitoneal content.\n\n\nFollow-Up and Outcome\nClear fluids were started on the second postoperative day. The patient had mild abdominal distension, pain, and nausea. On the third postoperative day, she had increasing abdominal distension and stopped passing flatus. The abdominal US showed a large amount of collection in the peritoneal cavity. The blood laboratory data showed a leukocytosis (WBC of 22×103/mL with a left shift).\n\nA computed tomography (CT) scan of the abdomen and pelvis with contrast revealed a significant amount of free air and fluid throughout the abdomen and pelvis adjacent to the anterior abdominal wall. Multiple free gas locules were also seen in the mesentery, with contrast enhancement of multiple small bowel loops, with no evidence of contrast extravasation. The findings suggested a perforated viscus. After consulting the general surgery team, the patient was immediately taken to the operating room for an exploratory laparotomy, which revealed a small perforation in the rectosigmoid part with some spillage, peritonitis with bowel loop edema, and ureteral anastomosis disruption. The complexity of this case forced us to perform multi-staged interventions in a multidisciplinary fashion. Firstly, the gynecologist performed a hysterectomy due to endometritis (confirmed histopathologically), severe oozing, and suture disruption of the uterus. Secondly, the ureterocutaneous diversion of the left ureter was performed by a urologist, and the ureterostomy was created on the left side. Lastly, the general surgeon performed the colostomy procedure after the repair of the colonic injury, and the colostomy was created on the left side. On the fifth postoperative day, colostomy retraction occurred with wound infection, and communication between colostomy and ureterostomy was observed. Re-exploration was decided to relocate the sigmoid colostomy, and a transverse right-side end colostomy was done. One week postoperatively, the patient experienced a superficial skin abdominal wall infection complicated with wound dehiscence and hypoalbuminemia (albumin: 2 g/dL) that required treatment with several debridement, wound irrigation, antibiotics, and supportive therapy. The recommended antibiotics were linezolid (600 mg IV every 12 hours for 7 days), then changed to ceftriaxone (1g IV every 12 hours for 5 days) plus metronidazole (500 mg IV every 12 hours for 5 days) and changed to oral ciprofloxacin (500mg every 12 hours orally for 7 days). She gradually resumed her normal diet and was discharged 30 days later in stable condition. She required home care to assist with her colostomy, ureterostomy, and ambulation.\n\nSix months later, the colostomy was closed, and the ureter was anastomosed via the Boari tabularized bladder flap procedure (the bladder was opened on its anterior surface, and a full-thickness bladder flap was flipped caudally and tabularized for anastomosis to the proximal ureteral segment after double j stent insertion). After an uneventful postoperative recovery, the patient was discharged on the seventh postoperative day. One-month follow-up by US and voiding cystourethrography showed a normal appearance of the bladder with adequate bladder capacity and normal upper urinary tract system. Three months later, retrograde ureteroscopy showed an adequate caliber of the ureter. The patient was regularly followed up with the US for 3 months for a year. The patient had no irritative or gastrointestinal symptoms within 2 years of follow-up.",
    "summary": "A 30-year-old woman presented with decreased urination for 2 days after a C-section. Ultrasonography showed severe left hydronephrosis and moderate abdominal free fluid. A ureteroscopy revealed a total occlusion of the left ureter, and subsequently, a ureteroneocystostomy was performed. Two days later, the patient was complicated with abdominal distension that necessitated re-exploration. The exploration revealed colonic injury (rectosigmoid), peritonitis, endometritis, and ureteral anastomosis disruption. A colostomy, repair of colonic injury, hysterectomy, and ureterocutaneous diversion were performed. The patient's hospital stay was complicated, with stomal retraction requiring operative revision and wound dehiscence, which was treated conservatively. After 6 months, the colostomy was closed, and the ureter was anastomosed via the Boari-flap procedure."
  },
  {
    "id": "multiclinsum_gs_en_446.txt",
    "fulltext": "A 69-year old diabetic male with ischemic heart disease, severely reduced ejection fraction and surgical revascularization with quadruple coronary artery bypass grafting in 1997 presented to his family physician with nausea and dyspnea for 24 h in late August 2016. A subacute non-ST segment elevation myocardial infarction was diagnosed and partial thrombotic occlusion of the internal mammary bypass graft to the distal left anterior descending coronary artery was identified as culprit lesion. However, the remaining flow was reported to be TIMI grade 3. The venous bypass graft to the first diagonal branch was patent, whereas the remaining venous grafts to the intermediate and the posterior descending artery proved chronically occluded, as did all native coronary vessels. LV enddiastolic pressure (LVEDP) was severely increased (40 mmHg) and LV ejection fraction was below 15%. In spite of increasing congestion of the spontaneously breathing patient the remaining coronary flow was judged sufficient, and a conservative medical management was adjudicated and therapeutic anticoagulation and dual antiplatelet therapy were initiated. After initial recompensation the patient experienced repetitive hemodynamically relevant ventricular tachycardia that could not be controlled with ICD- and medical therapy and was associated with the repetitive need for inotropic support (INTERMACS level 3). Consequently, the patient was referred to our center for evaluation of advanced heart failure therapy. Due to coexistent severe cerebrovascular disease, chronic renal impairment and his advanced age, the patient was deemed ineligible for transplantation. Decision for permanent mechanical circulatory support (destination therapy) using an LVAD was made. For pre-existent mild aortic regurgitation a bioprosthetic AV (Edwards Perimount Magna 3000) was implanted along with a third-generation, continuous-flow LVAD (HeartWare, Framingham, MA). Initial postoperative echocardiography documented a normally working aortic bioprosthesis. Pulse pressure, as assessed by invasive arterial BP monitoring, was constantly ≥15 mmHg. At postoperative day 7 hemodynamic monitoring showed a repetitive distinct pattern with a brief decrease followed by a transient increase in peripheral arterial BP. This pattern occurred every 60 s and coincided with the LVAD flushing cycle. On close observation of the arterial BP waveform, no dicrotic notch was visible between systolic decline and diastolic runoff. Echocardiography testified permanent AV closure despite a residual LV ejection fraction of 15 to 20%.",
    "summary": "A 69-year old male patient with terminal ischemic cardiomyopathy was referred for long-term mechanical circulatory support. Due to mild aortic regurgitation both an aortic bioprosthesis and a continuous-flow left ventricular assist device were implanted. Postoperative echocardiography documented a patent aortic bioprosthesis and an acceptable residual systolic left ventricular contractility. During invasive arterial blood pressure monitoring repetitive transient slight blood pressure decreases followed by slight blood pressure increases coincided with programmed LVAD flushing cycles. Permanent pulsatile flow with a pulse pressure of ≥15 mmHg conveyed systolic opening of the aortic valve. Echocardiography, however, proved early permanent aortic valve closure. In retrospect, transformation of the automated LVAD flushing cycles into visible changes of the arterial blood pressure curve during invasive blood pressure monitoring is indicative of ejection of the complete cardiac output through LVAD itself, and therefore an early clinical sign of aortic valve closure."
  },
  {
    "id": "multiclinsum_gs_en_134.txt",
    "fulltext": "The patient was a 51-year-old man weighing 79 kg who was referred to a private hospital for treatment for general malaise, with nausea and repeated vomiting accompanied by abdominal pain and diarrhea with 36 hours of evolution, which led to a significant loss of fluids, causing dehydration and severe hypotension, which required admission to the intensive care unit. In his medical history, the patient stated that on April 15, 2020, he had eaten wild mushrooms that he had collected between alfalfa crops in his property in the Department of Lavalle, Province of Mendoza, where rainfall is scarce and temperatures are very extreme. The land has characteristics of a wide plain with extensive presence of sandy and saline soils, where xerophytic vegetation is suitable for goat farming and the development of ecological beekeeping. In this alfalfa crop, a microenvironment is generated that allows the growth of fungi, which he sometimes harvested to eat. On this occasion, he observed some fleshy fungi that he cooked and ate, the same day, at lunch. He reported that they were very rich and that he had eaten all the preparations, with nothing left for the rest of the family. The patient continued his story: after about 10 hours of ingestion, he began with abdominal pain and nausea, followed by vomiting and diarrhea, so he consulted the emergency room of a zonal hospital of low complexity, where he was treated symptomatically. The next day, after 36 hours of ingestion, he had a severe abdominal pain and nausea, followed by vomiting and diarrhea, so he consulted the emergency room of a hospital of low complexity, where he was treated symptomatically. On the night of April 16, 2020, he was admitted to the intensive care unit of the Private Hospital of the City of Mendoza with gastroenteric-colonic syndrome with bloody stools and severe dehydration (zero cm of venous water), which required admission to the intensive care unit, for parenteral rehydration with crystalline solutions (saline and 5% dextrose in water). Given the severity of the condition and the recent ingestion of wild mushrooms, the Center for Information and Toxicological Advice of Mendoza was notified, where they indicated, in addition to the support measures initiated, that a nasogastric tube should be placed and activated and that activated charcoal should be administered serially (50 g every 6 hours for 4 days). In addition to N-acetylcysteine (70 mg/kg every 4 hours until normalization of transaminases), phytomenadione (10 mg, once a day) and penicillin G EV (1,000,000 IU every 4 h), to block the uptake of the eventual presence of amatoxin, as well as metoclopramide and omeprazole EV (40 mg/d) were administered. On admission, blood was drawn for laboratory and the patient was prepared for dialysis. At 12 hours of admission to the ICU, diuresis was achieved (80 ml/h). The report of examinations of admission laboratory showed altered renal function and elevated hepatic transaminases. The relatives of the patient collected some of the fungi that he had eaten for identification. A photo was shared with the Argentine Toxicological Information Center (REDARTOX) and with an expert in mycology belonging to the Institute of Mycology and Botany (InMiBo), who explained that it could be a fungus of the Lepiota genus, containing amatoxins, such as Amanita phalloides. The fungus could be sent by post to the Center for Identification of Toxic Fungi of the InMiBo, Faculty of Exact and Natural Sciences, University of Buenos Aires on April 21, arriving on April 30, with the report issued on the same day. After a macro- and micro-morphological analysis, it was confirmed that the species was Lepiota brunneoincarnata Chodat & C. Martín. The cap had a diameter of 15 to 45 mm, convex to flat convex, with brownish-vinaceous scales with vinaceous tones, on a creamy base. Foot 20-60 x 7-13 mm, off-white, covered by brownish-vinaceous scales, also with vinaceous tones, on a creamy base. Spores (6.5-) 7-9 –(9.5) x 4-5 µm, ellipsoidal, hyaline, dextrinoid, basidios 32-33 x 6-7 µm. The phialides were 20-25 x 7-8 µm. The day 22 of admission was compensated, with normal renal function, hepatic transaminases without increase and amylase normal, but continued with nausea and gastric disorders. The day 24 of admission, in better condition, with normal renal function, hepatic transaminases and bilirubin in frank descent, persisting the gastric disorders. His hepatic transaminases increased dramatically (GOT, 435UI/L; GPT, 40 UI/L) 36 hours after ingesting the fungi, remaining elevated the first six days, entering a general trend of decline of the levels (Table 1). The day 11 of admission was discharged with normal hepatic transaminases (GOT, 36 UI/L; GPT, 40 UI/L). The patient also presented jaundice on day 3 of admission, when the total bilirubin reached its highest level (4.01 mg/dL), decreasing in the following days. Creatinine values were elevated the first three days of admission, with their highest level on day two (3.10 mg/dL), decreasing later to remain low for the rest of the treatment, without apparent problems. Creatinine and urea blood values returned to normal during the follow-up. Prothrombin times reached a maximum of 16.5 seconds on day 4, decreasing in the following days. Finally, he was discharged on day 27 of admission, recovered clinically and with laboratory values within normal parameters, 11 days after admission. On day 2 of June, when he was cited for a control, he was in good general condition and his last analytical was normal.\n",
    "summary": "This report describes the treatment of a 51-year-old patient who weighed 79 kg and was admitted to hospital 36 hours after eating mushrooms, which were identified as Lepiota brunneoincarnata, a species new to Argentina. The patient presented with general malaise, with nausea and repeated vomiting accompanied by abdominal pain and diarrhea. Thanks to a rapid anamnesis and approximate and early identification of the fungus, a nasogastric tube was placed and activated charcoal was administered serially. In addition to N-acetylcysteine, phytomenadione and penicillin G EV. The patient was discharged 11 days after admission.\n"
  },
  {
    "id": "multiclinsum_gs_en_494.txt",
    "fulltext": "46-year-old male, right-handed, sedentary, medical, no other significant history. Denies painful symptoms in the left elbow and shoulder prior to the onset of current condition. Initiates with mild respiratory symptoms and after nasal exudate is determined positive for COVID-19. Presents a mild illness that requires only symptomatic treatment. On the fifth day of the onset of the respiratory symptoms, he suddenly and intensely feels pain in the left elbow after a minor effort with the elbow flexed at 90o. He develops painful mobility limitations. He comes for emergency medical evaluation; on physical examination, he presents pain during elbow flexion and extension as well as pronosupination, pain on palpation in the anterior region of the elbow. He shows a Popeye elbow deformity, absence of the distal tendon of the biceps brachii, no evidence of neurovascular disorders. A padded sling is applied as initial treatment. The diagnosis of complete rupture of the distal insertion of the biceps brachii is confirmed by a magnetic resonance imaging. This study describes a complete avulsion of the tendon at its distal insertion with retraction of the tendon to about 8 cm from its insertion, with perilesional oedema. The patient is initially offered surgical treatment versus non-surgical treatment options. The patient opts for surgical treatment. Once the surgical management has been decided, the time at which it should be performed should be considered. In reports of this type of injury, it is recommended to carry out a surgical procedure within the first seven days after the injury in one group, 14 days in a second group or 21 days in a third group to achieve the best possible results of the treatment. However, in this case, we had to take into consideration that the patient was on the fifth day of the onset of COVID-19 symptoms. According to the recommendations of infectious diseases, it was recommended, at that time, to wait until day 14 to carry out a surgical procedure without complications, especially due to the high possibility of requiring intubation to ensure anaesthesia during the procedure. The waiting time from the onset of COVID-19 symptoms is based mainly on the safety of the patient, but also on the safety of the medical team that will carry out the procedure. Finally, a joint decision was made to operate the patient on the 17th day of the onset of symptoms.3\n",
    "summary": "46-year-old male COVID-19 positive patient with acute distal biceps tendon injury secondary to minimal trauma with no other risk factors. The patient was treated surgically following the orthopedic guidelines and safety for the patient and the medical staff due to the COVID-19 pandemic. The surgical procedure of the double tension slide (DTS) technique with a single incision is a reliable option and in our case of a low morbidity, with few complications and a good cosmetic option.\n"
  },
  {
    "id": "multiclinsum_gs_en_510.txt",
    "fulltext": "A 54 year old male with a history of Wolff-Parkinson-White syndrome resulting in cardiac arrest in his 20s, subsequently developed non-ischemic cardiomyopathy (New York Heart Association class IV with an ejection fraction of 15%.) He was admitted for heart failure and had a complicated cardiac care unit course with removal of AICD/Pacemaker due to endocarditis, and anticoagulation with Coumadin for right atrial thrombus/atrial fibrillation. He was discharged, but required multiple readmissions for heart failure, ultimately requiring venoarterial extracorporeal membrane oxygenation through the right femoral artery and left femoral vein as eCPR in January, 2020 and would remain on ECMO for 5 weeks. He underwent LVAD placement using left ventricle and ascending aorta cannulation sites 16 days after ECMO cannulation and subsequent tracheostomy in February for persistent respiratory failure.\n\nTwo days prior to removal of ECMO cannulas, the patient underwent right lower extremity guillotine amputation for dry gangrene due to iliac dissection and distal embolization. Five days later, on post LVAD day 25 there was noted to be stool leaking from the exit site of the driveline. The patient was taken to the operating room by the Cardiothoracic Surgery team and had a limited exploration, finding a bowel injury from the driveline. The injury was repaired with interrupted silk suture and the driveline was left untouched. Three days after this repair, Acute Care Surgery was consulted for stool leaking again from the driveline exit site. The patient was found to be profoundly septic. He was started on antibiotics and taken to the operating room for formal exploratory laparotomy and was found to have the LVAD driveline traversing the abdominal cavity from the right upper quadrant to the left mid flank. The driveline had injured the distal transverse colon and the prior repair was leaking. There was copious feculent fluid and numerous intra-abdominal abscesses that were drained. Due to the patient’s sepsis, the colon was stapled proximal and distal to the injured segment and the specimen was removed. The patient was left in discontinuity and a temporary abdominal dressing was placed for a planned second look surgery. He returned to the ICU where he was given antibiotics, mechanical ventilation and vasopressors.\n\nThree days later, during the planned second look surgery the abdomen appeared clean. Due to the necessity of the LVAD, the driveline could not be disconnected. The first priority was to mobilize the driveline out of the peritoneum. The left side of the patient’s abdomen was opened transversely to allow the driveline to come to the middle. The peritoneum was taken down from the right side of the patient’s abdomen to develop a retrorectus plane in an attempt to reposition the driveline to the intended extraperitoneal location. A smaller transverse incision was made on the right side to get the driveline in this retrorectus plane away from the midline. Thus the driveline was successfully removed from the peritoneum without disconnection. A right hemicolectomy was performed, but due to the driveline exiting near the right lower quadrant, an end ileostomy was brought out in the left lower quadrant. His fascia was closed and retention sutures were placed due to the patient’s poor nutritional status and degree of abdominal sepsis. The patient did well post operatively and was able to resume enteral nutrition on postoperative day 3, meeting his caloric demands by postoperative day 7. He underwent revision of his guillotine amputation 15 days after his last abdominal operation.\n\nThe patient’s course was complicated by an intra-abdominal abscess requiring interventional radiology drainage 3 weeks after his last abdominal surgery as well as prolonged IV antibiotic treatment for resistant organisms including VRE. The patient completed his antibiotic course and had his drains removed. At the time of this report, the patient remains hospitalized, tolerating enteral nutrition, off mechanical ventilation and undergoing physical therapy.",
    "summary": "A 54 year old male with a history of Wolff-Parkinson-White syndrome resulting in multiple readmissions for heart failure, ultimately required placement of a left ventricular assist device (LVAD). Several weeks later, he was found to have stool draining from the driveline site. The patient was taken to the operating room for limited exploration by the Cardiothoracic Surgery team and a bowel injury was identified and repaired. Three days after this repair, stool was once again leaking from the driveline site, requiring re-exploration by the Acute Care Surgery team. Intraoperatively, the prior repair was found to be leaking and multiple intra-abdominal abscesses were discovered. The transverse colon was resected and left in discontinuity. On a planned second look operation, the LVAD driveline was relocated to be extra-peritoneal and a colostomy was formed."
  },
  {
    "id": "multiclinsum_gs_en_450.txt",
    "fulltext": "He is a 48-year-old male patient who denies chronic degenerative diseases and surgical history. His condition began four months prior to his admission to our hospital, following the accidental ingestion of caustic, immediately inducing vomiting. He went to a private hospital where he was hospitalized for 15 days on a medical treatment and was discharged with oral tolerance to papillae. He reported that he began to have difficulty swallowing solid food, which progressed to liquids after one month. During this period, an endoscopic study was performed without the possibility of passing the esophageal stenosis, which is 25 cm from the dental arch. This is why a study protocol was initiated in our hospital, with an esophagogram with water-soluble contrast.\n\nBecause of the patient's extensive documented stenosis on esophagogram study and his inability to tolerate oral route, surgical procedure was decided, which consisted of a McKeown type esophagectomy.\n\nThe stomach was then released and a tubulized stomach was performed along with a Heineke-Mikulicz type pyloroplasty, with the tubulized stomach being elevated transhiatal. The cervical border was also performed for the preparation of the esophageal-gastric anastomosis in two planes.\n\nThe surgical procedure was completed without complications, the patient fasted for five days, after which he drank a contrast agent, and the passage of the contrast agent was observed without the presence of leakage from the anastomosis. Therefore, a liquid diet was initiated and, subsequently, a soft diet. The patient was discharged on the tenth day of his stay without complications.\n\nThe patient is currently being monitored, three months after gastric bypass surgery, with adequate tolerance to oral intake of both liquids and solids, and with good nutritional status. A radiological study of the swallow was performed with a water-soluble contrast agent, and an adequate passage of the contrast agent was observed, with no evidence of stenosis.\n",
    "summary": "The clinical case of a 48-year-old male patient with no chronic degenerative history is presented, who began to suffer after accidentally ingesting caustic substance 4 months ago, with dysphagia to liquids and solids, for which he was protocolized in our unit for definitive surgical resolution by means of gastric elevation.\n"
  },
  {
    "id": "multiclinsum_gs_en_566.txt",
    "fulltext": "A healthy 12-year-old boy presented to our clinic with abnormal vision of the left eye, described by the patient as “seeing a squiggly line”, which was evident on Amsler grid testing. A review of his family history confirmed no significant known ophthalmological disorders or relevant information. On examination, his best corrected visual acuity was 20/20 in both eyes, and the intraocular pressure was recorded as 14 and 13 mmHg in the right and left eyes, respectively. The anterior segments, pupillary light reflexes and extraocular motility examination were all unremarkable.\n\nFundus examination revealed bilateral elevated maculae with yellow subfoveal deposits, giving off the characteristic “egg yolk” appearance of the vitelliform stage of Best vitelliform macular dystrophy (BVMD). On close inspection of the left macula, a darkish lesion was identified inferior to the fovea, consistent with retinal pigmentary changes suggestive of a possible complicating macular neovascularization (MNV). Fundus autofluorescence showed a circular ring of hyperautofluorescence surrounding the fovea, consistent with lipofuscin accumulation at the diseased RPE. The dark inferior juxtafoveal examination seen on fundus examination coincided with a tiny hypoautofluorescent spot seen in the left eye.\n\nOptical coherence tomography (OCT) revealed bilateral subfoveal optically hyporeflective spaces and thickening of the cone outer segments. The left eye revealed an inferior juxtafoveal localized area of pigmentary elevation suggestive of MNV, which was confirmed as a neovascular frond by OCT angiography (OCTA). Electrooculography demonstrated an absent light rise with a significantly low Arden ratio of 1.1, confirming the diagnosis of BVMD.\n\nDespite an intact BCVA of 20/20, the patient was treated with 2 monthly intravitreal injections of ranibizumab (0.5mg/0.05 mL) based on the experienced metamorphopsia and irregular lines demonstrated on the Amsler grid. A month later, the patient presented with marked subjective regression of the metamorphopsia, which was equally evident on the Amsler grid. Surprisingly, OCT revealed complete resolution of the subfoveal optically hyporeflective space with restoration of the normal foveal contour. On OCTA en face scans of the outer retinal and choriocapillaris slabs, the MNV demonstrated subjectively clear shrinkage in size and arborization. Moreover, the inferior juxtafoveal hypoautofluorescent corresponding to the MNV appeared smaller.\n\nBased on the above, the patient was not offered any more injections, and was advised to follow up after four weeks while maintaining weekly monitoring at home using serial Amsler grid testing. A month later (2 months after the injection), the patient reported near disappearance of the symptoms and OCTA continued to demonstrate shrinking of the MNV. Of note, there was a small, but evident increase in the size of the subfoveal optically hyporeflective space, indicating rebound accumulation of the lipofuscin in the subfoveal space.\n\nOver the course of 2 years, the patient reported no new symptoms both on the Amsler grids or in his day-to-day activities. Serial en face OCTA images demonstrated near disappearance of the neovascular frond, and the inferior juxtafoveal hypoautofluorescent spot was undetectable. Strikingly, the most peculiar finding encountered on OCT was the gradual increase in the subfoveal space with a steady buildup of lipofuscin deposits. No further signs of activity were detected, and the right eye was not complicated by MNVs.",
    "summary": "A 12-year-old boy complaining of metamorphopsia presented with bilateral yellowish subfoveal deposits, suggestive of BVMD, which was confirmed by fundus autofluorescence and electrooculography. The left eye showed an inferior juxtafoveal complicating MNV, for which the patient was treated with two intravitreal ranibizumab injections. In addition to demonstrating a remarkable response to injection, both clinically and through various multimodal imaging modalities, optical coherence tomography (OCT) showed a surprising temporary resolution of the subfoveal hypopreflective space denoting a regression in the lipofuscin deposits accumulating at the RPE and the subfoveal space. Within 2 months, there was a subsequent build-up of the subfoveal space and lipofuscin reaccumulation through serial imaging despite the clear regression of the MNV. The patient remained stable over a course of 2 years."
  },
  {
    "id": "multiclinsum_gs_en_141.txt",
    "fulltext": "A 60-year-old woman was admitted to the nephrology department with epigastric pain, hematemesis and lower leg oedema. Arterial blood pressure was 90/50 mmHg, which was inside the normal range for this patient.\nLaboratory results were remarkable for disturbed liver enzymes with a cholestatic pattern: alanine amino-transferase (ALT) and aspartate amino-transferase (AST) levels were slightly elevated at 28 U/L and 61 U/L, respectively, while alkalic phosphatase levels (388 U/L) and γ-glutamyltransferase levels (291 U/L) were strongly elevated. Serum albumin levels were 24 g/L and the international normalized ratio was normal at 1.02.\nOther laboratory findings, including total bilirubin (0.32 mg/dL), direct bilirubin (0.26 mg/dL), total platelet count (176,000 platelets per microliter), and white blood cell count (8,400 cells per microliter), were within the normal range.\nThe patient had an extensive history of cardiac and renal disease. At the age of 11 years, congenital pulmonary valve stenosis was diagnosed for which the patient underwent valvulotomy. Subsequently, ill- tolerated atrial fibrillation and flutter developed for which flutter ablation was attempted unsuccessfully. Because the patient remained symptomatic, atrioventricular node ablation with pacemaker placement was performed.\nOral anticoagulation was started with fenprocoumon because of a CHA2DS2-Vasc score of 3 (woman, heart failure and peripheral vascular disease). At the age of 55 years, overt right heart failure developed and the patient continued to struggle with ascites and peripheral oedemas requiring multiple hospital admission. In addition, she also developed a problem of recurrent transudative pleural effusions of unclear aetiology.\nEchocardiography at that time showed severe pulmonary and tricuspid valve regurgitation with a moderately dilated right ventricle and right atrium. The left ventricle was slightly dilated with moderate mitral valve regurgitation. Right heart catheterization demonstrated pulmonary arterial pressures of 74/30 mmHg with a central venous pressure of 28 mmHg. A pulmonary homograft was placed when the patient was 57 years of age and concomitant tricuspid valve annuloplasty was performed. Despite a lower central venous pressure of 13 mmHg, the patient still continued to be readmitted multiple times for signs and symptoms of right heart failure. Persistent systemic venous congestion ultimately resulted in end-stage renal disease for which renal replacement therapy was started through intermittent haemodialysis. The case was complicated by recurrent severe gastro-intestinal bleedings, requiring frequent blood transfusions with up to 60 units of packed cells per year. Despite this in combination with intravenous iron substitution, haemoglobin levels varied between 5.3-8.8 g/dL. Because of these intractable bleeding problems, oral anticoagulation with fenprocoumon was stopped at the age of 59 years.\nA gastroscopy showed an erosive gastropathy with a diffuse congestive, friable mucosa. As a first- line prevention of recurrent gastric bleedings in the setting of cirrhosis, propranolol was started at a dose of 5 mg orally twice daily (the patient did not tolerate higher dosing because of low blood pressure). In addition, endoscopic coagulation of a fundic angioma and clipping of a Dieulafoy lesion had been performed.\nThese lesions were thought to be caused by hypertensive gastropathy. However, intractable bleedings remained.\nThe hepatic venous pressure gradient was measured at 16 mmHg (27 mmHg-11 mmHg). Although, there was some reluctance because of fear for worsening right heart failure, a management decision was made to create a TIPS. The procedure was uneventful. After TIPS placement, the hepatic venous pressure gradient decreased to 4 mmHg (14 mmHg-10 mmHg). Thus, although TIPS did lower the hepatic venous gradient considerably, portal pressure remained high because of the elevated central venous pressure.\nAfter TIPS placement, the patient developed signs of hepatic encephalopathy and ammonia levels of 77 μmol/L were measured. Treatment with oral lactulose and enemas was started with little improvement. At that time, another episode of gastric bleeding recurred.\nAbdominal ultrasonography showed good patency of the TIPS with normal Doppler flow. Gastric bleeding from an antral ulcus was detected with endoscopy, despite gastric hyperaemia being visually decreased compared to the situation before TIPS. A biopsy was performed that showed an oedematous foveolar mucosa, suggesting mucosal ischemia. Bleeding was too diffuse for additional endoscopic ligation. No worsening liver function was found on laboratory results, with the international normalised ratio 1.01 at this time. Echocardiography showed no meaningful changes compared to the situation before TIPS placement. The right ventricle remained moderately dilated with poor longitudinal function and persistent severe tricuspid valve regurgitation. However, the general condition of the patient deteriorated and fever with bilateral pulmonary consolidations developed.\nMulti-organ failure emerged and at this point the family of the patient decided to withdraw care. The patient died eventually 43 days after the TIPS procedure.",
    "summary": "A 60-year-old women with a history of congenital pulmonary valve stenosis developed right heart failure, cardiac cirrhosis and end-stage renal disease requiring renal replacement therapy. Cirrhosis was complicated by portal hypertension, resulting in intractable gastro-intestinal bleedings despite optimal treatment with beta-blockers and endoscopic band ligation. Because of fears for worsening right heart failure, a decision for placement of a transjugular intrahepatic portosystemic shunt (TIPS) was initially turned down. However, as intractable bleeding problems persisted and caused heavy transfusion needs, TIPS was ultimately performed as a rescue procedure. Although TIPS successfully reduced the hepatic venous pressure gradient from 16 mmHg to 4 mmHg, portal pressure remained high at 14 mmHg because of persisting right heart failure with elevated central venous pressure. Hepatic encephalopathy soon developed after TIPS placement and culminated in multi-organ failure after another episode of gastro-intestinal bleeding. At this point, the family of the patient decided to withdraw care and the patient died subsequently."
  },
  {
    "id": "multiclinsum_gs_en_273.txt",
    "fulltext": "A 30-year-old Chinese woman presented with a left ovarian mass during a routine physical examination. She was asymptomatic and had no prior medical history of brain tumors or neurological disorders. The patient suffered from polycystic ovaries at the age of 19 without any treatment. Serum levels of CEA, CA125 and CA19-9 were within normal ranges.\n\nAn MRI revealed a hypointense T1-weighted and hypertense T2-weighted lesion measured 6.3 × 4.8 cm in the left adnexal area, with a slightly lower signal mural attachment nodule. Additionally, the diffusion-weighted image (DWI) showed an isointense signal of the mural nodules. Therefore, it was considered as a benign or borderline tumor.\n\nThe patient underwent laparoscopic resection of the left ovary and fallopian tube. During the 12-months follow-up, she underwent pelvic and abdominal ultrasound examinations every three months, and no abnormalities were detected. She remained in good condition after surgery without chemoradiotherapy.\n\nPathological findings\nOn gross examination, a 5 × 3.5 × 1 cm cystic mass was found in the left ovary. Two mural nodules with diameters of 0.8 cm and 1.2 cm were observed, which were gray-red and soft in texture. Histologically, it formed a well-define nodule on low magnification. The components of teratoma included epidermis, skin appendages were visible in the surrounding mural nodule and cyst wall tissue. Under high magnification, it revealed disordered glial cells and ganglions proliferate in the mural nodule. Abnormal ganglions were aggregated, with large sized and irregular nucleus, which also exhibited obvious nucleoli, and binucleated cells was seen. The mitotic figures were hardly identified.\n\nImmunohistochemically, the glial cells were positive for GFAP and Olig2. The ganglion cells were positive for Neu-N, CgA, Nestin and CR. Moreover, the ganglion cells expressed CD34 and highlight the branched tumor cells. Weak expression of NSE and wild-type expression of P53 was observed in some tumor cells. Additionally, the tumor cells were negative for IDH1 and BRAF V600E. Ki67 index was approximately 5 %. Based on these findings, a diagnosis of ganglioglioma arising in an ovarian mature cystic teratoma was made.",
    "summary": "The patient, a 30-year-old woman with no prior medical history of brain tumors or neurological disorders, was found to have a cystic mass in the left ovary, accompanied by two mural nodules. Histologically, the mural nodule in the teratoma exhibited a combination of neoplastic ganglion and glial cells. Notably, the ganglion cells exhibited binucleation and focal distribution, with the occasional presence of Nissl bodies. Immunohistochemically, GFAP and Olig2 were positive in glial cells, chromogranin A (CgA), Nestin, CD34, Neu-N, and Calretinin (CR) were positive in ganglion cells. The tumor cells demonstrated a low Ki67 index, harbored a wild-type P53 expression and were negative for IDH1 and BRAF V600E. The patient underwent laparoscopic resection of the left ovary and fallopian tube and she was in good condition at 12 months follow-up."
  },
  {
    "id": "multiclinsum_gs_en_89.txt",
    "fulltext": "The female patient with a 7-week pregnancy achieved by IVF-ET resorted to our emergency services with abdominal pain, nausea, vomiting and diarrhea that had continued the last 3 days and gradually exacerbated. No abnormality was detected in the ultrasonographic examination, including embryonic cardiac activity, and conservative medical treatment was provided because the patient's complaints were related to pregnancy. However, the patient, whose complaints worsened, turned to our emergency services a second time.\n\nThe consultation was held in September 2021 at the General Surgery Unit of the Katip Çelebi University Faculty of Medicine, Atatürk Education and Research Hospital. There was no special condition in the patient's family history. There was a median incision scar above and below the umbilicus due to urological intervention in childhood. Body mass index was 24.6 kg/m2.\n\nThe patient was prescribed oral oestrogen therapy (2 mg/day Estradiol), intravaginal progesterone (4x200 mg/day) and acetylsalicylic acid (ASA, 100 mg/day) in the context of the IVF-ET protocol. She had tachycardia (110 bnp) at the time of admission, and her blood pressure and fever values were normal. At the time of baseline examination, signs of severe acute abdomen were observed. The laboratory findings were as follows; white blood cells: 24,800/µL, platelet count: 290,000/µL, C-Reactive Protein (CRP): 154 mg/L, INR:0.98 and beta-human chorionic gonadotropin (β-HCG): 54,335 mU/ml.\n\nAbdominal ultrasonography revealed intestinal anes dilations, free fluid in the pelvis, a left ovarian cystic lesion and a 7-week pregnancy sac, but no embryonic cardiac activity. Additionally, the gynecological consultation also confirmed the embryonic heartbeat was absent. The patient refused to undergo a computed abdominal tomography and other radiological tests.\n\nAfter the patient's abdominal pain and fever increased, blood tests were performed again and an increase in inflammation markers was observed. The patient accepted to undergo surgery after peritonitis findings exacerbated and her general condition started to deteriorate. We obtained informed consent from the patient. Surgical exploration encountered slightly serohemorrhagic fluid of 200 cc, as well as circulatory impairment and necrosis intermittently located at the two separate sections of the small intestine, beginning from the 90th cm after the Treitz ligament in the abdomen. A necrotic small bowel resection of approximately 150 cm was performed at two separate sections. The other findings observed during the surgery were as follows: 1) thrombi in the moderate and small-sized veins of the small bowel mesentery despite the presence of pulses in the arteries feeding the small intestines, 2) thickening of small bowel mesentery, 3) small and moderate-sized venous vein dilatation observed in the right halves of the right colon and transverse colon, and 4) left ovarian cystic lesion. Towards the end of the surgery, regeneration of ischemic fields was encountered in the small bowel segments close to the anastomosis. A second-look laparotomy was decided upon to control the presence of new ischemia in the small intestines.\n\nAdministration of intravenous total parenteral nutrition (40 cc/h), intravenous antibiotics and full anticoagulation with low molecular weight heparin (2*6000 anti-Xa IU) was initiated postoperatively and continued until discharge from the hospital. The embryo was removed after confirmation of stillbirth by the postoperative gynecological examination. The contrast-enhanced computed tomography (CT) performed on the 1st postoperative day revealed a long segment thrombus in the superior mesenteric vein (SMV) and pulmonary embolism. A second-look laparotomy was carried out 48 hours after the first surgery. The exploration showed that blood supply and feeding of all intestinal anuses were intact, while no anastomotic complication was present. The histopathological examination of the section resected in the first surgery demonstrated sporadic necrotic fields in the small bowel wall.\n\nThe patient's thrombophilia panel showed Factor V Leiden (FVL) (homozygous), methylenetetrahydrofolate reductase (MTHFR) (heterozygous) and plasminogen activator inhibitor 1 (PAI-1) 4G/5G (homozygous) gene mutations. The levels of protein S (49% [reference: 60-130%]) and protein C (62% [reference:70-140%]) were lower than normal limits. The patient was discharged without any complication. The patient has been monitored by the polyclinic without any complication since the 6th postoperative month.\n",
    "summary": "A 34-year-old woman presented with abdominal pain on the eighth day after cesarean section for placenta previa, which required suturing of B-Lynch for uterine atony and whose diagnosis was uterine necrosis. The patient required total abdominal hysterectomy, with satisfactory evolution. A systematic search of the literature was performed in the Medline databases via Pubmed, Embase and Web of Science. Series and case reports and cohorts of women with uterine necrosis after the use of sutures of uterine compression for control of postpartum hemorrhage were searched. Sociodemographic and clinical variables were analyzed at diagnosis, suturing technique, diagnostic tests and treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_105.txt",
    "fulltext": "A 38-year-old Chinese man was admitted to our hospital for more than two years with mild proteinuria accompanied by microscopic hematuria during laboratory examination. The patient was asymptomatic. There was no previous history of other diseases, and none of the patient’s family member had renal or autoimmune diseases. No history of ingestion of any drug or Chinese herbal medicine. On admission, his blood pressure was 151/81 mmHg, and physical examination revealed no specific signs of hyperlipidemia, such as corneal opacity or xanthomas. At presentation, he had proteinuria (0.94 g/24 h) and hematuria, but no leukocyturia. His estimated glomerular filtration rate (eGFR) was 84 mL/min per 1.73 m2. Total cholesterol and triglyceride levels were 205 mg/dL and 115 mg/dL, respectively. The immunological indicators, such as serum C3, C4, and IgA levels were normal. The other laboratory parameters are described in Table 1. Immunofluorescence assay showed strong staining for IgA, C3, and ApoE, but negative staining for IgG, IgM, C1q, and C4. Futhermore, double immunofluorescence showed that both KM55 and IgA stained positive in the mesangial region. Renal biopsy revealed markedly dilated capillary lumina filled with thrombus-like substances and mesangial proliferation. About 12% of interstitial fibrosis with tubular atrophy was also observed. Thrombus-like substances stained positive for Sudan III and ApoE. Electron microscopy revealed lipid granule deposition in the dilated glomerular capillary lumen, mesangial hyperplasia, and electron-dense deposition in the mesangial area. These pathological characteristics were consistent with those of LPG with IgAN.\n\nThe ApoE gene analysis revealed a heterozygous C→T transition in exon 3, which changed the amino acid at position 25 from arginine to cysteine (Kyoto mutation). Family genotyping showed that this mutation was transmitted from the father to his daughter. The serum ApoE was 14.4 mg/dL determined by enzyme-linked immunosorbent assay (LOT: 20210702, JianCheng Bioengineering Institute). Combined with the above findings, the patient was diagnosed with LPG accompanied by IgAN.\n\nAfter the renal biopsy, the patient was followed-up at the outpatient clinic of Daping Hospital. The plasma lipid level and eGFR were within the normal ranges for 18 months, even without lipid-lowering drugs. The proteinuria improved (fluctuated at + ~ ±; urinary albumin/creatinine ration from 186.06 mg/g Cr to 111.72 mg/g Cr) after administration of 10 mg of enalapril per day. Additionally, we followed-up with his daughter and her urine protein levels remained negative.",
    "summary": "A 38-year-old man was admitted to our hospital due to proteinuria and hematuria, which was found during urine examination. Renal function and blood lipid and lipoprotein levels were normal. After renal biopsy, the patient was diagnosed of LPG with IgAN. Analysis of the ApoE gene showed a heterozygous C→T transition in exon 3, resulting in a change in the 25th amino acid from arginine to cysteine (Kyoto mutation). Genetic analysis of the family showed that this mutation was inherited from his father and passed on to his daughter. Serum ApoE was 14.4 mg/dL. Combined with the above findings, the patient was diagnosed with LPG accompanied by IgAN. After 18 months of enalapril treatment without lipid-lowering therapy, the patient's renal function and blood lipid levels were stable and urine protein levels were significantly ameliorated."
  },
  {
    "id": "multiclinsum_gs_en_61.txt",
    "fulltext": "A 51-year-old male was admitted for the chemotherapy protocol FLAG-IDA (fludarabine, cytarabine, idarubicin and G-CSF) for an acute myelogenous leukemia with early relapse.\n\nOn the 12th day of treatment, while in the midst of a prolonged and profound neutropenia (absolute neutrophil count of 10 cells/µl), the patient developed fever, chills, and myalgia, associated with the sudden appearance of a nodular, erythematous lesion with necrotic center at the base of the neck. Blood cultures reported growth of Candida tropicalis . 48 hours later, despite broad-spectrum antimicrobial treatment, including amphotericin B, multiple reddish papular lesions appeared, mainly in the trunk, but also spread to the extremities.\n",
    "summary": "A 51-year-old male with profound and prolonged neutropenia 12 days after the start of chemotherapy for acute myelogenous leukemia developed a nodular, erythematous lesion with necrotic center at the base of the neck, associated with fever, chills, and myalgia. Invasive fungal infection was diagnosed after the development of Candia tropicalis in blood cultures. He developed multiple reddish papular lesions mainly concentrated in the trunk, but also spread to the extremities.\n"
  },
  {
    "id": "multiclinsum_gs_en_103.txt",
    "fulltext": "A 1-year-old girl was referred to our hospital with a 3-month history of diarrhea and weight loss. She was fed a mixed diet (breast and formula milk) from birth, beginning with rice and soybeans at 6 months and progressing to cows’ milk, wheat, and chicken eggs (yolk and white) at 8 months. She did not develop anaphylactic symptoms with formula milk and cows’ milk intake. There were no accompanying signs and symptoms related to other organs, such as mild eczema, skin dryness, or frequent upper respiratory tract infection due to cows’ milk allergy. Neither she nor anyone in her family had allergic diseases, such as atopic dermatitis or asthma. At 9 months of age, she developed vomiting, diarrhea, and anorexia; her previous diagnosis was infectious gastroenteritis and postenteritis syndrome. One month before her transfer to our hospital, she was admitted to the previous hospital because her symptoms did not improve for two months, and her weight loss progressed. During the 2 months prior to her admission, her diet was unrestricted. Although her vomiting improved after a few days of fasting, oral intake of elemental diets, formula milk, or rice porridge resulted in repeated diarrheas. Upon admission to our hospital, her physical examination revealed the following: height, 69.0 cm (standard deviation [SD] −2.2); bodyweight, 6641 g (SD −2.8), 999 g lesser than the weight measured 3 months ago; body temperature, 37.1 °C; heart rate, 96 beats per minute; and blood pressure, 88/50 mmHg. Her blood test results were as follows: white blood cell count, 16,900/mL (normal range [NR]: 7000–15,000); eosinophil percentage, 2.0% (NR: <5.6); hemoglobin, 9.9 g/dL (NR: 13.7–16.8); and platelet count, 679 × 103 cells/mL. Her laboratory test findings were as follows: total protein, 6.4 g/dL (NR: 6.8–8.1); albumin, 3.9 g/dL (NR: 4.1–5.1); aspartate aminotransferase, 35 IU/L (NR: 20–45); alanine aminotransferase, 17 IU/L (NR: 4–24); blood urea nitrogen, 7.4 mg/dL (NR: 8–20); C-reactive protein, 0.47 mg/dL (NR: <0.03); sodium, 135 mEq/L (NR: 137–147); potassium, 3.6 mEq/L (NR3.6–5.2); bicarbonate, 19.1 mmol/L (NR: 21.0–27.0); and lactic acid, 21 mg/dL (NR: 4–16). At this time, a sufficient number of calories, amino acids, and fat was being administered intravenously. The serum IgE level was 1028 IU/mL (NR < 30), and radioallergosorbent tests were positive for milk (63.7 UA/mL class 5), casein (9.8 UA/mL class 3), alpha-lactalbumin (51.6 UA/mL class 5), egg white (58.8 UA/mL class 5), egg yolk (10.8 UA/mL class 3), ovomucoid (13.2 UA/mL class 3), wheat (14.5 UA/mL class 3), and soybean (1.3 UA/mL class 2). Skin prick tests were not performed to confirm the results of specific IgE test. Immunoglobulin (Ig) levels (IgG, 954 [NR 357–989] and IgM, 89 [NR 29–190]) and lymphocyte subset ratios were normal. Fecal eosinophil tests were negative, and no infection was detected in stool culture tests. Stool adenovirus, rotavirus, and norovirus antigen tests were negative.\n\nImaging and endoscopy examinations were performed to determine the cause of the prolonged diarrhea. Abdominal computed tomography and ultrasound examinations revealed no abnormalities in the small intestine; the large intestine was dilated but no wall thickening was observed, suggesting nonspecific enteritis. An EGD showed no macroscopic abnormalities from the esophagus to the duodenum. However, histopathology of the duodenum mucosa revealed the loss of mucosal villous structure, crypt hyperplasia, crypt apoptosis, and lymphocyte and eosinophil infiltration (<20 eos/hpf) into the lamina propria, with partially formed crypt abscesses. Total colonoscopy showed no abnormal macroscopic findings; however, histopathology of the colonic mucosa revealed erosion of the mucous membranes; cryptitis with decreased goblet cells, fibrosis, plasma cells, and lymphocytes; and some eosinophil infiltration (<20 eos/hpf) into the lamina propria. These findings were similar to the findings in the duodenum mucosa.\n\nAutoimmune enteropathy and inflammatory bowel disease (IBD) were suspected; therefore, additional tests were performed. Antiautoimmune enteropathy-related 75 kDa antigen and anti-villin antibodies were absent and no significant pathogenic variants were found in 25 genes (covered by public insurance in Japan) related to monogenic IBD and immunodeficiency, polyendocrinopathy, enteropathy X-linked (IPEX) syndrome. EGID was considered in the differential diagnosis, but a diagnosis of FPE was finally suspected based on the characteristics of the gastrointestinal mucosa, such as atrophy of small intestinal mucosal villi, crypt hyperplasia, eosinophil infiltration below the EGID diagnostic criteria (<20 eos/hpf), and lymphocyte infiltration. Her peripheral blood eosinophil count was also not elevated. Chronic atypical (positive for specific IgE) non-IgE-GIFA was suspected (7). Her diarrhea disappeared after prednisolone (PSL) therapy (1 mg/kg) and the complete removal of formula milk, cows’ milk, and chicken eggs from her diet. No relapse occurred even after discontinuing PSL one month later. Adverse effects due to long-term treatment with PSL, such as hypertension, did not occur. Five months after discontinuing oral PSL and the complete removal of formula milk, cows’ milk, and chicken eggs, duodenal histopathology revealed normal mucosal villous structure and well-differentiated ductal arrangement. Three months after the second EGD, she resumed eating chicken eggs without experiencing gastrointestinal symptoms such as diarrhea and vomiting; however, 3 months later, her symptoms, including abdominal pain and diarrhea, relapsed within days of resuming cows’ milk consumption. Based on the abovementioned findings, FPE was diagnosed, with cows’ milk suspected to be the allergen source. At 2 years and 3 months, her height had improved to 81.5 cm (SD −1.4) and her weight to 11.4 kg (SD +0.33) without the occurrence of gastrointestinal symptoms.",
    "summary": "We describe the case of a 1-year-old girl with food protein-induced enteropathy (FPE) that was difficult to diagnose. She was referred to our hospital with a 3-month history of diarrhea, vomiting, and weight loss. Although her diarrhea improved after a few days of fasting, oral intake of elemental diets, formula milk, or rice porridge resulted in repeated relapses. The serum IgE level was 1028 IU/mL, and radioallergosorbent tests were positive for milk, casein, alpha-lactalbumin, and other allergens. A histopathology of the duodenal mucosa revealed loss of mucosal villous structure, crypt hyperplasia, crypt apoptosis, and lymphocyte and eosinophil infiltration (<20 eos/hpf) into the lamina propria. After prednisolone (PSL) therapy and the complete removal of cows’ milk and chicken eggs from her diet, the patient’s diarrhea disappeared. Five months after discontinuing oral PSL and complete removal of cows’ milk and chicken eggs, the duodenum exhibited normal mucosal villous structure and well-differentiated ducts. No abnormalities were observed in the egg rechallenge; however, diarrhea recurred after the cows’ milk rechallenge."
  },
  {
    "id": "multiclinsum_gs_en_18.txt",
    "fulltext": "We describe a 25-year-old woman diagnosed with AD since childhood and subsequent onset of slowly progressive vitiligo at the age of 16. At baseline examination, the patient presented diffuse cutaneous xerosis, excoriated papules and plaques on the back, and lichenified erythematous lesions on the upper limbs and dorsum of the hands with an Eczema Area and Severity Index (EASI) of 18. The patient reported intense itching (Number Rating Scale [NRS] = 10). Confluent achromic macules suggestive of vitiligo were also present on the elbows and on the face, predominantly on the eyelid region, bilaterally. The patient also showed multiple irregularly shaped achromic macules on the neck, trunk and dorsum of the hands, and initial hypopigmented manifestations on the left axillary region and left knee with a Vitiligo Area Scoring Index (VASI) of 0.45. Both skin conditions had an impact on her quality of life, resulting in a Dermatology Life Quality Index (DLQI) of 17.\n\nPrevious treatments for AD included topical and systemic corticosteroids, topical calcineurin inhibitors, antihistamines, and a short course of cyclosporine, which was discontinued due to intolerance. Previous treatment for vitiligo included short-term treatment with topical and systemic corticosteroids at disease onset and, for the first 2 years, without results. Subsequently, tacrolimus, a topical calcineurin inhibitor, was used for several years following a proactive pulsed maintenance regimen after an initial induction period, yielding minimal therapeutic benefits. Antioxidants and vitamin-based products were also used as adjuvant therapies. Due to logistical reasons, the patient refused phototherapy.\n\nGiven the coexistence of AD and vitiligo, and considering the potential additional benefits, systemic therapy with upadacitinib 15 mg daily was initiated after medical and laboratory evaluations to exclude pregnancy and other contraindications. Based on the approved indication of upadacitinib for AD, we opted to start treatment with a view to achieving the lowest effective dose.\n\nProgressive improvement of AD was observed after the first weeks of treatment with clinical remission at week 16 (EASI 0; NRS 0) associated with improved quality of life (DLQI 0). At the same time, clear improvement of vitiligo was observed with complete repigmentation of the achromic areas on the neck, trunk, back of the hands, and elbows (Fig. 1b), and partial but significant repigmentation of the achromic patches of the eyelid region (Fig. 2b) (VASI = 0.25). An almost complete remission of vitiligo was achieved at week 28 of treatment and was maintained up to 1 year of follow-up, with no side effects except for a slight worsening of acne, easily controlled with topical therapies.",
    "summary": "We describe a 25-year-old woman diagnosed with AD since childhood and subsequent onset of slowly progressive vitiligo at the age of 16. Systemic therapy with JAK1 inhibitor upadacitinib 15 mg daily was started, after a medical and laboratory evaluation to exclude pregnancy and other contraindications. Progressive improvement of AD was observed after the first weeks of treatment with clinical remission at week 16. At the same time, clear improvement of vitiligo was observed with an almost complete remission achieved at week 28 of treatment."
  },
  {
    "id": "multiclinsum_gs_en_17.txt",
    "fulltext": "A 70-year-old man with chronic renal disease due to diabetic nephropathy started hemodialysis in June 2013. He underwent a deceased-donor transplant with expanded criteria (93% kidney donor profile index [KDPI], one HLA-A, one HLA-B, and zero HLA-DR incompatibilities; and calculated antibody reactivity panel [PRAC] of 20% in class I and 0% in class II, with no donor-specific antibodies [DSA]) in August 2014. He had a positive CMV IgG serology and the donor's serology was unknown. The patient received induction therapy with a single dose of 3 mg/kg antithymocyte globulin and maintenance therapy with tacrolimus (TAC), mycophenolate sodium (MPS), and prednisone. No CMV prophylaxis was given. He had a favorable clinical course with a serum creatinine of 1.2 mg/dL after five years of transplant (eGFR CKD-EPI 61mL/min/1.73m2), without CMV infection or episodes of acute rejection.\n\nOne year after transplant, he was diagnosed with clear cell carcinoma of the native left kidney and underwent a curative nephrectomy. At this time, the dose of MFS was reduced to 360 mg BID and blood concentrations of TAC were maintained between 7 to 12 ng/mL.\n\nHe was admitted in December 2019 with a complaint of decreased visual acuity of the left eye with a seven day history, associated with local hyperaemia, but without any exudate. The patient had no complaints of the right eye. He underwent a complete ophthalmologic evaluation, which resulted in a diagnosis of suspected retinitis associated with herpes infection. Immediate empirical treatment with intravenous acyclovir was initiated and MFS was discontinued. A complete investigation for other immunodeficiency states was negative, including negative serologies for HIV, syphilis, bartonellosis and toxoplasmosis. The blood viral load for Herpes simplex and Varicella Zoster by polymerase chain reaction (PCR) was undetectable, but was positive for CMV (49 IU/mL - the lower limit of quantification is <31 IU/mL). At that time, we could not perform a quantitative nucleic acid amplification testing (QNAT) using ocular fluids. The hypothesis of tumor recurrence or possible neoplastic lesions was excluded by computed tomography. Six days later, the patient progressed with progressive worsening of visual acuity, involving also the right eye. A follow-up ophthalmologic evaluation revealed superior conical retinitis with significant artery sheath enlargement, microhaemorrhages, vitreous inflammation and temporal pigmentary alteration. Antiviral therapy was changed to ganciclovir, in order to cover both possible agents involved, Herpes and CMV. At that time, CMV DNAemia was undetectable. There was a progressive improvement in visual complaints, and another ophthalmologic evaluation showed a progressive healing of the retinal lesions 21 days after the initiation of ganciclovir. The treatment was extended for 28 days based on a follow-up ophthalmologic evaluation of the complete healing of the retinal lesions. He was discharged from the hospital with an improvement of his visual acuity, and no secondary prophylaxis was instituted.\n",
    "summary": "The authors report a 70-year-old man with diabetes renal disease who underwent a renal transplant (KT) in August 2014 with good clinical evolution. No previous CMV infection or episodes of acute rejection were reported. Five years after the transplant, he was admitted due to a reduced visual acuity of the left eye with seven days of evolution with associated hyperemia, without exudate. The ophthalmologic evaluation was compatible with acute retinal necrosis and presumably associated with CMV infection. He had a progressive improvement after the initiation of ganciclovir.\n"
  },
  {
    "id": "multiclinsum_gs_en_269.txt",
    "fulltext": "A 31-year-old female presented with right elbow pain for the past 3 years with no past injury to the elbow. Physical examination revealed elbow stiffness and tenderness of the lateral epicondyle of the humerus. Cozen assessment was positive, indicating a clinical diagnosis of lateral epicondylitis of the elbow. The plain radiograph showed patches in the right lateral condyle of the humerus and the dorsal part of the olecranon. Free spots in the dorsal region of the olecranon process of the ulna. Computed tomography (CT) showed a high-density macular focus and smooth edge of the lateral condyle of the right humerus and dorsal side of the ulnar olecranon. There was a high-density shadow with a clear boundary, no noticeable fracture line shadow in the elbow joint, and no noticeable swelling in the surrounding soft tissue. Indicating calcification of common extensor tendinosis. Since a bony mass was noted around the lateral epicondylar region of the elbow, CT was performed to exclude the extent and characteristics of this lesion and to rule out any hostile pathology, such as malignancy. The patient had undergone conservative treatment for approximately 2 years. Her visual analog scale score before surgery was 6/10. Her pain did not respond to conservative treatment with analgesics, physiotherapy, or a rest regimen. The pain recurred more intensely 1 week prior, to the extent that she could not use her right upper limb to perform daily activities, and her sleep was severely disturbed. Therefore, surgical treatment was recommended for her. The patient then underwent surgical exploration of the elbow under general anesthesia. A right elbow lateral incision of approximately 5 cm, an incision of the subcutaneous tissue exposed to the extensor tendon, and a milky white liquid outflow from the common extensor tendon region with dystrophic calcification was made. Decompression of the involved tendons and thorough cleaning were performed. Calcification was excised, and extensor tendon repair was done using 2-0 Vicryl sutures. The patient was advised to rest with minimal exercise for 1 month, followed by complete physical activities. Histopathological examination of the excised tissue revealed fibrous ligament tissue with calcifications. The postoperative plain radiograph showed complete removal of the heterotopic bony growth from the lateral epicondylar area with no recurrence of the heterotopic bone formation around the elbow joint. The patient had complete elimination of elbow pain (visual analog scale score 0/10), and at the follow-up of 6 months, she had no pain with full elbow function and a full range of elbow extension and flexion.",
    "summary": "Patient concerns: We detailed a young female who presented with progressive right elbow pain for the past 3 years with no past injury to the elbow. She had undergone conservative management for 2 years but was unsuccessful. Her pain became more intense 1 week prior, to the extent that she could not use her right upper limb to perform daily activities, and her sleep was severely disturbed. Therefore, she needed a possible therapeutic relief.\n\nDiagnosis: Clinical findings included elbow stiffness and tenderness of the lateral epicondyle of the humerus, and Cozen assessment was positive. Computed tomography showed a high-density macular focus and smooth edge of the lateral condyle of the right humerus and dorsal side of the ulnar olecranon. The plain radiograph showed patches in the right lateral condyle of the humerus and the dorsal part of the olecranon, indicating calcification of common extensor tendinosis.\n\nInterventions: Initially, conventional care was given to the patient with analgesics, physical therapy, or a resting regimen to decrease the pain and reduce the tedious load on the extensor tendon. Measures such as pain score, range of motion, and follow-up imaging after 8 weeks began until 2 years. However, her pain did not improve. Therefore, she was advised for surgical therapy and subsequently underwent surgical exploration of the elbow under general anesthesia. Histopathological examination of the excised tissue revealed fibrous ligament tissue with calcifications.\n\nOutcomes: At the 6-month follow-up, the postoperative plain radiograph showed complete removal of the heterotopic bony growth from the lateral epicondylar area with no recurrence of the heterotopic bone formation around the elbow joint. She had no pain with full elbow function and a full range of elbow extension and flexion (visual analog scale score of 0/10)."
  },
  {
    "id": "multiclinsum_gs_en_283.txt",
    "fulltext": "Patient information\nA male neonate was born via spontaneous vaginal delivery at 33 weeks of gestation due to an unknown cause of labor initiation. At birth, his body length was 42 cm, and his weight was 1.98 kg. No abnormalities were observed in the amniotic fluid, placenta, or umbilical cord, but scalp edema was noted. Shortly after birth, the infant developed respiratory distress, which required endotracheal intubation with mechanical ventilation and administration of pulmonary surfactant. This intervention allowed for a reduction in ventilator parameters, and nutritional support was provided via a peripherally inserted central venous catheter (PICC). By the 18th day of life, the infant exhibited stable breathing, tolerated feeding well, and had normal bowel sounds on abdominal examination. The parents opted for discharge at this time. However, on the 26th day of life, the neonate was readmitted to the neonatal department due to poor appetite, lethargy for 5 days, respiratory distress for 1 day, and poor responsiveness.\n\nPhysical examination\nPhysical examination revealed a body temperature of 38.2°C, a heart rate of 140 beats per minute and a respiratory rate of 42 breaths/min. The abdomen was soft, no intestinal type or peristaltic wave was found, the liver and spleen were not enlarged, and the bowel ringing was weak. He appeared lethargic with poor responsiveness. The jaundice and pallor in skin, a flat anterior fontanelle without signs of tension, and positive Kernig's sign with reduced muscle tone in the extremities were also observed.\n\nInvestigations\nThe blood routine examination revealed leukopenia (2.26 × 10^9/L) with neutropenia (1.12 × 10^9/L), elevated C-reactive protein (38.0 mg/L), and increased procalcitonin (1.100 ng/mL). Lumbar puncture showed normal pressure but elevated white cell count (1039.00 × 10^6/L), high protein (2.47 g/L) and low glucose (1.30 mmol/L) in cerebrospinal fluid (CSF). Aerobic blood culture and CSF culture was performed initially upon admission, which yielded negative results. No abnormality was observed in abdominal ultrasound, however, pulmonary ultrasound revealed bilateral consolidations and alveolar-interstitial edema. In addition, echocardiography showed patent foramen ovale. Large hyperechoic areas in the left frontal and parietal lobes, with absent diastolic blood flow in the anterior and middle cerebral arteries were indicated by cranial ultrasound.\n\nManagement\nTracheal intubation and mechanically ventilator support were performed upon admission. On the day of admission, the patient experienced convulsive attacks, manifested as oral tic, which were controlled by phenobarbital sodium. Notably, On the 2nd and 6th day after admission, two CSF metagenomic next-generation sequencing (mNGS) have identified C. butyricum with 382 and 98 sequencing reads, respectively, thus diagnosing C. butyricum suppurative meningitis. The medical history found that the patient continued to take probiotics containing C. butyricum from the 10th day of birth in order to promote the secretion of digestive enzymes and intestinal moistalsis, and shorten the time to reach total enteral nutrition. Therefore, probiotics-associated suppurative meningitis was considered a high possibility and the anti-infection therapy including meropenem and vancomycin was administrated without adjustment.\n",
    "summary": "We described a 26-day-old premature neonate who was diagnosed with probiotic-related C. butyricum meningitis. Upon the admission, suppurative meningitis was considered based on cerebrospinal fluid (CSF) biochemical test and neuroimaging examination, and C. butyricum was subsequently identified by CSF metagenomic next-generation sequencing. Given the history of administrating living C. butyricum products before admission, probiotics-associated suppurative meningitis was considered a high possibility, leading to the confirmation of anti-infection treatment including vancomycin and meropenem. Following this therapy, the infant's CSF profiles demonstrated improvement. Additionally, further phylogenetic analysis confirmed the high homologous of C. butyricum from CSF with probiotics."
  },
  {
    "id": "multiclinsum_gs_en_85.txt",
    "fulltext": "A 24 years old pregnant woman was admitted in Debre Tabor Comprehensive Specialized Hospital gynecology ward due to severe preeclampsia and preterm delivery. She did not have signs and/or symptoms of balantidiasis. She had no history of smoking, drinking alcohol, and other underlying chronic diseases. However, her caregiver health professional sent urine sample for routine urinalysis test to the inpatient laboratory department.\n\nThe urine physically appeared to be somewhat dark and turbid with little foam. The chemical examination (Agape ™ Urine Reagent Strips test kit) results revealed; Specific gravity of 1.01, pH=6.0, Albumin=1+, blood=3+ (hematuria), and Leucocyte=2+ (leucocyturia) which may be indicative of urinary tract infection (UTI). From the microscopic examination of centrifuged (3600RPM for 3 minutes) urine sediment, we found motile and ciliated parasite together with many white blood cells /high power field (HPF) and many epithelial cells/low power field (LPF). The processing of urine was conducted within five minutes after passage. The urine sediment repeated in the next morning revealed similar result.\n\nThe ciliated parasite appeared to be ovoid with rapid motility in circular fashion under the microscope slide. The entire body of the parasite was enclosed with short and uniform cilia which aided its motility. But, the cilia around the mouth appeared to be longer and clearly visible than the others. The parasite possessed the mouth part that was found at pointed anterior end (cytostome) and rounded posterior end (cytopyge). In addition, the body of the parasite contained several food vacuoles, macro- and micro-nuclei, and some red blood cells inside the cytoplasm. This parasite with unique morphological characteristics was confirmed by medical parasitologists and experienced microscopists jointly to be B. coli. We did not have gone to further staining of the parasite as we easily and correctly confirmed it with microscopy.\n\nHowever, this was incidental and strange finding from the urine and it has never been detected here even from stool. The stool sample was collected from the patient. The stool physically appeared formed. But, it was found negative for the parasite. Finally, the finding was reported to the concerning health care giver for intervention and additional information was collected if she had contact with risk factors. But, she had no history of contact with pigs. She came from rural area where goats, sheep and other domestic animals are always in close contact with humans. She also had history of feeding raw vegetables. In addition, there are monkeys around the area which might have contaminated the vegetables she ingested.",
    "summary": "A 24-year old pregnant woman was admitted due to severe preeclampsia and preterm delivery at Debre Tabor Comprehensive Specialized Hospital, gynecology ward. Her urine was presented to inpatient laboratory for routine urinalysis. We detected unusual and ciliated parasite from her urine sediment characterized by its active and rotary motility through its cilia and possessing macro- and micro-nuclei, several food vacuoles and ingested red blood cells inside the cytoplasm. Hematuria, many white blood cells and epithelial cells were also detected from the urine sediment, which suggests genito-urinary tract infection due to this parasite. This rare parasite finding was confirmed to be B. coli."
  },
  {
    "id": "multiclinsum_gs_en_334.txt",
    "fulltext": "A 21-year-old 25 week G3P1011 female with no PMH presented to the Emergency Department (ED) after sustaining a GSW wound to her left buttock while sitting in a car. On arrival, the patient was hemodynamically stable, with vitals within normal limits. Primary and secondary surveys were significant for mild distress, lower abdominal pain, a gravid uterus, and a GSW just superior to the left greater trochanter with no exit wound. There were no signs of vaginal or rectal bleeding during evaluation. Obstetrics and gynecology (Ob/Gyn) subsequently performed a bedside ultrasound that was negative for fetal heart tones. Abdominal and pelvic x-rays demonstrated a trans-pelvic bullet trajectory with the bullet lodged in the anterior abdominal wall. The patient was hemodynamically stable, and underwent Computed Tomography (CT) of the abdomen and pelvis which demonstrated an acute comminuted fracture of the left iliac bone, passage of a bullet through the fetal cranium terminating near the placenta, a moderate quantity of free fluid in the pelvis suggestive of peritoneal blood product with concern for active extravasation from the uterus, and no evidence of retroperitoneal fluid collection.\n\nManagement\nAfter imaging the patient was taken immediately to the operating room for emergent exploration of maternal injuries with OB/Gyn on standby to evaluate the cause of fetal demise. A midline laparotomy was performed to access the abdominal cavity, with no blood visible upon entry. The liver, spleen, stomach, and pancreas were inspected with no noted injuries. The bowel was run from the ligament of Treitz to the terminal ileum with no signs of injury to the mesentery or bowel. The colon was examined from the cecum to the peritoneal reflection of the rectum, and no injuries were noted. A large left retroperitoneal hematoma at the left lower cervico-uterine junction was noted and explored. The ureter was identified without injury. The left iliac artery and vein were inspected from the common iliac past the bifurcation and GSW in the pelvis, with both structures without injury. The bullet traversed the uterus, with two perforations noted in the left anterior and mid posterior uterus. Given that the bullet had traversed the full layer of the myometrium, OB/Gyn determined that surgical intervention by their team was warranted.\n\nThey began by ligating the hypogastric artery and using vessel loops to control the bilateral internal iliac arteries and minimize intraoperative bleeding, with subsequent delivery of the fetus and placenta. The fetus had sustained a GSW to the right temporal and left occipital regions, and was declared deceased upon delivery. Uterine injuries from bullet fragments were repaired with 0-vicryl. The OB/Gyn team performed a hysterotomy repair with 1–0 vicryl suture in a continuous locked fashion. The bilateral ovaries and fallopian tubes were inspected and appeared unremarkable. A non-expanding left sided hematoma was visualized in the left broad ligament. There was also some bleeding from the area around the uterine artery and vein in the left lower pelvis. The left uterine artery was ligated with a 2–0 vicryl suture. The abdomen was then examined and irrigated. The Fascia was closed with 1–0 PDS suture in a continuous fashion, and skin was closed with staples. Estimated blood loss (EBL) was 650 ml at the conclusion of the case.\n\nFollow up\nThe patient followed up with Trauma Surgery on November 15, 2023. She stated that she was doing well, tolerating her diet, and that her pain was well controlled. Staples were removed from her midline incision and the patient was sent home with no further follow up appointments. Per patient preference, she preferred to follow up with her primary OB/Gyn at an outside facility.",
    "summary": "A 21-year-old 25 week G3P1011 female with no past medical history (PMH) presented to the Emergency Department (ED) after sustaining a GSW wound to her left buttock while sitting in a car. She presented with an acute comminuted fracture of the left iliac bone, and passage of a bullet through the fetal cranium terminating near the placenta. Management consisted of immediate resuscitation, imaging, and emergent abdominal exploration leading to delivery of a non-viable fetus."
  },
  {
    "id": "multiclinsum_gs_en_537.txt",
    "fulltext": "30-year-old woman with a history of celiac disease and a diagnosis in 2021 of adeno-squamous infiltrating carcinoma of the cervix, stage IV b, with retroperitoneal and abdominal-pelvic lymph node involvement. She completed intensity-modulated radiotherapy (IMRT) in the pelvis and retroperitoneum with boost in the left paramedian and concurrent cisplatin for 6 cycles. She also completed 2 courses of chemotherapy with cisplatin/gemcitabine. After 8 months, a control PET-CT scan showed an increase in size and metabolic activity of retroperitoneal and abdominal lymph nodes, which led to the initiation of treatment with pembrolizumab after demonstrating PDL1 expression in the initial biopsy. After the 8th cycle, immunomediated hypothyroidism was diagnosed, and levothyroxine was indicated, and continued with pembrolizumab due to favorable response. In January 2023, she was admitted for epigastralgia, late postprandial vomiting of 6 weeks of evolution and loss of 10 kg of weight. Physical examination did not reveal relevant data. Hto 33%, Hb 10 g/dL, ferremia 64 mcg/ dL, ferritin 250 ng/ml, transferrin 113 mg/dL, hypoproteinemia (4 g/dL) and hypoalbuminemia (2.4 g/dL). Anti-transglutaminase antibodies and HIV serology were negative. Abdominal and pelvic TAC: stomach with thickened walls. VEDA: extensive ulcerated lesion in the antrum and corpus of the stomach, edematous, with white-yellowish material (pseudomembranes) that denuded the mucosa when it was detached and compromised the pylorus. In the 2nd duodenal portion, a decrease in the height of the folds (in relation to a history of celiac disease) was observed. Flow cytometry: negative for lymphoproliferative process. Histology: antral mucosa with marked reactive and reparative epithelial changes, extensive denudation and erosion of the surface epithelium with accompanying white-yellowish fibrinoleucocyte material. In the lamina propria, an increase in the inflammatory infiltrate consisting of lymphocytes, plasma cells and numerous polymorphonuclear cells with exocytosis in the glandular epithelium was observed. Helicobacter pylori and cytomegalovirus (CMV) infection were ruled out. Immunohistochemistry: expression for PDL1 (Clone SP263), with a combined positive score (CPS) of 35%, which included a relative contribution of epithelial cells of 25% and inflammatory cells of 10%. With the suspicion of immunomediated gastritis, pembrolizumab was discontinued and meprednisone 0.5 mg/kg/day was initiated; it progressed favorably with tolerance to solid and liquid food. After three weeks of initiation of treatment, endoscopy was repeated, which evidenced a stomach with clear mucous content, fundus and body without lesions, antrum with congestive mucous and multiple extensive and superficial ulcers covered by fibrin. The descent of corticosteroids was initiated, and the reexposure to pembrolizumab will be defined with the oncologist in charge.\n",
    "summary": "A patient with cervical cancer under treatment with pembrolizumab presented with nausea, vomiting and weight loss. Endoscopy demonstrated an ulcerated lesion covered by mucous in the antrum and corpus of the stomach. The biopsy revealed extensive denudation of the gastric mucosa with fibrinoleucocyte material. The lamina propria showed an increase in lymphocytic and polymorphonuclear inflammatory infiltrate. Immunohistochemistry confirmed PDL1 positivity (clone SP2630) and a combined positive score (CPS) of 35%, with a relative contribution of epithelial cells of 25% and inflammatory cells of 10%. After three weeks of treatment with 30 mg of meprednisone, endoscopy showed a stomach with clear mucous content; fundus and corpus without lesions, antrum with congestive mucous and multiple extensive and superficial ulcers covered by fibrin.\n"
  },
  {
    "id": "multiclinsum_gs_en_217.txt",
    "fulltext": "A 65-year-old man had been a heavy smoker and had smoked at least 20 cigarettes every day since the age of 20. He suffered from back and pelvic pain and penile swelling with pain for five months. He suffered from gross hematuria for two months. He visited our hospital in December 2022. He suffered from priapism and could not undergo cystoscopy. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a bladder tumor invading the prostate and penile base, and multiple bone metastases with pelvic and vertebral bones (Th3 and Th12-L5). He received a needle biopsy of the bladder and prostate lesions transperineally. The pathological findings revealed urothelial carcinoma. He underwent palliative radiation (30 Gy/10 fr) through vertebral (Th3 and Th12-L5) and pelvic bones for pain control.\n\nThe patient initially received gemcitabine and cisplatin (GC) therapy after palliative radiation. After completing two courses of GC therapy, there was little change in the size of both primary and metastatic lesions compared to before chemotherapy. He also suffered from myelosuppression associated with GC therapy. We therefore discontinued GC therapy after only three courses. He began to receive pembrolizumab therapy (200 mg once every 3 weeks). Due to his increasing back pain, a CT scan was conducted four weeks after starting pembrolizumab therapy to assess the early treatment response. CT showed that both the primary and metastatic lesions had notably reduced in size, and no new lesion was detected.\n\nIn September 2023, he fell, resulting in a pathological femoral neck fracture, and received hemiarthroplasty. Pathological examination of the fracture site revealed no residual tumor tissue. He is currently undergoing pembrolizumab therapy (400 mg once every 6 weeks since September 2023), and as of March 2024, no recurrence has been observed.",
    "summary": "A 65-year-old man was diagnosed with bladder cancer invading the prostate and penis and multiple bone metastases. He underwent palliative radiation (30 Gy/10 fr) through vertebral bones (Th3 and Th12-L5) and pelvic bones for pain control. The patient received pembrolizumab therapy after three courses of gemcitabine and cisplatin therapy. CT four weeks after starting pembrolizumab therapy showed that both the primary and metastatic lesions had notably reduced in size, and no new lesion was detected. He subsequently fell, resulting in a femoral neck pathological fracture, and underwent hemiarthroplasty. Pathological examination of the pathological fracture site revealed no residual tumor tissue."
  },
  {
    "id": "multiclinsum_gs_en_250.txt",
    "fulltext": "A 29-year-old male was admitted to our hospital with a complaint of left arm numbness lasting for 1 week on 6 October 2023. During physical examination, he was found to have hypertension, with significantly differing blood pressure readings between the upper limbs: 200/68 mmHg in the right arm and 125/90 mmHg in the left arm. Computed tomography angiography (CTA) revealed a marked stenosis at the aortic arch (Zone 2, just before the LSA), with a narrowed diameter of 5.04 mm, and a dilated descending aorta measuring 29.65 mm in diameter.\n\nThe planned treatment approach for CoA with a Cheatham–Platinum stent (CP stent) presented several challenges. The location of the stenosis, situated at the junction between the aortic arch and the descending aorta, involved a sharp 90-degree angle, increasing the risk of stent fracture due to high blood flow forces. Additionally, the stenosis was highly restrictive, which raised concerns that a single stent might not fully correct the narrowing. The distal descending aorta’s diameter was 5–6 times larger than the stenosed segment, complicating the potential for proper sealing of the stent and increasing the risk of stent migration or embolization. The dilated aorta also heightened the risk of aortic dissection, rupture, and pseudoaneurysm formation. While conventional stents have been effective for discrete CoA, the combination of severe stenosis and distal aortic ectasia required a more tailored approach.\n\nTo address these challenges, we adopted an innovative strategy combining a balloon-expandable stent (BES) with a self-expanding stent (SES) for the treatment of CoA. Placement of the SES will occlude the LSA, so an axillary-axillary artery bypass needs to be established before the main operation. The incision is made 1 cm below the left and right clavicles, after which subcutaneous tissue and muscles are carefully separated in layers. The bilateral axillary arteries are then exposed and prepared for subsequent use. Following heparinization, blood flow is temporarily occluded, and an 8 mm synthetic graft is anastomosed end-to-side. A long, curved vascular forceps is employed to create a subcutaneous tunnel near the left axillary artery to facilitate the end-to-side anastomosis. Intraoperative imaging confirmed the patency of the aortic arch and the left common carotid artery proximal to the stenosis. The stenosed segment measured 5.04 mm in diameter. A self-expanding stent (Medtronic®, 30-30-195 mm) was first inserted via the right femoral artery and positioned distally to the left common carotid artery with slowly dilating. The 14 F sheath was then exchanged, and a BES (NuMed® CP) was placed at the site of the stenosis. Both internal and external balloons (NuMed® BIB, 16–45 mm) were inflated simultaneously, effectively dilating the stenotic region. After satisfactory position and expansion, both the internal and external balloons and the stent were simultaneously released. This step was completed in 47 s, and angiography showed a significant improvement in the stenosis, with the diameter increasing to 15.95 mm. Post-procedure, the stenosis at the distal end of the left common carotid artery was successfully relieved, confirming a positive outcome.\n\nDuring the procedure, arterial blood pressure was recorded at 5-min intervals. The trends in systolic blood pressure, diastolic blood pressure, and peak-to-peak values. Both systolic and diastolic blood pressures exhibited a significant decrease following the implantation of SES and BES. After the deployment of both stents, the arterial blood pressure dropped from 244/94 mmHg to a normal value of 117/73 mmHg. The peak-to-peak value also decreased markedly from 132 to 44 mmHg, reaching its lowest point of 8 mmHg after BES released, and subsequently rising to a normal range of approximately 41 mmHg within a few minutes. The difference between the right radial artery and lower limb pulse was reduced to 2–8 mmHg, indicating improved circulatory dynamics.\n\nThe CTA performed 4 days after the procedure showed satisfactory aortic remodelling, with the minimal aortic diameter increasing from 5.04 to 15.95 mm. This resulted in a reduction of the patient’s blood pressure from 244/94 to 117/73 mmHg. Post-operatively, the patient was started on aspirin therapy to prevent thrombosis for 6 months. Antihypertensive medications were discontinued as blood pressure remained stable. The patient and their family expressed their gratitude to us before discharge, stating that they no longer experienced symptoms such as headaches or dizziness after the operation. They were also pleased that this minimally invasive treatment approach spared them the discomfort associated with open-chest surgery. One month after discharge, the patient came for a follow-up examination, and the CTA showed that the diameter of the stenosed segment of aortic arch was 6.00 mm, indicating that the stents had been mildly dilated one month after implantation. Comparing the CTA at discharge, the implanted stents had not undergone any displacement. According to the patient’s daily self-measurement of blood pressure, the blood pressure had been within the normal range, and the pressure difference between the blood pressures of both hands was less than 10 mmHg.",
    "summary": "A 29-year-old hypertensive patient with a coarctation of the aorta and a descending thoracic aortic aneurysm was evaluated for treatment. Contrast-enhanced computed tomography angiography (CTA) revealed significant narrowing at the aortic arch (Zone 2, proximal to the left subclavian artery) with a diameter of 5.04 mm. Additionally, the descending aorta had an aneurysmal dilation measuring 29.65 mm. We applied an innovative approach combining a balloon-expandable stent (BES) with a self-expandable stent (SES). Post-procedure CTA demonstrated favourable aortic remodelling, with the narrowest point of the aorta expanding from 5.04 to 15.95 mm."
  },
  {
    "id": "multiclinsum_gs_en_579.txt",
    "fulltext": "73-year-old man of Latin American origin, with a mother with a diagnosis of Alzheimer's-type dementia with a negative genetic panel; brother with a diagnosis of ALS; sister with a diagnosis of Parkinson's disease. The progressive symptomatology began in 2016 and was characterized by progressive symptoms of hyposmia, hypoacusis, constipation and insomnia, which required evaluation by otorhinolaryngology and audiology, without a diagnostic conclusion. In 2020, relatives noticed that the patient had problems with episodic memory, forgetting objects of daily life, problems with earnings in his business (commerce). These symptoms were progressive until the patient began to have limitations in daily tasks, such as driving and changing gears, as well as leaving his home. At the end of that year, the patient began to have distal muscle weakness, manifested by opening bottles, brushing his teeth, which progressed insidiously, non-fluctuating, without a predominant time.\n\nIn January 2021, the patient began to have gait disturbances, which led to frequent falls of more than 6 times a week, due to postural instability. The patient came for evaluation in May. He was given a 16-point MoCA test with alterations in language fluency and repetition of sentences; in abstraction, delayed recall and visuospatial and executive problems. The Luria test was positive. The patient presented a hypomimetic face, spoke with hypophonia, was intermittent and slow, and had a decreased gag reflex, generalized left-sided stiffness, generalized hypotrophy, left-sided bradykinesia, generalized strength of 4/5, 3/4 muscle stretch reflexes, abolished abdominal-cutaneous reflexes, bilateral Hoffmann and Trömner signs, bilateral plantar extensor response, tactile evoked lower limb fasciculations, short steps, freezing of gait when turning, positive pull test (postural instability). He was treated with levodopa carbidopa in a gradual dose. After 3 months of follow-up, the patient had shown no improvement in Parkinson's symptoms, increased muscle weakness and lower and upper motor neurone data persisted. With these findings, a magnetic resonance (MR) of the brain was performed. The nerve conduction velocity (NCV) showed axonal motor neuropathy of thoracic limbs in relation to atrophy and sensory nerve conduction without alterations. Electromyography (EMG) showed active denervation (increased insertional activity, fibrillation potentials, fasciculation) and chronic reinnervation (polifasic motor unit action potentials, and low recruitment to maximum contraction) in all 5 body segments, which is consistent with motor neurone disease.\n\n\nEMG showed increased insertional activity in the deltoid, biceps, triceps, bilateral common digital extensor and bilateral tongue muscles. There were abundant fibrillation potentials and fasciculation was predominant in the thoracic limb muscles. During contraction, a polyphasic, large amplitude motor unit action potential (MAUP) was observed. At maximal contraction, a decrease in recruitment was observed in most of the muscles tested.\n\nThe patient was lost to follow-up one year. When he returned for evaluation, he was bedridden, aphasic, with increased parkinsonism and motor neuron syndrome. A genetic panel was performed, which was negative for C9ORF72, as well as 143 other genes involved in neuromuscular and neurodegenerative diseases, including the VCP, MAT3, ALS-associated, NOTCH3, frontotemporal dementia-associated genes, without alterations. A pathogenic variant for the POLG gene was reported: C.2209G>C, p. Gly737Arg, related to autosomal dominant and recessive mitochondrial depletion syndrome. A genetic counselling session was performed and the patient was informed. In May 2022, the patient presented with dysphagia and was wheelchair-bound, so he was sent to have a gastrostomy performed.\n",
    "summary": "We present a case of Latin American origin that initially manifested with systemic symptoms of more than 6 years of evolution, with subsequent cognitive alterations. Then he presented gait alterations and motor symptoms suggestive of parkinsonism with atypical data and data of motor neuron disease. Extension studies were performed that confirmed findings consistent with upper and lower motor neuron involvement. We observed a mutation in the POLG gene, related to mitochondrial depletion syndrome.\n"
  },
  {
    "id": "multiclinsum_gs_en_536.txt",
    "fulltext": "Male patient in his seventh decade of life. Farmer, with no medical history. Active smoking for 40 years with a smoking index of more than 40, exposure to wood smoke and mining. He presented in August 2021 with pleuritic-type chest pain associated with inspiration, which is why he came for evaluation. During the initial approach, the presence of a pulmonary tumor was detected in the left upper lobe through a chest X-ray, which is why he was referred to a third-level hospital for further diagnostic evaluation. A computed tomography (CT) scan identified a pulmonary tumor located in the upper left lobe that retracted the major fissure, multi-lobed, with spiky edges, heterogeneous with hypodensities suggestive of necrosis, measuring 54.9 × 30.1 × 41.2 mm and extending to the pleura. The presence of a tumor in another anatomical site was not evident. A core biopsy was performed, which was reported to the pathology department of the hospital as a non-small cell carcinoma (NSCLC) with angiolymphoid invasion and necrosis, which was negative for the immunohistochemical markers TTF-1, P40, ALK-1 (clone D5F3 Ventana), PDL-1 (clone SP263 Ventana) and ROS-1. In addition, real-time PCR was performed for mutations in the K-RAS and EGFR genes, which were negative. Subsequently, a PET/CT was performed, in which hyperglycolytic metabolism was observed in the tumor (SUVmax of 12.1) and lymph nodes of the 4L, 4R and 10R stations. With an ECOG 0, EVA 0, no white molecular alterations and the exclusion of another primary and/or metastatic site, it was decided to perform a left superior lobectomy with lymphadenectomy for proper classification (TNM). The surgical resection product measures 22 × 13.5 × 4 cm, and the tumor, 6 × 5.4 × 4.8 cm. Histologically, the neoplasia has a large, poorly differentiated cell morphology, with comedonecrosis and angiolymphoid invasion. In this diagnostic scenario, and with the previous inconclusive biopsy, it was decided to perform an immunohistochemical panel to determine the mesenchymal origin, such as vimentin, which is negative; epithelial, such as OSCAR cytokeratin, which is positive diffuse, and a differentiation panel consisting of TTF-1, P40, Napsina A, CD56, Synaptofisina and INSM1, which are all negative, in addition to SMARCA4/BRG1, which is preserved, and the exclusion of metastases in the dissected lymph nodes, confirmed with immunohistochemistry.\n\nUnable to determine a cell differentiation lineage through immunohistochemistry and real-time PCR studies, integrated next-generation sequencing (NGS) testing for DNA and RNA in paraffin-embedded tissue was performed with the Ion Torrent Genexus™ (ThermoFisher Scientific) instrument. The 50-gene panel tested negative for mutations. Based on the histological, immunophenotypic and molecular evidence, the diagnosis of a LCC-NI was determined.\nThree months after the surgery, the patient presented with paresthesia and tonic-clonic movements in the left forearm, as well as decreased strength in the left lower extremity that prevented walking. An MRI was performed, which reported a metastatic lesion in the right parietal lobe, which was later confirmed by biopsy.\n",
    "summary": "We present the case of a 69-year-old male with a history of heavy smoking who presented with pleuritic pain and a tumor in the right upper pulmonary lobe, which was removed by lobectomy. Pathological evaluation showed a large cell morphology without any immunophenotype, molecular or genomic alterations by next generation sequencing (NGS) studies, and was diagnosed as a LCC-NI.\n"
  },
  {
    "id": "multiclinsum_gs_en_188.txt",
    "fulltext": "A 63-year-old woman with a medical history of chronic myelogenous leukaemia (CML), chronic obstructive pulmonary disease and heart failure with preserved ejection fraction presented to the hospital with a 2-day history of increasing shortness of breath. The patient was diagnosed with CML 4 years perviously and was treated with dasatinib. The patient had two admissions over the past year for shortness of breath with bilateral pleural effusions, greater on the right. Diagnostic and therapeutic thoracentesis both times were consistent with exudative chylous effusions. On this admission, she reported dyspnoea unresponsive to inhaled albuterol, without symptoms of chest pain, orthopnea or pedal oedema. She had no significant surgical or family history. She was an everyday smoker of five cigarettes daily for 40 pack years. In the emergency department, she required 3 L of oxygen to maintain her oxygen saturation above 89% but did appear to be in significant respiratory distress. Physical examination was remarkable for diminished breath sounds on both lungs but more so on the right side.\n\n\nInvestigations\n\nOn admission, laboratory workup revealed elevated brain natriuretic peptide at 1131 pg/mL, haemoglobin of 9.5 103/μL; white blood cell count and electrolytes were within normal limits. Chest X-ray showed large right-sided pleural effusion, which was confirmed on CT angiogram of the chest. There was no evidence of pulmonary embolism, mediastinal lymphadenopatμhy or pulmonary lesions. Echocardiogram showed an ejection fraction of 61% with moderate to severely dilated right ventricle and right ventricular systolic pressure of 60 mm Hg. Thoracentesis was performed and 2.2 L of pleural fluid was removed. Pleural fluid analysis showed triglycerides 700 mg/dL, cholesterol 145 mg/dL, lactate dehydrogenase level (LDH) 125 U/L and total protein 4.2 g/dL. Serum LDH and total protein were 210 U/L and 8 g/dL, respectively. Pleural fluid white cell count was 1100 with 82% lymphocyte predominance, and fluid cytology was negative for any malignant cells.\n\n\nDifferential diagnosis\n\nThe differential diagnosis for recurrent pleural effusions is broad. Chylothorax due to lymphoma was ruled out as pleural fluid cytology was negative for malignant cells; chylothorax secondary to trauma was ruled out as the patient denied a history of trauma, specifically chest trauma, and thoracic surgical interventions, while chylothorax due to pulmonary sarcoidosis was low on the differential as CT of the chest did not show hilar adenopathy, bronchial wall thickening or ground glass opacities.\n\n\nTreatment\n\nOn admission, the patient was treated with supplemental oxygen, ipratropium bromide–albuterol sulfate nebulised treatments, prednisone, doxycycline, ceftriaxone and furosemide. Due to persistent hypoxia, diagnostic and therapeutic thoracentesis was performed. Chylothorax was attributed to dasatinib in light of her recurrent effusions and the absence of an alternate explanation. On her prior admissions, the dose of dasatinib had been reduced from 100 to 80 mg to try to prevent reaccumulation of pleural fluid. Despite dose reduction, she had two hospital admissions in 3 months for symptomatic right-sided pleural effusion requiring thoracentesis. Dasatinib was changed to nilotinib.\n\n\nOutcome and follow-up\n\nThe patient was followed up as an outpatient with her primary care physician for 1 year. Electronic medical records review and phone interview confirmed no evidence of recurrent chylothorax.",
    "summary": "A 63-year-old woman with a medical history of chronic myelogenous leukaemia treated with dasatinib, chronic obstructive pulmonary disease and heart failure with preserved ejection fraction presented with difficulty in breathing. Chest X-ray showed large right-sided pleural effusion, which was confirmed on a CT angiogram of the chest. Echocardiogram showed an ejection fraction of 61% with moderate to severely dilated right ventricle and right ventricular systolic pressure of 60 mm Hg. Diagnostic and therapeutic thoracentesis was performed, and 2.2 L of pleural fluid was removed. Pleural fluid analysis was consistent with chylothorax. Significant symptomatic improvement was noted after thoracentesis. In the absence of an alternate explanation, chylothorax was attributed to dasatinib, which was switched to nilotinib. This resulted in resolution of her pleural effusions."
  },
  {
    "id": "multiclinsum_gs_en_152.txt",
    "fulltext": "41-year-old male patient who was admitted to the emergency department in 2016 with polytrauma as a result of a traffic accident; with trauma to the lower limbs, the X-ray shows a fracture of the left tibial plates and a fracture of the right subtrochanter, thoracoabdominal trauma and mild cranioencephalic trauma.\nOsteosynthesis of femur with long cephalomedullary nail with closed focus was performed to correct the subtrochanter fracture and an external transarticular knee tutor was applied as a provisional measure to control local damage; 15 days later, definitive osteosynthesis of his tibial fracture was performed. Adequate and satisfactory evolution of tibial plates.\nBetween 2016 and 2019 he had sporadic episodes of pain in the right hip that subsided easily with anti-inflammatory and analgesic treatment without limiting his daily activities. X-ray examination showed fatigue of the distal blocks with doubts about the consolidation of the fracture.\nIn 2020, the pain in the hip increased and did not respond to medical treatment and was accompanied by functional limitations. The control X-ray showed a rupture of the cephalomedullary nail in its proximal third and a fracture of the subtrochanteric fracture.\nIn February 2020, there was a failed attempt to remove osteosynthesis material (extra-institutional), so he was referred to our institution. He was taken to surgery on February 8, osteosynthesis material was removed, curettage was performed and a culture of non-union focus was taken. Culture was positive for Klebsiella pneumoniae and he received intravenous meropenem treatment for 10 days. Subsequently, he underwent a surgical wash with drainage of the haematoma on February 20 to carry out new osteosynthesis with cephalomedullary nail + autologous bone graft (taken from both iliac crests) in the non-union focus.\nReactivation of infection in March 2020, requiring new surgery for washes and surgical debridement (#5). New Enterobacter bacteria is isolated and is managed with vancomycin and meropenem. At the end of April, she completes medical treatment and is discharged in stable conditions.\nIn May 2020, the osteosynthesis material was removed due to persistence of the infection, and a TENS endomedular nail covered with cement with antibiotics (gentamycin) was left.\nAt the end of May, after two surgical washes, the TENS nail was removed, resection of fracture edges (up to healthy bone), endomedular bone graft with a 10 cm segment of non-vascularised fibula (autologous) and fracture fixation with a distal femoral condylar support plate; VAC system placement and definitive wound closure in a second time on 28 May 2020. The patient evolved adequately, the surgical wound healed completely to the present day with infection in remission and radiological evidence of fracture consolidation, as well as asymptomatic patient with preserved function of the limb.\n",
    "summary": "41-year-old male with a right subtrochanter fracture from a traffic accident requiring osteosynthesis. Subsequently, the cephalomedullary nail was broken in its proximal third, the fracture did not unite, and there were infections at the fracture site. He was treated with multiple surgical washes, antibiotic therapy, and an unconventional orthopedic and surgical procedure such as the use of a distal femur condylar support plate and an endomedular bone graft with a 10 cm segment of non-vascularized fibula. Patient with satisfactory and favorable evolution.\n"
  },
  {
    "id": "multiclinsum_gs_en_466.txt",
    "fulltext": "A 70 year old male patient with a medical history significant for hepatitis C, treated withinterferon therapy three years prior, and prostate enlargement. Despite persistent negative virological results on follow-up, the patient was referred to our department due to suspicion of hepatocellular carcinoma (HCC). Notably, the patient’s lifestyle includes daily consumption of 300–500 ml of whiskey with no history of smoking. Blood tests were negative for HBs antigen and positive for HCV antibodies. Liver function was Grade A with a Child-Pugh classification of 5 points, and liver damage was also Grade A. The ALBI score was −2.43, ALBI Grade 2a, and ICG R15 19.1%. Tumor markers were normal with CEA 2.5 ng/ml, but high AFP 1984 ng/ml and CA19-9 3135 U/ml.\n\nContrast-enhanced computed tomography (CT) scan: A multinodular fused mass with a maximum length of 91 mm spanning the posterior segment and caudate lobe was observed. HCC was detected by dark staining in the early phase and by washout in the equilibrium phase. The primary branch boundary of the right portal vein was obscured. A hemangioma was seen in S5 of the liver, and a small cyst was observed in S6 of the liver.\n\nInitial treatment strategy: The HCC diagnosis was cT3N0M0, cStage III. There was no border to the first branch of the portal vein, and right caudate lobe resection of the liver was considered a radical resection. However, the resection limit was 44% based on a residual liver ICG R15 of 40% [4], and resection was judged impossible because of poor residual liver function.\n\nTargeted therapy: The initial treatment consisted of targeted therapy with a molecularly targeted agent (lenvatinib, 8 mg) and transcatheter arterial embolization (TAE). A CT scan performed 4 weeks after the start of treatment showed that the tumor had increased by approximately 120% to a maximum length of 110 mm. We switched to a combination of atezolizumab (1200 mg) and bevacizumab (1000 mg) targeted therapy, which has been reported to be useful in lenvatinib-negative cases. No adverse events occurred with both targeted therapies. A CT scan performed after four courses of atezolizumab plus bevacizumab showed that the tumor had shrunk to a maximum diameter of 60 mm, the contrast effect had disappeared, and the mass had a generally low absorption.\n\nTumor markers were normalized to 3.4 ng/ml AFP and 18 U/ml CA19-9.\n\nSurgical findings: post-hepatic lobectomy. Blood loss was 293 ml. 6 h 23 min.\n\nHistopathological findings: Grossly, the tumor was yellowish-white with other nodal fusions. Histologically, most tumors were necrotic, and there was no evidence of residual active HCC. Epithelioid granuloma formation was observed in the surrounding area, which was considered a post-treatment change.\n\nPostoperative course: The patient showed no signs of postoperative liver failure; however, CT performed on postoperative day 7 revealed the formation of a truncal abscess. Percutaneous drainage quickly relieved the inflammatory, and the patient was discharged from the hospital on postoperative day 22 without drain removal. The drain was removed on postoperative day 38. The patient is currently alive 16 months postoperatively without recurrence. There is no recommended treatment after resection, and no additional treatment was provided.",
    "summary": "The patient, a man in his 70s, developed an 11.5-cm HCC (T3N0M0 Stage III) in the posterior hepatic zone after being virologically negative for hepatitis C. The tumor was near the right portal vein branch, making the liver lobe unresectable due to poor liver function. Upon tumor enlargement, he was treated with atezolizumab and bevacizumab. After 5 courses, the tumor significantly shrank, allowing for complete resection with posterior segment removal. The surgery revealed mostly necrotic tumors with no active cancer cells remaining."
  },
  {
    "id": "multiclinsum_gs_en_365.txt",
    "fulltext": "79-year-old female patient, right-handed, who presented with a clinical picture of a month and a half of evolution, characterized by the presence of a necrotic tumor at the ulnar edge of the fifth finger of the left hand. The patient reported having suffered a sharp injury with a glass in the region where the tumor subsequently developed. Initially evaluated in the office for follow-up of the injury; reported the appearance of said tumor and the progressive growth of the same one month after the initial trauma. On physical examination, she presented a 3 cm diameter, black, ulcerated, necrotic lesion with signs of perilesional cutaneous suffering in relation to the proximal phalanx, with no signs of active bleeding at the time of evaluation. She also presented hypoesthesia of the ulnar edge of the finger, showing a two-point discrimination capacity of 15 mm. The patient had undergone an ultrasound and an angiography that reported the presence of a 10 × 7 mm hypoechoic image that could correspond to a hematoma in the painful region reported by the patient. Due to the slow evolution and the progressive growth of the tumor, surgical resection of the same was indicated. The surgical procedure was performed with the patient in dorsal decubitus under general anesthesia with her affected upper limb on a hand table. Through a Bruner volar approach, the resection of the tumor was performed; it was observed that the same was in continuity with the ulnar collateral digital artery of the fifth finger. The resection of the inA lucid tumor included the excision of the segment of the digital artery that was in relation to the same, since it presented irreparable damage. Subsequently, under microscopic magnification, heparin was washed from both arterial ends and an arterial end-to-end anastomosis of the ulnar collateral digital artery of the fifth finger was performed using micro-surgical technique, using Nylon 10-0. Subsequently, the hemostatic cuff was removed, confirming the patency of the vascular suture. Also, during the surgical procedure, the ulnar collateral nerve was found to be intact, so only a neurolysis of the same was performed. In the immediate postoperative period, immobilization was performed with a volar hand-held cast to protect the vascular suture. Two weeks later, the skin sutures were removed and rehabilitation of finger mobility was initiated. Results of the clinical case The patient was evaluated weekly until the removal of sutures and then monthly until discharge. She presented a favorable evolution without development of a new tumor or associated complications to the wound. She evolved with a visual analog scale of pain of 0/10 in both rest and activity and fully recovered the range of joint mobility at six weeks. In relation to the sensory deficit, at the six-week check-up she continued with a two-point discrimination of 15 mm, being 5 mm at twelve months. The resected tumor was sent to pathology confirming the diagnosis of pseudoaneurysm.\n",
    "summary": "79-year-old female patient, who developed a fast-growing necrotic tumour after a cut to the fifth finger of her left hand. Ultrasound and angiography suggested a haematoma. Surgical treatment was decided, during which it was observed that the tumour involved the ulnar collateral digital artery of the fifth finger. The lesion and the involved arterial segment were resected. She had a post-surgical course without complications. The histopathological diagnosis of pseudoaneurysm of the lesion was confirmed.\n"
  },
  {
    "id": "multiclinsum_gs_en_492.txt",
    "fulltext": "A 68-year-old male patient was admitted to the hospital on January 10, 2022 owing to a history of progressive weakness and numbness of the limbs for over 7 years. The patient had initially presented with numbness and swelling pain in his toes 7 years prior, followed by the development of glove and stocking-like changes in the limbs, limb weakness, and instability when walking. Despite the successive administration of neurotrophic and immunoregulatory treatments, his condition continued to progress. Two years ago, he presented with bradycardia and gastrointestinal dysfunction. One month ago, he developed paresthesia below T10, urinary retention, and orthostatic hypotension occurred 1 month ago. He presented to our hospital after the development of pulmonary embolism, heart failure, renal insufficiency, respiratory and urinary system infections, and other symptoms. He reported having no history of heavy metal or poison exposure, and his past and family history was unremarkable. Physical examination revealed a supine blood pressure of 130/70 mmHg and a standing blood pressure of 80/47 mmHg. The proximal muscle strength of his bilateral upper limbs was grade IV, his distal muscle strength was grade III, and the muscle strength of both lower limbs was grade III. Numbness at the distal end of both elbow joints and below chest 10 was evident together with hypoesthesia. Cardiac color Doppler ultrasonography revealed a rough myocardial ecco with some spot-like changes potentially consistent with amyloidosis. Biopsy samples of skin from the abdominal wall and lower right extremity did not reveal any deposition of an apple-green substance under polarized light. Genetic testing revealed a heterozygous mutation in exon 2 of TTR c.148G > A (p.Val30Met). As related examinations excluded other diseases, the patient was diagnosed with TTR-FAP with spinal cord damage. The patient’s condition gradually worsened, and he had malignant arrhythmia. After being transferred to the intracardiac intensive care unit, he was treated with drugs and a pacemaker and was discharged. Oral clofenadifen soft capsules were provided for treatment after discharge. The patient ultimately died of heart failure 7.5 years after initial symptom onset.",
    "summary": "Patient concerns: A 68-year-old man was diagnosed with the TTR c.148G>A (p.Val50Met) mutation by ultrasound, pathological, and genetic analyses. He presented with a late-onset, complicated spinal cord injury. The diagnostic process was tortuous, and despite the administration of regular treatment (conventional drugs, cardiac pacemaker, and the specific drug clofenadifen), the patient died.\n\nInterventions: To confirm TTR-FAP, ultrasound, MRI, pathological, and genetic tests were performed.\n\nOutcomes: The patient ultimately died of heart failure 7.5 years after the initial onset of symptoms."
  },
  {
    "id": "multiclinsum_gs_en_65.txt",
    "fulltext": "A 36-year-old Thai primigravida mother gave birth to a male newborn at a gestational age of 41 weeks by cesarean section due to maternal preeclampsia. Both parents were healthy and had no history of consanguineous marriage. The pregnancy was normal until 40 weeks of gestation when prenatal ultrasonography diagnosed bilateral intracerebral hemorrhages in the fronto-parieto-temporo-occipital regions. The newborn had a birth weight of 3,500 g. Owing to hypoxic-ischemic encephalopathy, his Apgar scores were 1, 3, and 3 at 1, 5, and 10 min, respectively, necessitating intubation and ventilatory support. A ventriculoperitoneal (VP) shunt was performed to manage obstructive hydrocephalus, yet recurrent intracerebral hemorrhage (ICH) occurred postnatally. Brain imaging after the birth did not reveal any vascular malformation, brain tumor, brain infection, or intradural venous thrombosis. Congenital coagulopathy was further excluded. After weaning off intubation and initiating oral feeding at 7 days of age, the patient experienced multiple episodes of vomiting and reflux after being fed breast milk or infant formula and exhibited intermittent abdominal distension. Stool volume ranged from 20 to 100 ml/day, and the stool consistency was runny and soft, with no history of constipation. The vomiting and reflux persisted despite switching to lactose-free and hypoallergenic infant formulas. Clinical suspicion arose for non-IgE-mediated cow’s milk protein allergy (CMPA) due to equivocal serum level of specific IgE to cow’s milk and no dermatologic symptom. At 2 months of age, the patient developed clinical signs of sepsis secondary to an infected VP shunt caused by Staphylococcus aureus. Concurrently, marked abdominal distension was noted. No history of necrotizing enterocolitis was documented. Abdominal X-ray radiograph showed multiple dilated bowel loops without air-fluid levels or pneumoperitoneum. Abdominal ultrasonography revealed generalized bowel dilatation without midgut volvulus or malrotation. Gut obstruction was therefore excluded. The physician suspected bowel ileus associated with sepsis and the infected VP shunt. Antibiotics were administered.\n\nFollowing the removal of the infected VP shunt at the age of 3 months, right and left external ventricular drains (EVDs) were subsequently inserted. Although marked abdominal distension decreased, mild abdominal distension occurred intermittently. Additionally, few to frequent episodes of vomiting per day were consistently documented. Serratia marcescens ventriculitis from the infected EVD occurred at the age of 5 months. Despite the antibiotic treatment, the patient continued to suffered from brain abscesses and recurrent ICH. Brain CT at 6 months of age revealed extensive bilateral encephalomalacia, hydrocephalus and a recent hemorrhage in the right high frontal lobe. Both parents, acknowledging the poor prognosis, agreed to forgo resuscitation for the patient. The infant passed away at the age of 7 months, cradled in the arms of the mother. Both parents consented to donate the infant’s body as a cadaver to the Department of Anatomy, Faculty of Science, Mahidol University. Formal informed consent for cadaver preservation and postmortem examination was obtained. The infant’s body was preserved using formalin injection and embalming technique.\n\n\nPostmortem examination\nGross examination of the thoracic and cervical regions revealed a retroesophageal right subclavian artery (RRSA) originating from the proximal thoracic aorta instead of the brachiocephalic trunk, and causing a notable compression on the posterior esophageal wall. The RRSA measured 0.6 cm in diameter at its origin and 4.4 cm in length. No Kommerell diverticulum was observed. Intriguingly, the left bronchial artery originated 0.6 cm from the origin of RRSA, rather than from the thoracic aorta. The esophagus measured 1.5 cm in flat diameter, and the RRSA-to-esophagus diameter ratio was 0.4. The right inferior laryngeal branch of the right vagus nerve did not form a loop with the RRSA, and was therefore identified as the right non-recurrent inferior laryngeal nerve. The left recurrent laryngeal nerve looped around the aortic arch. No cardiac anomaly was observed.\n\nGross examination of the abdomen unveiled a stenotic colon commencing from the distal half of the transverse colon to the proximal sigmoid colon measuring 15.5 cm in length. The stenotic segment accounted for nearly 50% of the total length of the colon. The narrowest colonic segment measuring 0.6 cm in diameter was noted at the descending colon, while the unaffected colon ranged from 1 to 1.5 cm in diameter. The ratio of the stenotic colon’s diameter to the normal colon’s diameter ranged from 0.4 to 0.6. However, a small patent lumen was present along the stenotic colonic segment without atresia. Prior to the colonic stenosis, the proximal transverse colon showed marked dilation, measuring 2.3 cm in diameter, with loss of mucosal folding. The stomach, small intestine, mesentery, liver, pancreas, spleen, kidney, ureter and urinary bladder appeared normal. There was no pyloric stenosis, annular pancreas, intestinal atresia, gut malrotation or volvulus. No fibrous adhesion was observed between the abdominal viscera and the abdominal wall. The brain revealed bilateral encephalomalacia, ICH and dilated ventricles. Representative tissue samples from the brain, thoracic and abdominal viscera were collected.\n\nMicroscopic examination\nAll tissue samples were processed, sectioned and stained with hematoxylin and eosin (H&E). Histological assessment of the esophagus, stomach, small intestine, large intestine and rectoanal canal revealed normal mucosa, submucosa, muscularis propria and serosa/adventitia.\n\nThe stenotic colonic wall exhibited intact four layers with ganglion cells present in the submucosa and muscularis propria. A submucosal fibrosis was observed in the stenotic colon. The muscularis propria remained continuous, with no segmental absence of intestinal musculature. The brain showed hematomas in both cerebral hemispheres without evidence of viral cytopathic change, vasculitis, amyloid deposition, thromboembolism or neoplasm.",
    "summary": "A Thai male newborn was born by cesarean section at gestational age of 41 weeks. One week before birth, intrauterine asphyxia and idiopathic bilateral intracerebral hemorrhage were diagnosed by prenatal ultrasonography. Despite postnatal interventions including a ventriculoperitoneal shunt and subsequent external ventricular drain, the intracerebral hemorrhage recurred and progressed. Concurrently, the patient experienced multiple episodes of post-feeding vomiting, intermittent abdominal distension, and regular defecation without constipation. Sepsis secondary to an infected shunt occurred, accompanied by marked abdominal distension. The physician clinically suspected non-IgE-mediated cow's milk protein allergy and ileus associated with sepsis. Tragically, the patient succumbed at seven months due to a brain abscess stemming from an infected external ventricular drain. Ultimately, postmortem examination unraveled double alimentary tract obstruction, consisting of RRSA and CCS. The RRSA, originating from proximal thoracic aorta, caused notable esophageal compression and functional stenosis which led to the frequent vomiting and reflux. The CCS involved the distal transverse colon, descending colon and proximal sigmoid colon, accounting for nearly 50% of the colon. The CCS was therefore the exact cause of intermittent abdominal distension. The stenotic colon contained submucosal and myenteric plexuses, excluding Hirschsprung disease."
  },
  {
    "id": "multiclinsum_gs_en_77.txt",
    "fulltext": "A 50-year-old Filipino female working as a domestic help presented to the outpatient department of the hospital in March 2022 with abdominal pain, a history of weight loss, and irregular vaginal bleeding for 2 months. On further questioning, she revealed fatigue, and on-and-off diarrhea for the past month. There were no other complaints.\n\nHer menstrual history showed that she had menarche at the age of 12 years and had regular cycles of 28–30 days with 4–5 days of bleeding, without any intermenstrual or postcoital bleeding. Her last normal menstrual cycle was 2 months back. She had had irregular vaginal bleeding for the preceding 2 months since then. She was married with two children born vaginally. She is not known to have any gynecological illnesses such as fibroids and had not received any treatment for any gynecological problems. She had not received the human papillomavirus vaccine and had been following her cervical cancer screening with normal results. She did not report any chronic medical illnesses, surgery, or allergies. Her family history was negative for any gynecological or familial cancers. She denied any long-term medication, habituations, or addictions. She had not been sexually active for the last 14 years after separation from her husband.\n\nOn examination, she was conscious, cooperative, alert, and well-oriented to person, place, and time with normal mood and behavior. She had mild conjunctival pallor, but no icterus, cyanosis, or clubbing. There was no pedal edema or enlarged lymph nodes. The thyroid gland was normal to palpation. The respiratory system examination showed a respiratory rate of 22 breaths per minute and evidence of free fluid in the right pleural cavity. The abdomen was distended and soft to palpation, with a large non-tender cystic mass arising from the pelvis. The bowel sounds were normally heard. Speculum examination showed cervicitis and revealed a large adnexal mass on the left side and a bulky uterus with restricted mobility. The examination of other systems revealed no abnormality. Imaging and other investigations were ordered, as the symptoms suggested a possible malignant etiology. The imaging revealed pleural effusion. Further imaging revealed a possible ovarian malignancy with suspicion of pulmonary metastasis. A thoracocentesis was done, but the fluid was negative for malignant cells.\n\nA staging laparotomy was done by total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy on 22 March 2022. Intraoperative findings showed an enlarged left ovary with a large complex multicystic mass containing mucinous and serous fluid. The size was 20 cm × 20 cm, and it was adherent to the left ureter, fallopian tube, and the small intestine posteriorly, weighing approximately 2245 g. Slightly hemorrhagic ascitic fluid around 600 mL. Her enlarged right ovary measured 5 × 5 cm, with a endometriotic cyst adherent to the posterior peritoneum and cecum. She had an enlarged 10-week size uterus with multiple fibroids. The appendix, omentum, and other visceral surfaces looked normal.\n\nThe histopathology report showed chronic cervicitis, an enlarged uterus, proliferative endometrium, and a benign endometrial polyp. There were multiple intramural leiomyomas with focal degenerative changes. The right ovary showed a hemorrhagic cystic corpus luteum and an unremarkable right tube. The left ovarian capsule had ruptured in two areas, but the surface was not involved. There were solid and cystic areas in the left ovary. The solid area showed an NEC of 6.5 × 4.2 cm, and the cystic area revealed a large mucinous borderline tumor of 23.0 × 18.0 cm, without any evidence of stromal invasion.\n\nThe left fallopian tubal surface involvement was not identified. The immunohistochemistry and tumor markers further confirmed the tumor to be NEN. There was no evidence of malignancy in the omental biopsy, and the regional lymph nodes were not involved. The pleural effusion resolved after drainage and did not recur. The report stated the high-grade tumor showed an organoid pattern of mild pleomorphic cells with vesicular nuclei, coarse chromatin (salt and pepper type), and many mitotic figures. Differential diagnosis includes NEN or sex cord stromal tumor or high-grade epithelial carcinoma. Cancer staging is presented below:\n\nCancer staged: staging form: ovary; AJCC V7-clinical; FIGO Stage IA (T1a, N0, M0)\n\nCancer staged: staging form: ovary; AJCC V7-pathologic; FIGO Stage IA (T1a, N0, cM0)\n\nCancer staged: staging form: Surveillance, Epidemiology, and End Results (SEER) Summary Staging—SEER Summary: localized (localized)\n\n\nOncology multidisciplinary meeting was done, and the pathologic tumor stage was changed from pT1a to pT1c1 and the FIGO stage from IA to IC1 (surgical spill present) for the left ovarian NEC. The case was discussed in the multidisciplinary team, and she was referred to oncology for systemic chemotherapy. However, the patient did not report for chemotherapy and was lost to follow-up.\n\nThe patient again presented in February 2023 to the emergency department with abdominal pain. She was diagnosed with recurrent metastatic NEC, given the previous diagnosis and imaging findings. The patient was started on chemotherapy with cisplatin/etoposide and continued eight cycles until Sept 2023. There was an inadequate response to the chemotherapy, so second-line treatment with leucovorin calcium (folinic acid), fluorouracil, and irinotecan hydrochloride (FOLFIRI) was started. From the time of follow-up until December 2023, she had responded to five cycles of treatment with evidence of remission and symptomatic improvement.",
    "summary": "We are reporting a case of primary ovarian neuroendocrine neoplasm in association with an epithelial borderline tumor. She is a 50-year-old Filipino woman who presented with nonspecific symptoms. Initial imaging revealed a large mass with suspicion of widespread metastasis. However, further imaging and laparotomy revealed early-stage neuroendocrine neoplasm, a large borderline epithelial tumor, with no evidence of pulmonary metastasis, despite having pleural effusion. She was lost to follow-up, presented again after a year with evidence of residual disease/metastasis, and was treated with chemotherapy."
  },
  {
    "id": "multiclinsum_gs_en_63.txt",
    "fulltext": "A 40-year-old female bus driver was presented for recurrent chest pain over the past six months. She often woke up with pain early in the morning, and the discomfort was characterized by subxiphoid stuffy pain radiating to the left chest, shoulder, and arm, which lasted <2 min with spontaneous remission. The episodes became more frequent in the recent month. The patient reported no past medical history, family history of premature CAD, and traditional cardiovascular risk factor except for a body mass index of 24.7 and previous light smoking. Blood pressure was 117/76 mmHg. The laboratory tests were unremarkable including normal serum N-terminal pro-B-type natriuretic peptide and troponin level. Low density lipoprotein cholesterol level was 1.34 mmol/L, and glycosylated haemoglobin (HbA1c) level was 5.3%. Her treadmill exercise test taken in another hospital 3 months before was positive, with ST-segment depression in II, III, and avF leads (>1 mv), as well as anterior wall leads (0.8 mv) during the test. The patient was diagnosed with CAD. The following invasive coronary angiography in that hospital showed 40% stenosis in the middle segment of the left anterior descending artery, and coronary spasm was also considered given that the guide wire was blocked when passing through the brachial artery. The patient was discharged and treated with diltiazem, aspirin, and rosuvastatin for 3 months. She reported certain relief of discomfort with decrease in both frequency and intensity, but still suffered from episodic pain below the xiphoid. The patient had serial miserable life experience before suffering from the refractory angina. She became emotionally charged and often cried after witnessing her father-in-law crushed to death by a falling building 8 years before, followed by discovering the infidelity of her husband the next year. The patient was referred to our hospital for further assessment of the role of mental stress in the aetiology of angina. She reported depression and poor sleep quality. Psychological scale evaluation, including Perceived Stress Scale and Hospital Anxiety and Depression Scale, suggested that the patient was in a state of high stress, anxiety, and depression. Left ventricular ejection fraction (LVEF) was normal (62%) on routine transthoracic echocardiography, and apparent structural heart disease was excluded. Myocardial perfusion imaging including contrast-enhanced echocardiography and PET with N-13 ammonia during mental stress testing were scheduled on separate days.\n\nMental stress testing was conducted in the morning with a fasting state. Diltiazem was discontinued one day before test. The patient was settled in a quiet and dim room, with a tailored head-mounted virtual reality device. Three pre-set mental stress tasks, including modified Stroop test, public speech, and mental arithmetic, were executed in sequence after a 15-min rest, with each task lasting 3–4 min. Echocardiography with contrast agent was performed at rest, the third minute and seventh minute of the testing and recovery, respectively. The patient was emotionally devoted and cried with grief when recalling her painful experiences during the part of public speech. She reported mild chest pain shortly after the speech task ended, which gradually aggravated with concomitant sweat. Apical perfusion delay (∼4 s) in replenishment following high-mechanical index (MI) flash impulse series was simultaneously observed on myocardial contrast echocardiography, along with hypokinetic regional wall motion and thickening abnormality at the left ventricular apex. A reduced LVEF (42%) compared to admission was noted, and left ventricular global longitudinal strain (GLS) was −17.1% (normal value < −20%). The patient was asked to take deep breathing in supine position to calm down. The chest pain was relieved without further intervention, and apical wall motion went back to normal on real-time echocardiography with normal LVEF and GLS measurements. Summed difference score (SDS), defined as difference between PET scans during mental stress testing and at rest carried out 1 or 2 days before enhanced echocardiography, was 3, which also revealed myocardial ischaemia.4 Hence, the patient was newly diagnosed with MSIMI.\n\nReactive hyperaemia index (RHI, normal value ≥ 1.68) reflecting peripheral microvascular function was measured on Endo-PAT 2000 (Itamar Medical Ltd, Caesarea, Israel), and showed mild decline 30 min after mental stress testing when compared to rest (1.6 vs. 2.0). Endothelial dysfunction was therefore noted. Coronary flow reserve (CFR) calculated with adenosine test on PET performed the day before enhanced echocardiography was 3.5, demonstrating normal endothelium-independent microvascular function. The patient was finally diagnosed with microvascular angina and MSIMI. Escitalopram was added to the treatment of her previous triple therapy to ease her anxiety. She also kept regular low-intensity exercise as recommended. The patient reported much less chest pain and anxiety during one month follow-up after discharge.",
    "summary": "A 40-year-old female bus driver suffered from refractory angina despite medical treatment over the past six months. Invasive angiography showed merely 40% stenosis in the middle segment of the left anterior descending artery while coronary spasm was also suspected. Mental stress assessment was conducted given her psychosocial adversities in the past few years and high scores during the psychological scale evaluation. The patient reported aggravated chest pain during mental stress testing. Apical perfusion delay (∼4 s) in replenishment following high-mechanical index flash impulses was simultaneously observed on myocardial contrast echocardiography, along with hypokinetic apical wall motion. A reduced left ventricular ejection fraction (42%) compared to admission (62%) was also noted, and left ventricular global longitudinal strain was -17.1% (normal value < -20%). Reactive hyperaemia index reflecting peripheral microvascular function showed mild decline. The patient was diagnosed with MSIMI on positron emission tomography (PET) and effectively treated with escitalopram."
  },
  {
    "id": "multiclinsum_gs_en_370.txt",
    "fulltext": "A male neonate was born at 37 weeks of gestation through caesarean section due to a breech presentation. Apgar scores were 8 and 9 at the 1st and 5th minutes, respectively. The baby was admitted to neonatal intensive care unit (NICU) at seven days of life (DOL) because of chest retractions and fever (38.5°C). At admission, he was pale with moderate tachypnoea and dyspnoea and chest auscultation revealed bilateral fine gasps. Chest X-ray showed accentuated bronchovascular markings. White blood cell (WBC) count was 11.9 × 109/L (polymorphonuclear cells, 59.4%), the C-reactive protein level was within a normal range, and the blood culture was sterile. RSV type A was identified from the nasal secretion sample using multiplex polymerase chain reaction. The nasopharyngeal samples were negative for bacteria. Empirical antibiotic therapy (penicillin 150.000 IU//kg/die and gentamicin 5 mg/kg/die) was administered after admission to the NICU. Nasal continuous positive airway pressure (nCPAP) was started a few hours after admission, and an increasing fraction of oxygen was required because of the worsened respiratory conditions. In the following hours, i.v. systemic corticosteroids were added to the therapy. Chest X-ray scan, after 24 hours of admission, showed opacities in the upper right and hilar-perihilar left lung regions. Antibiotics were discontinued after four days of therapy because of the infant’s clinical improvement, the sterile blood culture, the RSV detection in the nasopharyngeal samples, and the normal procalcitonin levels; nCPAP was replaced with high-flow nasal cannula. Three days after discontinuing the antibiotic therapy, the clinical conditions of the baby worsened. He presented with severe hypotension; i.v. fluids and catecholamine support were administered to treat the ongoing septic shock. Chest X-ray displayed massive opacification of the right upper and left lower lobes of the lungs. Heart ultrasound revealed a moderately hypertrophic interventricular septum that normalised in a few days. Wide-spectrum antibiotics (ampicillin 150 mg/kg/die, gentamicin 5 mg/kg/die, and cefotaxime 100 mg/kg/die) were administered, and nasal-CPAP was re-started. The WBC count was 23.2 × 109/L (polymorphonuclear cells, 77.7%), and the C-reactive protein level increased to 15.2 mg/dL. Blood culture yielded S. pneumoniae serotype 3, whereas CSF culture was sterile; i.v. cefotaxime was administered for 10 days, until the baby fully recovered, and the C-reactive protein and procalcitonin levels were within normal ranges. nCPAP was discontinued after 13 days, and then, the baby was discharged home. The following clinical course was uneventful and the neurodevelopmental outcome was within the normal range at 18 months of age.",
    "summary": "We present the case of a 7-day-old infant admitted to hospital with chest retractions and fever. The baby was hospitalised, empirical antibiotic therapy was administered, and non-invasive ventilation was started. When the viral aetiology was identified and clinical conditions improved, antibiotics were discontinued. However, after 48 hours, the newborn’s condition worsened because of pneumococcal septic shock. Intravenous fluids, catecholamine support, and wide-spectrum antibiotics were administered. Non-invasive ventilation was re-started and continued until the full recovery."
  },
  {
    "id": "multiclinsum_gs_en_586.txt",
    "fulltext": "71-year-old woman, who was admitted to the emergency department of the Hospital of Mataró (Barcelona, Spain) on September 9, 2020 with progressive weakness, for which admission to neurology was decided. Her medical history included arterial hypertension, essential tremor, arthrosis and mild anxiety disorder, under treatment with gabapentin, sertraline and tramadol. The patient had consulted her general practitioner on September 1, 2020 for abdominal pain, along with mild diarrhea that lasted 24 hours. The next day she began to feel weak and, over the next few days, dyspnoea and dysphagia appeared, for which laryngitis was suspected and prednisone was prescribed. On September 8, 2020 she was visited again by her general practitioner for global worsening of weakness; she also presented dysarthria, dysphagia and bilateral ptosis, for which she was referred to the hospital emergency department.\n\nShe had no fever on arrival, her blood pressure and heart rate were normal, and her physical examination was normal with the exception of moderate tachypnea. The neurologic examination showed bilateral ptosis of the eyelids, bilateral facial paralysis, bilateral mydriasis that was unresponsive to light and accommodation, bilateral ophthalmoparesis for both supra- and infra-version, moderate tetraparesis of the extremities (3/5), and severe dysphonia and dysphagia. She was conscious and her speech content was normal, as were her myotatic reflexes, sensation, and coordination. Fatigability maneuvers were inconclusive and an ice test was performed, which was positive, transiently improving ptosis.\n\nThe polymerase chain reaction (PCR) for SARS-CoV-2 was repeatedly negative (in his outpatient and in the hospital). The arterial blood gas showed hypoxemia: 75, with 95% SO2, and the rest of the explorations performed in emergency were normal (chest radiography, routine blood analysis, electrocardiogram).\n\nSupportive treatment with oxygen, intravenous fluids, nasogastric tube feeding and measures to prevent complications were initiated. The condition stabilised on the third day of admission to the hospital, without requiring advanced respiratory support, and a slow improvement began on the eighth day, with tolerance to the adapted diet for dysphagia. During the first week she had arterial hypotension, which was corrected with intravenous fluids. From the second week, she was able to initiate physical rehabilitation, with good evolution, so she was transferred to a specific rehabilitation centre on the 19th day, and then she was able to walk with bilateral support. At the follow-up visit in neurology outpatient consultations six weeks later, the patient was completely recovered.\n",
    "summary": "We describe a confirmed case of foodborne botulism in a patient treated in our hospital in September 2020. The clinical presentation in the first case was the development of bilateral cranial nerve palsy within a few days, including dysphagia, dyspnoea and dysarthria, together with severe midriasis and tetraparesis, preceded by diarrhoea, while her relative had nonspecific and transient symptoms. We found consistent autonomic dysfunction in the form of arterial hypotension. Given the pandemic situation at that time, SARS-CoV-2 infection was repeatedly ruled out before considering alternative diagnoses. Botulinum neurotoxin B was detected in the patient's faeces, confirming the diagnosis of botulism, which we linked to the ingestion of a homemade bean preserve. The differential diagnosis of the case was completed by ruling out other possible etiologies.\n"
  },
  {
    "id": "multiclinsum_gs_en_319.txt",
    "fulltext": "2-year-old female patient, eutrophic, with a history of recurrent UTIs (3 episodes of common uropathogens in outpatient management) and an ultrasound finding of left hydronephrosis with an anteroposterior diameter of the pelvis of 40 mm and a left megaureter. She was prescribed prophylaxis with trimethoprim-sulfamethoxazole until the urinary tract studies were completed, but this was not done.\n\nConsulted for a 24 hour history of fever and dysuria. On physical examination, he was in good general condition and hemodynamically stable (heart rate 108/min, respiratory rate 18/min, blood pressure 90/60 mmHg). Abdominal examination within normal limits with negative lumbar percussion. He did not have associated respiratory symptoms. Normal otoscopy.\n\nGiven the clinical picture and his background, a urine analysis was performed that showed: density 1.010, pH 6, protein +, glucose negative, ketones negative, hemoglobin traces, nitrites positive and sediment with leukocytes 15-20/cpo. With suspicion of UTI, a sample was collected for uroculture and empirical treatment was initiated with ceftriaxone 50 mg/kg/day intramuscularly on an outpatient basis.\n\nOn the fourth day of evolution, Streptococcus pneumoniae > 100,000 CFU/ml (sensitive to oxacillin, penicillin, aminopenicillin, levofloxacin and trimethoprim-sulfamethoxazole and third generation cephalosporins) was isolated in the urine culture. Because she had persisted with a fever on the fourth day of intramuscular antibiotic treatment, she was hospitalized for intravenous therapy. A complete 13-valent pneumococcal vaccine scheme (2+1 scheme) was found. It was also recorded that the girl was an only child and did not attend day care.\n\nOn admission, tests revealed leukocytosis of 19,600/mm3 with left shift (neutrophils 48%), normocytic hypochromic anaemia with haemoglobin of 9.3 g/dL, haematocrit 31.3% (mean corpuscular volume 74 fl and mean corpuscular haemoglobin 22 pg), platelets 361,000/mm3, normal renal function with creatinine 0.27 mg/dL, urea 15 mg/dl and elevation of C reactive protein of 131 mg/L (reference value: 0-5 mg/L).\n\nThe renal ultrasound reported a right kidney 80 mm in longitudinal diameter, orthotopic, of conserved shape and echo-structure, with adequate corticomedullar differentiation, without dilatation of urinary tracts or lithogenic images and a left kidney of 80 mm in longitudinal diameter, orthotopic with dilatation of the renal pelvis of 34 mm, homolateral ureter dilated in its entire extension measuring 13 mm in its distal third and parenchymal thinning (8 mm), with loss of corticomedullar differentiation, without significant changes in relation to the previous ultrasound studies.\n\nHe received treatment with ceftriaxone 50 mg/kg/day intravenous with cessation of fever and clinical improvement at 24 hours, without presenting abscesses or other complications. The blood cultures that had been taken at the time of admission (after 4 doses of intramuscular ceftriaxone) were negative. In the laboratory examinations taken prior to discharge, there was improvement in the inflammation parameters (leukocytes 10,200/ mm3 and C-reactive protein 23 mg/L). He was discharged 5 days later, completing 10 days of oral antibiotic therapy with amoxicillin-clavulanic acid at 40 mg/kg/day.\n\nSubsequently, a cystourethrogram (CUGM) was performed under antibiotic chemoprophylaxis, which revealed the presence of left-sided grade V vesicoureteral reflux (VUR) with normal urethra and bladder.\n\nAfter 6 months free of ITUs, a renal scintigraphy with dimercaptosuccinic acid was performed that showed the left kidney with severe functional compromise (relative renal function 7%) and the right with normal uptake, after which it awaits urological resolution (left nephroureterectomy), maintaining antibiotic prophylaxis until the same. In addition, he continues nephrological follow-up for functional monorrhea.\n",
    "summary": "2-year-old girl with megaureter and left hydronephrosis diagnosed in the context of a study of recurrent UTI, with poor adherence to prophylactic treatment, who was hospitalized for a new episode of febrile UTI without response to outpatient treatment with broad spectrum antibiotics. Streptococcus pneumoniae was isolated in the urine culture. The patient was treated with parenteral ceftriaxone with good clinical evolution and, due to the finding of the atypical germ added to her history of renal malformation, prophylaxis was restarted and imaging studies were completed. The micturating cystourethrogram showed left vesicoureteral reflux grade V. The renal scintigraphy showed the left kidney with severe functional compromise, so surgical indication was raised. This case, together with the 16 additional cases identified in the literature review, revealed that 12 of them (70%) presented concomitant nephrourological conditions.\n"
  },
  {
    "id": "multiclinsum_gs_en_237.txt",
    "fulltext": "Patient information\nA 44-year-old man was admitted to our hospital with chief complaints of pneumaturia and repeated cystitis. The patient also had a history of hypothyroidism.\n\nEnhanced contrast-enhanced computed tomography revealed multiple diverticula of the sigmoid colon, and the boundary between the diverticulum and the bladder was unclear. Lower gastrointestinal endoscopy revealed a fistula in the rectosigmoid colon approximately 15 cm from the anal verge. Cystoscopy revealed a fistula in the left posterior wall of the bladder. A sigmoidovesical fistula was diagnosed and laparoscopic surgery was planned. Intraoperative findings revealed severe inflammation around the sigmoidovesical fistula, and severe adhesions had also formed between the ileum and bladder. The ileum and bladder were difficult to exfoliate because of severe adhesions. Therefore, we decided to perform a combined bowel resection. The rectosigmoid colon, including the fistula, was mobilized and resected. The bladder fistula was transected and closed using a knotless barbed suture (V-LocTM 180, Covidien, Mansfield). The sigmoid-rectal anastomosis was reconstructed using the double-stapling technique. The partial ileum resection was reconstructed with functional end-to-end anastomosis (FEEA). In addition to the presence of a 2-site anastomosis, there was severe inflammation in the surrounding area, and considering the risk of anastomotic leakage, a diverting loop ileostomy 30 cm proximal to the ileo-ileal anastomosis was created.\n\nSurgical procedures included laparoscopic high anterior resection, partial small bowel resection, partial cystectomy, and diverting loop ileostomy. The operation time was 236 minutes, and blood loss was 50 mL. The postoperative course was uneventful, and ileostomy closure was planned 1 month after the initial surgery. Under laparoscopic assistance, adhesions between the omentum and abdominal wall around the stoma were removed. Full mobilization was performed around the stoma, and the intestine was pulled outward. The ileum was reconstructed using FEEA. The surgical procedure involved laparoscopy-assisted ileostomy closure. The operation time was 100 minutes, and the blood loss was 30 mL.\n\nClinical findings\nOn the day after surgery, symptomatic shock occurred due to low blood pressure (<80 mm Hg) and tachycardia. Blood tests showed hemoglobin decreased from 15.3 before surgery to 8.6 g/dL after the surgery.\n\nDiagnostic assessment\nAbdominal computerized tomography (CT) revealed a large amount of high-density fluid in the abdominal cavity. The diagnosis was postoperative bleeding and hemorrhagic shock. A central venous catheter was inserted, and 8 units of red blood cells and 8 units of fresh frozen plasma were administered to stabilize the vital signs. The vitals stabilized, and no progression of anemia was observed after that. Although hemostasis was achieved, severe abdominal distention and high inflammatory response levels (C-reactive protein [CRP] at 42.9 mg/dL and white blood cell count [WBC] of 18,500/μL) persisted 7 days after surgery.\n\nContrast-enhanced CT revealed that the intra-abdominal hematoma was localized in the left and right lower abdomen, and percutaneous drainage was considered possible. On the 8th postoperative day, 18Fr drainage tubes were inserted into the left and right lower abdomen through CT-guided puncture, and a large amount of old blood was drained. After drainage, the inflammatory reaction and abdominal distension caused by the residual hematoma infection improved (CRP at 1.9 mg/dL and WBC of 5000/μL). No progression of anemia was observed. On the 14th postoperative day, drainage in the right lower abdomen changed from old blood to intestinal juice. A drain angiography revealed delayed anastomotic leakage at the ileostomy closure site. There were no signs of peritonitis with good drainage, but the drainage was approximately 100 to 200 mL, and flatus from the drain continued. No decrease in drainage was observed for the following 14 days.\n\nTherapeutic intervention\nAlthough reoperation was considered, severe intra-abdominal adhesions were expected due to the history of past surgeries, postoperative bleeding, and anastomotic leakage. Therefore, reoperation was judged to be a high-risk procedure. Contrast-enhanced CT showed that an organized hematoma remained in the mesentery of the small intestine, and the ileum on the 10 cm distal side of the anastomosis was compressed near the remaining hematoma. Considering the stenosis of the ileum on the anal side of the anastomosis due to residual hematoma as the cause of anastomotic leakage, fluoroscopic balloon dilation of the stenosis area through the drain on the 24th postoperative day was attempted. A Cordis BRITE TIP® sheath introducer (8 Fr × 23 cm) was placed at the fistula where anastomotic leakage occurred after the drain angiography. A radifocus GT wire (0.016 inches, 180 cm, 90°) (Terumo, Tokyo, Japan) and a Renegade HI-FLO microcatheter (135 × 20 cm) (Boston Scientific, Tokyo, Japan) were used to reach the terminal ileum. Using Selecon MP catheter II (6Fr, 80 cm, φ20 mm) (Terumo), the stenosis area was identified in the ileum due to compression of the hematoma where the balloon could not pass.\n\nFluoroscopic balloon dilation was performed on the stenosis of the ileus using a CRE PRO GI wireguided balloon (180 cm, 15–18 mm) (Boston Scientific), inflating to 16.5 mm diameter at 4.5 atm for 3 minutes.\n\nFollow-up and outcomes\nFrom the day after the balloon dilatation, the amount of drainage decreased markedly, and flatus and defecation were observed from the anus. One week after balloon dilation, the drainage was almost zero, and the anastomotic leakage was judged to have resolved. The drain was gradually removed. Oral intake was good, and he had regular bowel movements. He was discharged on the 45th postoperative day. Since then, no recurrence of the stenosis or anastomotic leakage has been reported.",
    "summary": "Patient concerns: We report the case of a 44-year-old man with delayed anastomotic leakage after ileostomy closure caused by the compression of an intra-abdominal hematoma that healed quickly after fluoroscopic balloon dilatation of the bowel stenosis area.\n\nDiagnoses: Postoperative bleeding and hemorrhagic shock occurred on postoperative day 1 after ileostomy closure. Vital signs stabilized after blood transfusion, and computerized tomography-guided drainage was successfully performed to reduce the hematoma volume. However, residual hematoma compressed the ileum on the anal side of the anastomosis, leading to delayed anastomotic leakage.\n\nInterventions/outcomes: Fluoroscopic balloon dilation of the stenotic area through the drain was successfully performed, and the anastomotic leakage healed quickly."
  },
  {
    "id": "multiclinsum_gs_en_26.txt",
    "fulltext": "A 71-year-old Japanese woman with a past medical history of type 1 diabetes, end-stage renal disease, complete atrioventricular block, and previous myocardial infarction was admitted to the Gastroenterology service of our hospital for evaluation and treatment of acute loss of consciousness secondary to hypoglycemia. At the time of admission, she had a permanent pacemaker and was undergoing hemodialysis three times a week. The Orthopedics service was contacted to evaluate swelling, heat, and redness of her left hand due to a bite wound at the tip of her left middle finger that was self-inflicted during an episode of dementia. A standard course of intravenous cefazolin (1g per day) was prescribed to treat presumptive cellulitis. The infection did not respond and progressed despite two full days of antibiotic treatment. Bacterial culture of the lesion revealed methicillin-resistant Staphylococcus aureus (MRSA). Upon physical exam, the patient displayed all four of Kanavel’s cardinal signs of flexor tenosynovitis. Vancomycin infusion (trough value, 15–20 μg/mL) was initiated to treat the MRSA infection, together with wound debridement and a partial amputation at the distal interphalangeal joint. Decompression of the median nerve was performed to relieve pressure resulting from a purulent abscess. While redness and swelling persisted after this procedure, the progression of the infection appeared to be somewhat reduced. While the antibiotic course of Vancomycin was continued, on day 5 the patient suddenly complained of abdominal pain, dark brown blood in the stool indicative of a gastrointestinal bleed, and developed signs consistent with systemic shock. Her initial systolic blood pressure reading was 60 mmHg which responded to acute administration of vasopressors. Laboratory data included an elevated white blood cell (WBC) count of 9890 per mm3, together with increased serum levels of C-reactive protein (CRP; 259.7 mg/L) and creatinine (421.7 µmol/L) and reduced levels of sodium (132 mEq/L), blood glucose (2.6 mmol/L), and hemoglobin (8.2 g/dL). Findings from an abdominal computed tomography (CT) study resulted in a diagnosis of non-occlusive mesenteric ischemia; an emergency small bowel resection was performed. Tube feedings were initiated and continued for one week. Norepinephrine was added to her regiment to maintain blood pressure at levels necessary to sustain organ perfusion with a target mean arterial pressure of 70.\n\nDuring her hospital stay, the patient was exposed to SARS-CoV-2 after extended close contact with an infected individual while undergoing dialysis. Her nasal swab test was positive for COVID-19 using a loop-mediated isothermal amplification assay. Four days after the positive test, she developed signs of acute pneumonia. Results of a chest radiograph and CT scan confirmed this diagnosis and revealed consolidation of the lungs as well as bilateral pleural effusions. Antiviral treatment with favipiravir (200 mg orally twice per day) was initiated and the patient was transferred to the intensive care unit. This was in accordance with recommendations at the time of administration. The patient was hypervolemic with increased oxygen demand. Continuous hemodiafiltration was performed to avoid fluid overload.\n\nImmediately before exposure to COVID-19, the patient developed clinical signs of necrotizing fasciitis. The infection had extended into the fascia and the surrounding musculature of her left hand. While emergency hand amputation was deemed necessary, the patient developed septic shock and required mechanical respiration due to a sudden increase in oxygen demand. High flow oxygen was administered continuously via the endotracheal tube, and her antiviral regimen was changed to remdesivir (100 mg intravenous once a day) together with intravenous hydrocortisone (200 mg/dose). Remdesivir was still under compassionate-use status at the time. While undergoing treatment for acute life-threatening events, the infection progressed to include the phalanges of the left middle finger, with bone necrosis visible on radiography. Vancomycin (500 mg) was prescribed to manage the osteomyelitis and prevent its further spreading. The patient subsequently developed acute respiratory distress syndrome (ARDS). Although the patient’s COVID-19 infection was under control after two weeks, she developed disseminated intravascular coagulation (DIC; score >4) which may have accelerated bacterial growth. As heparin was contraindicated in this case, ART-123, a recombinant and soluble form of thrombomodulin alpha was administered intravenously (12,800 U once per day for 3 days) to dissolve the systemic clots. The infection progressed to include necrosis of the entire third digit as well as the skin, fascia, and musculature up to the radio-carpal joint with signs of progressive invasion into the forearm. Unfortunately, COVID-associated hospital restrictions and shutdowns precluded further surgical treatment at this time.\n\nThe patient ultimately recovered from COVID-19. At two weeks after the initial diagnosis was made, the patient was weaned from mechanical ventilation and the endotracheal tube was withdrawn. Two weeks post-extubation, the patient completed the treatment for COVID-19 and had a negative SARS-CoV-2 antigen test. A major amputation at the distal third of the forearm was then performed. The tissues were debrided and lavaged completely during the procedure and all infected tissue was removed. Because the amputation site was proximal to her indwelling hemodialysis shunt, its replacement was discussed with vascular surgeons and nephrologists. The procedure revealed heavy calcification of the arteries of her left forearm with tortuosity and possible occlusions both proximal and distal to the shunt. The bruit and thrill detected in the shunt also suggested the possibility of distal hypoperfusion ischemic syndrome. Adequate skin flap coverage was achieved and the stump was closed; a follow-up radiographic study revealed no complications. The stump appeared to be healing well, one month later, the patient succumbed to septic shock and cardiopulmonary arrest.",
    "summary": "A 71-year-old woman presented with an uncontrolled infection following a self-inflicted bite wound to her left middle finger. A bacterial culture of the lesion revealed methicillin-resistant Staphylococcus aureus (MRSA). The infection could not be controlled with antibiotics or additional interventions, including debridement and minor amputation. She contracted severe COVID-19 while in the hospital which limited the available treatment options. In an attempt to control the infection, the patient ultimately underwent a major amputation of the distal left forearm. While recovering from the procedure, the patient succumbed to septic shock and cardiopulmonary arrest."
  },
  {
    "id": "multiclinsum_gs_en_517.txt",
    "fulltext": "A 37-year-old male presented to our tertiary uveitis facility in January 2020 by referral for further vitreoretinal evaluation. His symptoms were flashes and photopsias predominantly in the right eye. He had previously been diagnosed with presumed bilateral BSCR in the summer of 2016. Initial laboratory evaluations, including complete blood count, complete metabolic panel, hemoglobin A1c and iron studies, were all unremarkable. Laboratory evaluations for infectious etiologies, including QuantiFERON-TB Gold (QFT), rapid plasma reagin (RPR), and fluorescent treponemal antibody absorption (FTA-ABS) tests, were all negative or non-reactive. Magnetic resonance imaging of the brain in September 2016 was unremarkable. In November 2016, the patient was treated with topical corticosteroid and intravitreal bevacizumab in the right eye (OD), as well as 60 mg daily oral prednisone. In December 2016, he was started on immunomodulatory therapy (IMT) with cyclosporine and methotrexate, which were both stopped in 2017 due to a possible lack of efficacy. The patient was then started on adalimumab, during which his symptoms (flashes and floaters) reportedly improved. After about 1 year of therapy, adalimumab was stopped due to reduced serum iron levels in early 2019. In October 2019, he received a fluocinolone acetonide intravitreal implant 0.18mg injection OD but noticed no subsequent improvement in visual symptoms.\n\nOn initial exam in January 2020, the patient noted moderate ocular discomfort (OD > OS), hazy vision (OD > OS), and floaters (OU). Visual acuity was 20/20 OU. On initial evaluation, review of systems was negative from a systemic standpoint. Intraocular pressures were 13 mm Hg OD and 12 mm Hg OS. Anterior segment exam was notable for 1+ flare bilaterally, with mild posterior subcapsular cataract OD, but otherwise unremarkable. Dilated fundus exam was notable for optic disc edema (OD > OS) and peripapillary and peripheral ovoid hypopigmented chorioretinal lesions (OU). The right eye also showed temporal peripapillary atrophy, 1+ vitreous cells, macular retinal pigment epithelium pigmentary changes, and small retinal hemorrhage in the superotemporal quadrant periphery. Spectral domain optical coherence tomography (SD-OCT) showed optic disc elevation in peripapillary intraretinal fluid with mild epiretinal membrane (ERM) OD > OS. Wide-angle fluorescein angiography (FA) (OPTOS Plc, Dunfermline, UK) showed hazy media, disc leakage and peripapillary staining OD, and diffuse optic disc leakage with mild segmental staining of venules along the inferior temporal arcade OS. There was hyperfluorescence of several of the lesions in the peripapillary region and along the inferior temporal arcade without any sign of leakage OU.\n\nTwo weeks later, full-field electroretinography (ffERG) showed mild-to-moderate global retinal dysfunction, with clear geographic regions of macular depression (OD > OS). The 30 Hz flicker implicit times revealed significant delay in both eyes (OS > OD). Visual evoked potential showed relatively symmetric delay for both small and large stimuli, suggesting mild optic nerve dysfunction. Goldmann visual fields (GVF) and Humphrey visual fields (HVF) showed blind spot enlargement OD and normal blind spot with no generalized constriction OS. Laboratory evaluations were notable only for human leukocyte antigen (HLA) A29 positivity. Angiotensin converting enzyme, lysozyme, and repeat QFT test results were all within normal limits.\n\nAt 1-month follow-up visit in February 2020, the patient noted stable visual acuity, some improvement in floaters in both eyes, and persistent haziness predominantly OD. Visual acuity remained 20/20 OU. Intraocular pressure was 15 mm Hg OD and 8 mm Hg OS. Anterior segment exam was notable for 1+ flare OU. Dilated fundus exam was notable for 0.5+ cells and 0.5+ haze in vitreous OU. Overall examination findings of the posterior pole were stable Findings in SD-OCT and wide-angle FA were relatively unchanged since the first visit. Wide-angle indocyanine green chorioangiography (ICG) showed clear media, multiple hypocyanescent spots in the posterior pole and midperiphery in the intermediate phase, and hypocyanescent spots faded in the late phase OU. Fundus autofluorescence showed hypofluorescence around the optic disc and retina.\n\nThe patient was diagnosed with BSCR based on HLA-A29 positivity, typical fundus appearance, and negative evaluation for other autoimmune and infectious etiologies. Given the patient’s active disease as evidenced by optic disc edema associated with vitreous cells in both eyes, along with highly suggestive FA and ICG findings, the patient was begun on therapy with infliximab at a dose of 7.5 mg/kg monthly. He was also given 3 days of intravenous (IV) methylprednisolone at a dose of 1000 mg/day followed by a tapering course of oral prednisone.\n\nThe patient did not come to follow-up visit until April 2021 and received eight cycles of 7.5 mg/kg infliximab infusions along with 1000 mg prednisone for 3 days during that period. VA declined to 20/40 OD due to posterior subcapsular cataract (PSC) formation and was 20/20 OS. No AC cell and flare were present in both eyes. Vitreous was hazy OD due to PSC and clear OS. Optic disc SD-OCT did not show significant changes. On FA, media was blurry at the center OD due to cataract formation. Partial optic disc staining was present in OU. There was no retinal vascular staining and capillary leakage in OU. Staining of peripapillary chorioretinal lesions in both the early and late frames of the FA remained the same OU. Four months later, the patient received additional four cycles of IFX infusions along with 1 day of 1000 mg methylprednisolone. VA decreased to 20/70 OD due to progression of PSC and was 20/20 OS. Ophthalmic examination, SD-OCT and FA findings remained unchanged. ICG was performed and hypocyanescent spots showed marked improvement with scattered few hypocyanescent spots at posterior pole (OS>OD) in both eyes on ICG. Electrophysiological testing including ffERG, mfERG, and VEP and visual field testing, including GVF and HVF, remained the same since the initial visit. Although there was significant improvement in ocular findings on examination and both in FA and ICG, mycophenolate mofetil 2000 mg daily was added to his treatment regimen due to the presence of optic disc edema and there remained a few hypocyanescent spots at the posterior pole in ICG.",
    "summary": "A 37-year-old male presented to our tertiary uveitis facility with bilateral ocular discomfort, hazy vision, and floaters. Ocular examination was notable for vitritis, optic disc edema, and ovoid hypopigmented chorioretinal lesions, visible on indocyanine green chorioangiography as multiple hypocyanescent spots in the intermediate phase. Full-field electroretinography and visual evoked potential showed global retinal dysfunction and optic nerve dysfunction. Laboratory evaluations were notable only for human leukocyte antigen (HLA)-A29 positivity. The patient was diagnosed with BSCR and started on oral prednisone and eventually managed with infliximab."
  },
  {
    "id": "multiclinsum_gs_en_144.txt",
    "fulltext": "We present the case of a 78-year-old man with known history of chronic atrial fibrillation, hypertensive heart disease, and nonischemic cardiomyopathy. He had a global reduction in left ventricular ejection fraction of 40–45%, and his echo-cardiogram was without significant abnormality. The patient had been followed in the cardiac outpatient clinic, where he was treated for American College of Cardiology (ACC) stage C chronic heart failure with New York Heart Association (NYHA) class III symptoms. Despite several changes in his diuretics and attempts to control his fluid status, he had a 40-pound weight gain over a 3-month period, with significant increase in shortness of breath. As his decompensation of heart failure progressed, he was hospitalized for 8 days and treated with intravenous (IV) furosemide. Because of his NYHA classification and admission to the hospital for heart failure exacerbation, invasive hemodynamic monitoring with CardioMEMS implantation was indicated and performed. Implantation of his CardioMEMS was performed in Grand Blanc, Michigan at an altitude of 837 feet with an atmospheric pressure of 731.2 on April 9, 2019. Initial hemodynamic measurements from cardiac catheterization showed a PA systolic pressure of 45 mmHg, PA diastolic pressure of 16 mmHg, and a mean PA pressure of 30 mmHg. The right atrial pressure was 21 mmHg, right ventricular pressure was 44/17 mmHg, and the pulmonary wedge mean pressure was 24 mmHg. The procedure was completed without complications and the patient was discharged the same day.\n\nAfter implantation of the CardioMEMS, the patient remained stable for 4 weeks without worsening symptoms of heart failure. He was compliant with his daily CardioMEMS readings with a PA mean ranging between 27 to 31 mmHg, and PA diastolic pressure 17 to 21 mmHg These overall hemodynamic findings were stable compared to those at the time of implant.\n\nThe patient then visited Denver, Colorado for 4 days at an altitude of 5280 feet with an atmospheric pressure of 596.8 atm on May 5, 2019. Recordings from the first day of his visit showed a PA systolic pressure rise from 44 mmHg to 73 mmHg, PA mean pressure rise from 30mmHg to 53 mmHg, and PA diastolic pressure rise from 20 mmHg to 40 mmHg. Concomitantly, he noticed a significant increase in shortness of breath and lower-extremity swelling. He did not seek medical attention but instead contacted his primary cardiologist in Michigan. His baseline nasal canula oxygen was increased from 1 liter to 2 liters and his furosemide does was doubled from 40 mg daily to twice daily. Fortunately, this treatment improved the patient’s symptoms and prevented a hospital admission. Because hospital admission was avoided, laboratory values, diagnostic imaging, and clinical vital signs were not available.\n\nThroughout his 4-day hospital stay, his invasive pressures remained high but slowly decreased and stabilized with a PA systolic of 72 mmHg, PA mean of 49 mmHg, and a PA diastolic of 35 mmHg on the day prior to returning to Michigan. On the fifth day, he returned to Michigan and his invasive pressure measurements normalized quickly, with a PA mean pressure of 29 mmHg and a PA diastolic pressure of 20 mmHg. He has continued to do well while in Michigan on continued maintenance diuretics and daily monitoring of PA pressures with his CardioMEMS device.",
    "summary": "We present the case of a 78-year-old man with an exacerbation of heart failure while traveling to high altitude. Elevation of his pulmonary artery (PA) pressures were detected by his implanted CardioMEMS device. Understanding the expected change in PA pressure recordings helped to identify a true exacerbation of heart failure in our patient. This led to a prompt change in medical therapy, which ultimately prevented hospitalization."
  },
  {
    "id": "multiclinsum_gs_en_131.txt",
    "fulltext": "An male patient in his early 20s presented to our hospital on April 4, 2023, with a 2-day history of abdominal pain. The patient had no prior history of pulmonary TB. The patient weighed 35 kg and was 1.7 m tall, and physical examination revealed that the patient was malnourished, with pallor and non-palpable superficial lymph nodes. The patient presented with tenderness, rebound tenderness, and muscular guarding throughout the abdomen. Bowel sounds were absent. Laboratory findings showed a white blood cell count of 11.2 × 109/L (normal range: 3.5–9.5 × 109/L), neutrophil count of 97.9% (normal range: 50% to 70%), and hemoglobin, albumin,interleukin-6, and procalciton in levels of 42g/L, 17.5 g/L, 66.30 pg/mL, and 0.606 ng/mL, respectively (normal ranges: 120–160 g/L; 35–50 g/L; 37.3 to 46.3 pg/mL; and <0.05 ng/mL, respectively). Computed tomography (CT) imaging of the abdomen revealed a large amount of free gas and fluid in the abdominal cavity. The patient was diagnosed with perforation of the digestive tract.\n\nOn April 4, a laparoscopic exploration was performed, revealing yellow purulent fluid (1000 mL) in the abdominal cavity, intestinal edema, and segmental thickening with multiple patchy ulcers invading the muscle layer in the ileum 80 cm from the ileocecal valve, with the small intestine measuring 3.4 m in length. A 0.5 cm diameter crevasse was found in the ileum 30 cm from the ileocecal valve, with overflowing intestinal fluid and regional mesenteric lymph node enlargement. Ileal repair and ileostomy were performed, and a pelvic drainage tube was inserted. On the 4th postoperative day, the patient developed a fever with a temperature of 39.5 °C, and light green fluid was extracted from the pelvic drainage tube at a rate of 100 mL/24h. Repeat CT imaging of the abdomen showed a large amount of free gas and fluid.\n\nEmergency open surgery was performed on the 5th postoperative day, revealing a 0.3 cm diameter crevasse 70 cm away from the ostomies, inflammatory changes in the intestinal canal, increased abdominal pressure, and darkened intestinal canal color. The crevasse was repaired with 3 to 0 absorbable wire, 2 Lee double cannulas were placed in the abdominal cavity, and the incisions were covered with a polypropylene mesh. Histopathological examination confirmed multifocal amorphous pink caseating necrotic material and Langhans giant cells in the lymph nodes. Acid-fast bacilli (AFB) staining, Gomori methenamine silver (GMS) staining, and periodic acid–schiff–naphtholsulfone S (PAS) staining were negative, but M tuberculosis was detected in the mesenteric lymph node by polymerase chain reaction (PCR). On the 7th postoperative day, 1000 mL of bright red fluid accompanied by a blood clot was discharged from the stoma due to bleeding from a stress ulcer in the small intestine.\n\nOn the 20th day, enteral nutrition was initiated concomitantly with an ATT regimen that consisted of an intensive phase with 1 month of isoniazid 100 mg qd, rifampicin 125 mg qd, and ethambutol 85 mg tid. After 1 month, enteral nutrition and oral diet were alternated for 2 months, then changed to oral diet alone, and the patient was discharged to continue a maintenance phase of ATT, which consisted of isoniazid 100 mg qd and rifampicin 125 mg qd. Five months later, the patient’s weight had increased by 20 kg, and he began exercising outdoors. Laboratory findings showed a white blood cell count of 9.52 × 109/L (normal range: 3.5–9.5 × 109/L), neutrophil count of 74% (normal range: 50% to 70%), a hemoglobin level of 130 g/L (normal range: 120–160 g/L), and an albumin level of 43 g/L (normal range: 35–50 g/L), with normal liver and kidney functions. The patient underwent a successful ostomy reversal. At the 12-month follow-up, his body weight had increased to 65 kg, PCR testing for M tuberculosis was negative, and anti-TB drugs were discontinued. The test results of the patient in prior- and post-treatment are summarized.",
    "summary": "Patient concerns: We conducted a retrospective analysis of a patient with ileal perforation due to intestinal TB. A male in his early 20s (initial weight, 35 kg) presented with a 2-day history of abdominal pain, exhibiting tenderness, rebound tenderness, and muscular guarding upon physical examination. Computed tomography (CT) imaging revealed a significant amount of free gas and fluid in the abdominal cavity. Subsequently, the patient underwent ileal repair and ileostomy.\n\nDiagnoses: Histopathological examination confirmed multifocal amorphous pink caseating necrotic material and Langhans giant cells in the mesenteric lymph nodes. A polymerase chain reaction (PCR) assay confirmed infection with M tuberculosis.\n\nInterventions: On the 20th postoperative day, enteral nutrition was initiated concomitantly with antitubercular therapy (ATT). After 1 month, enteral nutrition and oral diet were alternated for 2 months, then changed to oral diet alone, and the patient was discharged to continue ATT. Five months later, the patient's weight increased by 20 kg, and he began exercising outdoors. The patient underwent a successful ostomy reversal.\n\nOutcomes: At the 12-month follow-up, his body weight had increased to 65 kg, PCR testing was negative for M tuberculosis, and antituberculosis drugs were discontinued."
  },
  {
    "id": "multiclinsum_gs_en_186.txt",
    "fulltext": "A 73-year-old man was referred for SAVR to address symptomatic aortic valve regurgitation (AR). Two years earlier, he presented with multiple exanthematous lesions. A skin biopsy revealed plasma cell infiltration, leading to a referral to a haematologist. Computed tomography revealed systemic lymphadenopathy and hepatosplenomegaly. A renal biopsy performed for renal dysfunction confirmed AA amyloidosis; a lymph node biopsy showed interfollicular plasmacytosis and a hyperplastic germinal centre, consistent with the plasmacytic subtype of iMCD, supported by elevated plasma IL-6 levels. The patient was administered intravenous TCZ (640 mg every 2 weeks), alongside prednisolone (10 mg daily). The skin rash and lymphadenopathy resolved. Echocardiography revealed moderate pure AR and left ventricular enlargement. Since the patient gradually experienced exertional dyspnoea with progressive left ventricular enlargement, SAVR was deemed necessary.\n\nDue to haemorrhoid bleeding and hepatosplenomegaly, a hepatologist was consulted; Child–Pugh grade A liver cirrhosis and oesophageal varices were diagnosed. A preoperative team conference involving an intensivist and pharmacist reviewed the mechanisms of action of TCZ, potential complications, and perioperative management. Surgery was performed 26 days after the last TCZ dose. During the perioperative period, TCZ was withheld, whereas steroids were continued orally or intravenously. Preventive measures for surgical site infections (SSIs) included screening for methicillin-resistant Staphylococcus aureus nasal carriage, skin antiseptic preparation, prophylactic antibiotic therapy, and hyperglycaemia control. The nasal culture was positive for coagulase-negative Staphylococcus. Surgical aortic valve replacement was performed via median sternotomy under cardiopulmonary bypass, with 65 min of cardiac ischaemic time and 128 min of cardiopulmonary bypass time. Blood transfusions, including red blood cells, plasma, and platelets were required; the patient was extubated the following day. The pathological findings revealed focal fibrous thickening without amyloid deposits.\n\nThe surgical wound showed no signs of infection on postoperative Day 2; negative pressure wound therapy (NPWT) was initiated on the closed surgical wound to prevent SSI. Negative pressure wound therapy was discontinued on postoperative Day 13, without apparent SSI. The patient was discharged on postoperative Day 17 without any signs of infection.\n\nAlthough IL-6 levels temporarily increased on postoperative Days 1 and 2, they progressively decreased until postoperative Day 24, then rose again following TCZ resumption. C-reactive protein (CRP) levels were slightly elevated, peaking at 0.56 mg/dL on postoperative Day 2. By postoperative Day 24, CRP had increased to 1.06 mg/dL without infection. Before the increase in CRP, vascular endothelial growth factor levels increased on postoperative Day 13.\n\nThe patient did not experience recurrence of skin rash or lymphadenopathy during the perioperative period. Postoperative creatinine levels temporarily increased but returned to preoperative levels by Day 24. Tocilizumab was resumed on postoperative Day 30 after confirming the absence of infection, including SSI.",
    "summary": "A 73-year-old man with Castleman disease, treated with TCZ, underwent surgical aortic valve replacement via median sternotomy for aortic valve regurgitation with exertional shortness of breath. Comprehensive measures for preventing surgical site infection along with close examination were implemented during the perioperative period. Tocilizumab was discontinued 26 days before surgery and resumed 30 days after surgery, during which plasma IL-6 levels decreased. There was no evidence of infection or exacerbation of Castleman disease. Vascular endothelial growth factor levels increased before an increase in C-reactive protein levels following hospital discharge and prior to TCZ resumption."
  },
  {
    "id": "multiclinsum_gs_en_5.txt",
    "fulltext": "A 64-year-old female patient presented to the emergency department after falling from her own height, resulting in a head injury.\n\nHe had a history of hypertension, hypothyroidism, and rheumatoid arthritis that had been treated with 5 mg prednisolone daily and 5 mg tofacitinib every 12 hours for three years. He had not reported adverse effects associated with the medication.\n\nOn admission, no structural abnormality was reported on the head CT scan. Although she did not have urinary symptoms, a urine test was performed that suggested infection, so cefepime was started and a urine culture was requested. In addition, because she was an immunosuppressed patient, blood cultures were requested.\n\nThe basic laboratory tests performed at admission are summarized in Table 1. The patient's relative leukocytosis and lymphopenia are noteworthy. The MALDI-TOF blood culture revealed the presence of Cryptococcus neoformans.\n\nThe second skull CT scan revealed noncommunicating hydrocephalus. The lumbar puncture yielded a cloudy cerebrospinal fluid with a viscosity that did not allow the opening pressure to be measured. The protein count was 1000 mg/dL, the leukocytes 2 per mm3, the glucose 33 mg/dL, and the Cryptococcus antigen was positive. C. neoformans was detected in the cerebrospinal fluid culture. In addition, a high resolution chest CT scan demonstrated multilobar nodular involvement.\n\nWith these findings, acute meningitis caused by C. neoformans and disseminated cryptococcosis were diagnosed. Treatment with liposomal amphotericin B was initiated at a daily dose of 5 mg/kg and fluconazole was initiated at a daily dose of 400 mg/day, as 5-fluorocytosine was not available. Despite the treatment initiated, the clinical condition of the patient worsened and she eventually died.\n",
    "summary": "A 64-year-old woman with a confirmed diagnosis of disseminated cryptococcosis secondary to tofacitinib use is presented. Other causes of immunosuppression, such as human immunodeficiency virus (HIV) infection, were ruled out. She had been diagnosed with rheumatoid arthritis three years earlier and was on a biologic agent that inhibits JAK enzymes. Very few cases of pulmonary and meningeal cryptococcosis have been reported in this type of patient.\n"
  },
  {
    "id": "multiclinsum_gs_en_395.txt",
    "fulltext": "A 73-year-old man was operated on 5 years ago in another health center for a diagnosis of a left gluteal tumor. The lesion was removed and the biopsies were compatible with a high-grade epithelioid sarcoma (pT1b-N0M0). Given a close surgical margin (< 0.5 mm), a margin extension was performed. The histopathology was negative for residual neoplasia. Nevertheless, the patient received radiotherapy with 50 Gy in 25 fractions and 10 Gy of reinforcement in 5 fractions.\n\nAt 4 years of follow-up, the patient presented with mild pain, induration and retraction of the skin around the scar. On rectal examination and endoscopic evaluation, the anal canal and rectal mucosa were normal. The magnetic resonance imaging (MRI) showed a soft tissue mass in the left ischiorectal fossa infiltrating the gluteus maximus muscle and close to, but not contacting the levator ani muscle or coccyx. The positron emission tomography/computed tomography (PET/CT) scan showed a hypermetabolic lesion at the same site with no evidence of distant spread. The case was discussed in a multidisciplinary committee, where the lesion was determined to be non-pelvic floor threatening, and resection of the lesion with preservation of the anal canal and pelvic floor was decided with intraoperative biopsy as a safety measure to ensure the margin. Subsequently, a CT angiography and ultrasound doppler was performed to plan reconstruction. During surgery, the patient underwent a laparoscopic ileostomy and a complete resection of the lesion and tissue from the ischiorectal fossa in lithotomy, preserving the pelvic floor and the levator ani muscle. Intraoperative biopsies showed margins free of neoplasia towards the levator ani muscle. The patient was changed to prone position and the plastic surgery team performed the soft tissue coverage using a superior gluteal artery perforator artery (SGAP) flap along with a partial rotation of the gluteus maximus muscle for obliteration of the dead space. Blood loss was 150 ml and the operation time was 6 h. The patient was discharged uneventfully 25 days later due to the management of the flap. Final histopathology confirmed a recurrent epithelioid sarcoma with actinic changes and negative surgical margins (the closest margin was the medial, towards the levator ani, 2 mm). In addition, immunohistochemistry was positive for EMA (epithelial membrane antigen), CD34 (transmembrane glycoprotein) and total cytokeratins, and negative for INI-1 (Integrase Interactor-1). Follow-up was decided and the closure of the ileostomy was scheduled 3 months postoperatively, which was performed without complications. The patient then underwent pelviperineal rehabilitation with excellent results, reporting good continence, minimal and infrequent episodes of faecal leakage and high satisfaction with their functional defecatory and scar quality.\n",
    "summary": "We present a case of a 73-year-old man with a history of resection of a left gluteal tumor in another center 5 years ago. The biopsy was compatible with a high-grade epithelial sarcoma (ES), with a surgical margin of less than 0.5 mm that required subsequent margin expansion. In addition, adjuvant radiotherapy was performed. In the fourth year of follow-up, the patient developed pain and induration with retraction in relation to the surgical scar, and a local tumor recurrence was detected. After a multidisciplinary discussion, a disfunctionalization with laparoscopic loop ileostomy and tumor resection with preservation of the anus and pelvic floor was performed. The defect was covered by the plastic surgery team using a perforating flap of the upper gluteal artery. The biopsy confirmed the tumor recurrence and the surgical margins were negative. The patient was discharged 25 days postoperatively for flap care, without complications. After one year of follow-up, the patient did not present a tumor recurrence, the ileostomy was closed, and his functional results in terms of defecation and wound healing were good.\n"
  },
  {
    "id": "multiclinsum_gs_en_576.txt",
    "fulltext": "A 41-year-old woman with obesity and 6 years of untreated diabetes mellitus presented to the emergency department with a history of 7 days of fatigue and 2 days of dyspnoea. In addition to these symptoms, she reported bilateral and abdominal lower back pain, which partially improved with paracetamol.\n\nOn presentation, the patient was hemodynamically stable, with dyspnoea, tachypnoea and an oxygen saturation of 80%. The chest X-ray showed bilateral basal alveolar infiltrates and the rapid test was positive for IgM against COVID-19. The chest tomography found a bilateral ground glass pattern that occupied 35% of the pulmonary parenchyma without signs of pulmonary embolism.\n\nDue to an initial blood glucose of 500 mg/dL, urine ketones and severe metabolic acidosis, the patient was diagnosed with severe metabolic acidosis.\n\nInitial management included oxygen therapy, saline hydration, insulin, ceftriaxone, dexamethasone, and ivermectin. Three days later, the lower back pain and abdominal pain worsened, and an abdominal contrast scan was requested, which revealed perfusion defects in both kidneys, predominantly in the left kidney, suggestive of renal infarctions. There was no evidence of extra-renal thrombosis. Based on these findings, anticoagulation was initiated with 60 mg enoxaparin every 12 hours. The additional physical examination did not show signs of peripheral ischemia, and the electrocardiogram showed a sinus rhythm. The patient had no history of atrial fibrillation.\n\nThe respiratory and hemodynamic evolution of the patient was unfavorable, requiring mechanical ventilation and vasopressors. Subsequently, nine days later, the patient presented acute renal injury (with oliguria, posterior anuria and water overload) and conventional hemodialysis was initiated (the only type of hemodialysis available in our hospital) with non-tunneled catheter.\n\nTwo weeks later, the patient was still on hemodialysis, mechanical ventilation, and anticoagulation. She died in the third week of treatment.\n",
    "summary": "We present the case of a 41-year-old female patient with diabetes mellitus and obesity who was admitted to the emergency department for low back pain, respiratory failure associated with COVID-19 pneumonia, diabetic ketoacidosis and shock. The patient had acute renal injury and required hemodialysis. Contrast abdominal tomography showed bilateral renal infarction and anticoagulation was initiated.\n"
  },
  {
    "id": "multiclinsum_gs_en_123.txt",
    "fulltext": "We present the case of a 38-year-old woman with no relevant personal history, a resident of the Autonomous City of Buenos Aires (CABA), who consulted for fever, generalized myalgia and arthralgia, ocular retrograde headache of intensity 5/10 and a single episode of non-dysenteric diarrhea of 6 days duration. Her husband had been hospitalized three weeks earlier for a nonspecific febrile syndrome associated with lymphopenia, thrombocytopenia and aseptic hepatitis with a discharge without a diagnosis of aetiology. On admission, she presented a pruritic erythematous maculo-papular rash on the dorsum of hands and feet with a predominance in metacarpo-phalangeal joints and generalized abdominal pain without signs of peritoneal irritation, with no other alterations. A laboratory examination was performed that showed lymphopenia (367/mm³) with the rest of the series normal, normal renal function and normal hepatic panel, with no findings of hepatitis A, hepatitis C or hantavirus. Serological tests for human immunodeficiency virus, hepatitis A, hepatitis C and toxoplasmosis were negative. The chest X-ray and abdominal ultrasound did not show pathological findings. Serological tests for viral infections (human immunodeficiency virus, hepatitis A, hepatitis C and hantavirus) were negative. The patient presented a deepening of lymphopenia (170/mm³), severe thrombocytopenia (30,000/mm³), prolonged aPTT (50 sec) and elevated transaminases (AST: 162 U/L; ALT: 103 U/L) without hyperbilirubinemia. She also presented daily febrile episodes, metrorrhagia and the appearance of facial oedema with bilateral bi-palpebral oedema. She progressed acutely with somnolence, photophobia and fine tremors of the tongue, with localized petechiae in the axilla and inner arm. A computed tomography (CT) scan of the brain was performed, which showed no densitometric alterations of the parenchyma, and lumbar puncture with physical and chemical examination of cerebrospinal fluid (CSF) was negative. The CSF panel for meningitis/encephalitis was negative, and culture of the CSF was negative. She was empirically treated with 2 g/d intravenous ceftriaxone for 7 days with negative blood cultures and negative urine cultures. She subsequently developed acute abdominal pain in the left flank with a fall in the haemocrit, prolonged aPTT (50 sec) with an increase in the value of Factor V (202%) and hepatitis (AST: 2134 U/L; ALT: 699 U/L). A CT scan of the abdomen and pelvis with intravenous contrast was performed, which showed a 60 mm thick haematoma extending from the hypochondrium to the left iliac fossa, limited to the left abdominal wall with leakage of contrast, without emergency surgical procedure. Serological samples were sent to the National Institute of Human Viral Diseases Dr. Julio I. Maiztegui for dengue (IgM DENV), leptospirosis (IgM-IgG by MAT) and hantavirus (IgM) with non-reactive results and RT-PCR of JUNV that was positive. Since clinical suspicion was after the eighth day of the onset of symptoms, she did not receive plasma from convalescent. She had a good evolution, achieving hospital discharge.\n",
    "summary": "We present the case of a 38-year-old woman with no relevant personal history, a resident of the Autonomous City of Buenos Aires, who consulted for fever, retroocular headaches, myalgias, arthralgias and pruritic maculo-papular rash on the back of hands and feet of 6 days evolution. The laboratory showed lymphopenia, severe thrombocytopenia and anicteric hepatitis. The spouse had been hospitalized three weeks earlier for a similar condition without an etiological diagnosis. Subsequently, the patient developed metrorrhagia and axillary petechiae associated with photophobia, somnolence and fine tremor of the tongue, with normal cerebrospinal fluid, receiving treatment with ceftriaxone 2 g/day intravenous for 7 days. The computed tomography of abdomen and pelvis showed a left abdominal wall hematoma. Serological samples were derived to the National Institute of Human Viral Diseases Dr. Julio I. Maiztegui for dengue virus, leptospirosis and hantavirus with non-reactive results and RT-PCR of Junín virus that was positive.\n"
  },
  {
    "id": "multiclinsum_gs_en_553.txt",
    "fulltext": "An 83-year-old male patient was admitted to our cardiology department for TAVI. The patient had a history of amyloid and valvular cardiomyopathy with preserved left ventricular ejection fraction and severe calcific aortic stenosis (peak gradient 55 mmHg, mean gradient 41 mmHg, and valve area 0.65 cm2), with predominantly septal left ventricular hypertrophy and no obstruction. The patient was on apixaban for paroxysmal atrial fibrillation. He was 170 cm tall and weighed 56 kg [body mass index (BMI) 19.38 kg/m2). The 12-lead resting electrocardiogram (ECG) on admission showed sinus rhythm with first-degree atrioventricular block (PR interval 470 ms), complete right bundle branch block (QRS duration 172 ms), and left anterior fascicular block with an axis of −153°.\n\nA Sapien 3 Ultra 23 mm valve was successfully implanted via the right femoral artery under local anaesthesia. On post-operative Day 2, telemetry monitoring revealed brief episodes of asymptomatic third-degree atrioventricular block with a ventricular rate of 41 b.p.m, necessitating implantation of a dual-chamber pacemaker.\n\nA dual-chamber pacemaker (Medtronic Azure XT DR) was implanted under local anaesthesia on the left side. Due to the absence of cephalic access, active-fixation pacemaker leads were introduced via the left subclavian vein. The ventricular lead (Medtronic 4076–58 cm) was screwed into the mid-septum with 18 turns of the screw using a RVOT Stylet Kit (St. Jude Medical). The atrial lead (Medtronic 4076−52 cm) was positioned multiple times in the right atrial appendage using an appropriate J-curved stylet. However, atrial pacing thresholds were excessively high (3 V/1 ms), likely due to atrial remodelling. The atrial lead was ultimately fixed with 17 turns of the screw, in accordance with the manufacturer’s recommendations, to the posterolateral region of the free wall of the right atrium (RA). This final position achieved adequate atrial sensing (1 mV) and a pacing threshold of 0.75 V at 0.4 ms at the time of implantation.\n\nUpon return from the operating room, the patient was asymptomatic. Physical examination was unremarkable. The ECG demonstrated atrial and ventricular pacing at 60 b.p.m. with adequate capture. Follow-up echocardiography revealed satisfactory function of the aortic bioprosthesis and no evidence of pericardial effusion.\n\nAt H + 6 post-procedure, the patient became haemodynamically unstable. He was eupnoeic with a heart rate of 60 b.p.m. in sinus rhythm and hypotensive with a blood pressure of 93/47 mmHg (mean arterial pressure 52 mmHg). Pulmonary auscultation demonstrated asymmetry with decreased breath sounds on the right side. There were no signs of shock, such as mottling or cold extremities. Follow-up echocardiography revealed a 5 mm left ventricular lateral pericardial effusion. Pacemaker interrogation revealed an elevated atrial pacing threshold of 3 V/0.4 ms in bipolar configuration and complete absence of atrial capture at 5 V/1 ms in unipolar configuration, suggestive of atrial lead tip perforation. Chest radiography revealed an opacity extending to the mid-lung field without evident obliteration of the diaphragmatic dome or costophrenic angles. No mediastinal shift was observed. The cardiac device leads appeared to be in appropriate position. The atrial lead was in contact with the RA free wall. Chest computed tomography (CT) demonstrated a moderate unilateral right haemothorax without visible contrast extravasation in arterial or venous phases. The tip of the atrial lead was in contact with the lateral wall of the RA, without evidence of parietal breach or indirect signs of rupture. A small pericardial effusion was observed, with integrity of the large mediastinal vessels.\n\nAfter consultation with cardiac surgeons and considering the patient’s haemodynamic stability, we decided against emergent lead repositioning or effusion drainage due to the patient’s anticoagulation with apixaban. Laboratory tests revealed anaemia (haemoglobin 11.2 g/dL, n > 13 g/dL) and elevated high-sensitivity troponin T (241 ng/L, n < 14 ng/L). The patient was transferred to the surgical intensive care unit for close monitoring. To reverse the effects of apixaban, 500 IU of prothrombin complex concentrate was administered.\n\nAt H + 12 post-procedure, the patient’s haemodynamic status deteriorated despite initiation of vasopressor support with norepinephrine. He experienced cardiac arrest with an electro-mechanical dissociation. Immediate cardiopulmonary resuscitation was initiated. The patient regained spontaneous circulation after 2 min of chest compressions and administration of 1.5 mg of epinephrine (no-flow time 0 min and low-flow time 2 min). Transthoracic echocardiography excluded cardiac tamponade. Pleural ultrasound demonstrated worsening of the right pleural effusion without evidence of pneumothorax. Chest radiography revealed complete opacification of the right hemithorax. Arterial blood gas analysis indicated severe anaemia with haemoglobin of 7.2 g/dL (n > 13 g/dL), haematocrit 22.1% (n > 35%), and hyperlactataemia of 4 mmol/L (n < 1.6 mmol/L).\n\nThe patient was urgently transferred to the operating room for emergency surgical intervention. A vertical median sternotomy was performed to access the thoracic cavity. Upon opening the right pleura, a large 2-L haematoma was evacuated. Inspection revealed a laceration of the RSPV in contact with the screw-in helix of the atrial lead. The laceration was repaired using 5-0 Prolene non-absorbable suture. A small amount of clotted blood was visualized in the pericardial space. Examination of the RA revealed a pseudoaneurysm caused by the atrial lead. Subsequently, the atrial lead was secured within the RA.\n\nThe patient was rapidly extubated and transferred to the cardiac intensive care unit. His clinical course was favourable. Pacemaker interrogation demonstrated satisfactory electrical parameters for both atrial and ventricular leads. Follow-up echocardiography revealed no pericardial effusion, and chest radiography showed no recurrence of haemothorax. The patient was discharged on post-operative Day 5 (7 days after initial admission).",
    "summary": "An 83-year-old male with amyloid and valvular cardiomyopathy underwent dual-chamber pacemaker implantation for third-degree atrioventricular block following transcatheter aortic valve implantation. The active-fixation atrial lead was positioned on the right atrial free wall. Six hours post-implantation, the patient developed haemodynamic instability. Echocardiography revealed a small pericardial effusion, while pacemaker interrogation showed an increased atrial pacing threshold. Chest imaging demonstrated a moderate right haemothorax. Initially, conservative management was recommended. However, the patient's condition deteriorated, progressing to cardiac arrest requiring brief cardiopulmonary resuscitation. Emergency sternotomy revealed a large right haemothorax and laceration of the right upper pulmonary vein in contact with the atrial lead screw. The laceration was repaired, and the atrial lead was repositioned. The patient recovered well and was discharged 5 days after surgery."
  },
  {
    "id": "multiclinsum_gs_en_174.txt",
    "fulltext": "Female, 14 years of age, who began to suffer in March 2021, presenting pain in the right pelvic limb with predominance in the knee, of intensity 8/10 on the visual analogue scale (VAS), which limited walking, reporting at least three previous episodes. Therefore, she went to the Regional Hospital of the State of Veracruz in July of the same year, where she had radiographs of the right pelvic limb, finding a bone lesion in the mid-section of the femoral shaft, with irregular edges, with periosteal reaction in the cortical anteromedial part, which showed sclerotic areas with a well-defined transition zone. In the axial computed tomography (CT) of the pelvic limbs in September 2021, there was an irregular bone lesion in the mid-section of the right femur, in the anteromedial face, with a sclerotic pattern and osteolysis. The first percutaneous biopsy was performed in the operating room in September 2021, which was sent to pathology, where a sample was reported as insufficient. The Paediatric Oncology Service was requested for evaluation, which, in the negative result, requested a new biopsy to standardise conduct. A bone scan with technetium 99 was performed in October 2021, where an abnormal increase in osteoblastic activity was observed in the mid-section of the femur. In the thoracic CT, there were calcified right paracardiac metastases of approximately 2 cm and peripheral metastases of 0.5 cm. In October 2021, a second percutaneous biopsy was performed in the operating room, which was sent to pathology, where a sample was reported as amorphous extracellular matrix with bone metaplasia and scant cellularity. The Paediatric Oncology Service was requested for evaluation, which, in the negative result, requested a new biopsy to standardise conduct. A new evaluation was performed by the Paediatric Oncology Service, which justified, by the result of the biopsy, not meeting the criteria for initiation of chemotherapy. Subsequently, in December 2021, surgical treatment was decided by the Paediatric Orthopaedic Service. During the surgery, a tumour was found in the mid-section of the femur of approximately 13 cm in length by 3 cm in width, with firm consistency, irregular edges, ochre colour and a well-defined transition zone. A wide margin resection (approximately 15 cm) was performed and an intercalary femoral prosthesis was placed. The surgical piece was sent for definitive pathological study. Two weeks after the surgical procedure, a report of the surgical piece was received from the Pathology Service, which reported: low-grade osteosarcoma, hypocellular, positive in the fibroblast component, with irregular edges, ochre colour and a well-defined transition zone.\n\n\nSurgical technique\n\nWith the patient under general anaesthesia and in supine position, aseptic and antiseptic procedures and the placement of sterile surgical fields were performed. An anteromedial approach to the femur was chosen, using a longitudinal incision of approximately 25 cm, dissecting by planes until a gap between the rectus femoris and the vastus medialis muscles was found. The vastus medialis muscle was then dissected until the femoral diaphysis was found. A tumour was found in the middle third of the femoral diaphysis, approximately 13 cm long and 3 cm wide, which was removed with wide margins, and an osteotomy was performed 16 cm proximal to the knee joint surface. A bone marrow sample was sent for pathological examination, and the presence of free margins was confirmed by the pathological service. A second osteotomy was performed 16 cm distal to the greater trochanter, and a second bone marrow sample was sent, with a negative report for malignant cells. The proximal and distal femur was rimed with rims of diameters 9, 10 and 10.5 until the proximal digital fossa was passed. A bone anchor was placed, and the osteotomy was regularised. An endomedular nail was introduced until the distal limit was reached, and a diaphyseal prosthesis was placed with bone anchors and crowns at the diaphyseal ends. Locking pins were placed, and the length of the limb was compared with the contralateral limb. The interval between the rectus femoris and the vastus medialis muscles was repaired, and the joint was closed by planes.\n",
    "summary": "Female, 14 years old, with clinical picture characterized by increased volume and pain in the right thigh for six months. X-rays of the right femur were performed, finding a bone lesion with characteristics consistent with malignancy, so she was sent to a third-level unit to initiate an oncological protocol; two percutaneous needle biopsies were performed with Jamshidi needle, both with negative histological report for malignant cells. In high resolution pulmonary tomography, the presence of metastases was observed and the bone scintigraphy with Tc99 reported osteoblastic activity in the right femur. Treatment with resection was decided\n"
  },
  {
    "id": "multiclinsum_gs_en_176.txt",
    "fulltext": "A 56-year-old woman presented to our hospital with acute congestive heart failure. She needed dobutamine support and bilevel positive airway pressure for NYHA class IV dyspnea. Chest radiography revealed congestive heart failure. Echocardiography revealed severe aortic stenosis with heavily calcific bicuspid valve; the LVEF was significantly reduced at 15%. The aortic valve area measured 0.52 cm2. Mean pressure gradient was 49 mmHg. A peak aortic jet velocity was 4.4 m/s. Right-heart catheterization revealed a cardiac index of 1.6 L/min/m2 and pulmonary hypertension with the mean pulmonary artery pressure of 55 mmHg. Coronary angiography showed normal coronary vasculature without signs of significant stenosis. The pulmonary capillary wedge pressure was 37 mmHg. Computed tomography demonstrated a mildly dilated ascending aorta with a diameter of 42 mm. She was diagnosed as heart failure reduced ejection fraction (HFrEF) due to severe aortic stenosis. The society of Thoracic Surgeons predicted mortality score was 12.4%.\n\nOur heart team discussed her treatment. Our patient was a younger AS patient with severe LV contractile dysfunction and with bicuspid valve. Considering the severe LV contractile dysfunction, the patient seemed suitable for TAVI as the lack of ischemic cardiac arrest and extracorporeal circulation helps avoid ischemia, as well as ischemic reperfusion injury, inflammatory reaction, and oxidative stress. However, we hesitated to perform TAVI for this patient because extension of TAVI to such a younger patient with longer life-expectancy raises the issue of durability. Leaflet asymmetry of the implanted transcatheter heart valve which might occur after deployment into bicuspid valve may have an impact on long-term valve durability. While, conventional SAVR is possible while the heart is arrested with cardioplegic arrest, which is effective in majority of AS patients with acceptable morbidity and mortality. However, in some cases, especially in patients with impaired LV function like our patient, ischemic period followed by reperfusion period may lead to myocardial injury, which is associated with high perioperative mortality and morbidity. If SAVR could be performed with beating heart condition, the patient had benefited from this procedure without myocardial ischemia similar to TAVI. In spite of recent advances in myocardial protection methods, blood supply is the most effective technique of myocardial protection under beating heart condition. Cardioplegic arrest may induce reperfusion injury. In contrast, maintaining the myocardial contraction results in less myocardial edema and better cardiac function. We therefore decided to perform on-pump beating AVR with selective antegrade coronary artery blood perfusion.\n\nShe could not lie on her back due to severe orthopnea. Therefore, percutaneous cardiopulmonary support (PCPS) was initiated at the femoral vessels before the induction of general anesthesia. Surgery was performed via a median sternotomy. Cardiopulmonary bypass (CPB) was established after central cannulation. Under systemic temperature of 35–37 °C, CPB flow rates maintained at 2.5–2.8 L/min/m2, with a mean systemic pressure 60–80 mmHg. The aorta was crossed-clamped and opened. Direct 5-Fr silicon coronary perfusion cannulas (Sumitomo Bakelite, Tokyo, Japan) were inserted into the left and right coronary ostia, and oxygenated blood was continuously perfused at 34 °C and at a rate of 300 ml/min with mean perfusion pressure of 150 mmHg. The cannulas were fixed to the aortic wall with 5–0 prolene, and they were secured by tying them to a tourniquet. The valve was a severe calcific true bicuspid valve. Calcified leaflets were removed using the usual approach. The calcifications extending to the aortic annulus were carefully removed using a SONOPET ultrasonic aspirator (Stryker, Kalamazoo, MI) and scalpel. After sizing the annulus, a 21-mm Regent mechanical valve (St. Jude Medical, St. Paul, MN) was placed into the aortic annulus using continuous suture technique with three 2–0 prolene sutures. The aorta was closed using the standard technique. Horizontal mattress suturing was performed for the first layer. After de-airing of the left ventricle, the aortic clamp was removed. Running suturing was performed for the second layer to ensure hemostasis. Transesophageal echocardiography was used to access septal and ventricular wall motion during surgery. The patient was weaned off CPB and PCPS under intra-aortic balloon pumping (IABP) support. Post-operative echocardiography demonstrated improved wall motion and an increase in the ejection fraction of up to 40%. She resumed a completely normal lifestyle by 3 weeks after the operation.",
    "summary": "56 year-old female who required 6 γ dobutamine support due to congestive heart failure was diagnosed as severe aortic stenosis with bicuspid valve. Echocardiography revealed left ventricular ejection fraction (LVEF) was 15%. The patient was relatively young for TAVI, and TAVI was not licensed for patient presenting with a bicuspid aortic valve in places other than the limited institutions in Japan. On pump beating aortic valve replacement (AVR) was performed with selective antegrade coronary artery blood perfusion. She resumed a completely normal lifestyle by 3 weeks after the operation."
  },
  {
    "id": "multiclinsum_gs_en_413.txt",
    "fulltext": "A 31-year-old primigravida with an uncomplicated pregnancy presented in spontaneous labour at full-term. She has a history of recovered eating disorder and secondary amenorrhoea because of low body weight, necessitating conception through in vitro fertilization. Her family history revealed no predisposition to thrombotic events.\n\nFollowing the delivery of a healthy daughter through assisted forceps vaginal delivery, she immediately developed haemorrhagic shock due to retained placenta. This required a massive transfusion protocol comprising 5 L of intravenous fluids, six units of packed red cell concentrates, two units of fresh frozen plasma, one pool of platelets, and 2 g of tranexamic acid. Additionally, she was given intramuscular ergometrine and intrauterine carboprost. As she became more haemodynamically unstable with an arterial lactate of 8 mmol/L (0.4–1.3 mmol/L) and haemoglobin of 7.3 g/dL (12–16 g/dL), she was urgently intubated and transferred to theatre for delivery of the retained placenta.\n\nShe was subsequently admitted to the intensive care unit for multi-organ support following the development of disseminated intravascular coagulation characterized by thrombocytopaenia [59 × 109/L (150–450 × 109/L)], decreased fibrinogen levels of 1.3 g/L (1.7–4.1 g/L), increased prothrombin time of 17.2 s (9.8–11.3 s), and activated partial thromboplastin time of 117 s (21–29 s) with a significantly raised d-dimer of 35 mg/L (normal < 0.5 mg/L). Two days later, upon extubation, she exhibited difficulties in following commands and was diagnosed with speech apraxia by the stroke team. Brain magnetic resonance imaging (MRI) revealed acute extensive ischaemia involving both cerebral hemispheres and the cerebellum. There was a large area of cortical infarction in the right parietal lobe and additional infarcts in the frontal lobes, caudate nuclei, and left thalamus. The pattern of cortical involvement with subcortical sparring raised the possibility of a reversible vasoconstriction syndrome.\n\nHer electrocardiogram became noticeably abnormal with diffuse T-wave inversions. A high-sensitivity troponin-I was recorded at 37 000 ng/L (normal < 16 ng/L). Transthoracic echocardiography showed severe left ventricular (LV) systolic impairment, apical akinesia, and visible mobile echogenicity suggestive of thrombi. Therapeutic low-molecular weight heparin was initiated alongside heart failure (HF) therapy. One week later, she suffered from a second stroke due an acute middle cerebral artery (MCA) occlusion, resulting in aphasia and right-sided hemiparesis which required an emergency thrombectomy. Focused contrast-echocardiography revealed only small residual apical thrombus. Cardiovascular MRI showed late-gadolinium enhancement (LGE) in the inferior and inferoseptal segments of the akinetic LV apex, consistent with infarction. LV ejection fraction was 35%–40%.\n\nCardiac catheterization excluded spontaneous coronary artery dissection (SCAD) and confirmed the presence of normal coronary arteries. Despite the established safety of provocative testing, the patient expressed significant concerns about the risks and potential complications of inducing coronary vasospasm. Therefore, we decided to perform only a diagnostic coronary angiogram on that day, prioritizing patient’s wishes while still achieving diagnostic objectives.\n\nAfter three weeks of hospitalization with extensive multi-disciplinary input, her speech and motor abilities significantly improved. Her thrombophilia profile was unremarkable, including normal levels of antithrombin, protein C, and protein S along with a negative antiphospholipid screen. Additionally, there was no evidence of Factor V Leiden or prothrombin G20210A gene mutations. She was discharged on isosorbide mononitrate, oral anticoagulation, and maximum-tolerated HF therapy including ramipril 1.25 mg, spironolactone 12.5 mg, dapagliflozin 10 mg, and bisoprolol 2.5 mg once daily. A clinic review two months later confirmed full recovery of motor function. Follow-up echocardiography revealed a significant improvement in LV ejection fraction (45%–50%) with complete resolution of the LV thrombus.",
    "summary": "A 31-year-old primigravida suffered from post-partum haemorrhagic shock and disseminated intravascular coagulation following vaginal delivery. She was urgently resuscitated with intravenous fluids and blood products. Intramuscular ergometrine was administered, and surgery was required due to retained placenta. Two days later upon extubation, she demonstrated symptoms of speech apraxia. Brain magnetic resonance imaging (MRI) revealed extensive cerebral and cerebellar infarction with subcortical sparring. Her electrocardiogram showed diffuse T-wave inversions, and a high-sensitivity troponin-I peaked at 37 000 ng/L. Echocardiography showed severe left ventricular (LV) failure, apical akinesia, and thrombi formation. One week later, she suffered a middle cerebral artery stroke causing aphasia and right-sided hemiparesis, necessitating emergency thrombectomy. Cardiovascular MRI showed moderate LV systolic impairment and focal apical infarction. Coronary angiography was unremarkable. The most likely unifying diagnosis was severe ergotamine-induced coronary vasospasm causing acute myocardial infarction in the setting of life-threatening PPH. Following three weeks of multi-disciplinary care, her speech and motor abilities improved. She was discharged on long-acting nitrates, oral anticoagulation, and heart failure therapy with close outpatient monitoring. Subsequent echocardiograms showed marked improvement in LV ejection fraction (45%–50%)."
  },
  {
    "id": "multiclinsum_gs_en_80.txt",
    "fulltext": "A 32-year-old woman, gravida 1, para 0, complained of continuous vaginal fluid flow for more than 2 h and bloody amniotic fluid for 20 min in the 36th week of pregnancy. After admission to our hospital, placental abruption was immediately suspected, which led to an emergency cesarean section at 36-week gestation. During the operation, one-fifth of the exfoliated surface of the placenta was found. Birthweight was 2,500 g. Apgar scores were 5 at 1 min and 10 at 5 min. The patient reported a history of hereditary glucose-6-phosphate dehydrogenase deficiency (G6PD). There was no abnormality in her medical history and allergy history. Serology of maternal blood for human immunodeficiency virus, Chlamydia, and syphilis, Group B streptococcal status was negative. She had no history of a poor dentition or intrauterine device (IUD) use. Down’s screening at 17 weeks of pregnancy found a high risk of trisomy 18 syndrome. Further amniocentesis chromosome examination showed no obvious abnormality in the 46 chromosome karyotype. Physical examination was normal, and subsequent antenatal visits were unremarkable. There was no prior history of severe illness or surgery.\n\nThe patient began to experience lower abdominal pain on the second day after surgery, which was temporarily tolerable and was intermittent. Routine histologic examination of the placenta and cord was negative. Her postoperative hospital course was relatively uncomplicated and she was discharged home on postoperative day 3.\n\nOn postoperative day 6, she presented to the Emergency Department (ED) for chill but no fever, worsening lower abdominal pain, and new onset of pollakiuria, urgent urination, odynuria, and dysuria. Physical examination revealed a mass and severe tenderness in the abdominal bladder area. Gynecological examination found that the uterine cervix was smooth with no tenderness upon palpation and movement, a mass in the front wall of the vagina was palpable, and the tenderness was evident. She experienced severe pain when a catheter was inserted into the urethra. The catheter drains a small amount of urine. The patient did not have gross hematuria. A pelvic ultrasound exam revealed a mass measuring approximately 6.8 × 5.8 cm, which was located under the incision scar and in front of the bladder. Biological examination showed an inflammatory process with 19.820 WBC/mmy3 with 90.67% neutrophils and 3.93% lymphocytes, CRP 64.36 g/mm3. She was admitted for management of presumed pelvic hematoma.\n\nWe performed open surgery via cesarean section to remove the hematoma and check the incision site. Two cystic fluid dark areas were observed under the uterine incision during the operation. We punctured the abscess and absorbed dirty pink and foul-smelling pus. The puncture solution was reserved for aerobic and anaerobic bacterial cultures. After the uterine incision was opened layer by layer and the serosal sutures were cut off, a large amount of pus blood gushing out was observed at the lower muscle layer and the retroflection peritoneum of the bladder under the incision. Approximately 250 mL of bloody pus with a bad odor was absorbed. Then, we lavaged the space entirely, followed by the placement of a drainage tube. The patient received intravenous ceftazidime 3 g/day associated with levofloxacin 0.5 g/day for one week in the postoperative period. The puncture solution, the absorbed pus, and the drainage were respectively pumped into a blood culture bottle for aerobic and anaerobic culture. All three cultures grew the same A. odontolyticus species on the sixth operative day. When accurately diagnosed, the antibiotics were changed to IV penicillin 3.20 million IU every 6 h. The patient was discharged 19 days after admission on 2 g of oral Amoxicillin four times a day. The patient has been seen in the Infectious Diseases clinic on two occasions in the three months since discharge, and she remains well. Then, the patient discontinued Amoxicillin and continued to follow up for 10 months without recurrence.\n\n",
    "summary": "A 36-year-old woman was admitted to the hospital six days after the cesarean section with abdominal pain and dysuria. The second operation was diagnosed as pelvic abscess, debridement and drainage about 250 mL abscess. Bacterial culture of abscess confirmed as Actinomyces odontolyticus infection. Intravenous penicillin was given immediately, amoxicillin was taken orally for three months after discharge, and no recurrence was found after follow-up for ten months."
  },
  {
    "id": "multiclinsum_gs_en_75.txt",
    "fulltext": "A 24-year-old patient, gravida 1, at 40 weeks gestation by LMP, was brought to the emergency department by her family complaining of abdominal pain for 12 hours and active vaginal bleeding. She had no significant past medical history and never had antenatal care during pregnancy. She does not smoke or use drugs except antiemetics and analgesics (Navidoxine and Paracetamol). The patient had no significant personal or family history of congenital anomalies. She also denies a previous history of surgical operations, dilation and curettage, and abortions. Initially, the patient felt mild uterine contractions, minimal vaginal bleeding, and lower abdominal pain at night. The patient’s condition deteriorated in the morning, and she was brought to the hospital. The patient denies a trail of labor with misoprostol or oxytocin at home or another hospital. On examination, she was pale and distressed, with a blood pressure of 70/40 mm Hg and a maternal tachycardia of 120 bpm. The uterus was tender to palpation, with no contractions noted. The patient was hemodynamically unstable.\n\nAn ultrasound scan showed a fetus with no heartbeat in a transverse position. The location of the placenta could not be identified due to much free fluid in the abdominal cavity. Vaginal examination revealed a 3 cm dilated cervix with 50% effacement and active vaginal bleeding. Due to the emergency, we could not perform a detailed fetal ultrasound. The hemoglobin level at arrival was 5.4 g/dl. The patient was rushed to the operating room for an emergent operation due to suspicion of uterine rupture or placental abruption. The patient had immediate laparotomy under general anesthesia through a Pfannenstiel incision. At surgical exploration, massive hemoperitoneum was evident. A dead fresh female infant weighing 3140 grams with lethal skeletal dysplasia was found extruded in the abdominal cavity and was extracted with no need for a hysterotomy incision.\n\nThere was marked frontal bossing with large anterior and posterior fontanelles. The nasal bridge was flat, and the ears were low set. The limbs and fingers were remarkably short, proximally and distally, with redundant skin. There was a narrow thorax with a protuberant abdomen. Based on these findings, a Type 1 Thanatophoric dysplasia diagnosis was made. The fetal head and abdominal circumferences were 40 cm and 55 cm, respectively. After the evacuation of the hemoperitoneum, a rupture of the uterus from the fundus anteriorly to the lower segment down to the cervix was observed. There was no uterine anomaly in this case, and the location of the placenta was anteriorly in the uterine fundus. The bladder was intact. The uterine defect was repaired with a continuous double-layer closure with a 1–0 vicryl absorbable suture. After obtaining hemostasis, layers were closed anatomically. The total estimated blood loss was 3000 mL; the patient was transfused with three units of red cell pack and three units of fresh frozen plasma. The patient was discharged on the fourth postoperative day with a hemoglobin level of 9.6 g/dl in good condition. After one week of follow-up, the patient was advised to use a contraceptive method for two years and prompt antenatal care for subsequent pregnancies.",
    "summary": "The patient was 24 yrs. Old Primagravida, at 40 weeks gestation by LMP, presented with abdominal pain and active vaginal bleeding; she did not receive antenatal care during pregnancy; after initial abdominal ultrasonography and vaginal examination, laparotomy was performed due to high suspicion of uterine rupture. After dead fresh fetal extraction, the uterine defect was repaired successfully, and the patient was discharged home in good condition after several days."
  },
  {
    "id": "multiclinsum_gs_en_438.txt",
    "fulltext": "A 44-year-old woman with pulmonic valve stenosis and atrial septal defect underwent curative surgery at 4 years of age. At the age of 38 years, she noticed exertional dyspnea and was diagnosed with end-stage hypertrophic cardiomyopathy. At the age of 40 years, she was hospitalized for heart failure due to frequent atrial fibrillation attacks and implanted with a cardiac resynchronization therapy with defibrillator. Nonetheless, she had frequent hospital admissions, and in the current instance, she was hospitalized for heart failure exacerbated by atrial fibrillation attacks. She was administered medication for 1 month of hospitalization, which improved the circulation dynamics, but 3 days after discharge, she was readmitted and referred to our department with complaints of epigastric pain and loss of appetite.\n\nShe underwent upper gastrointestinal endoscopy for odynophagia and dysphagia, which showed a deep circumferential ulcer with white exudates in the esophagus, 28 to 36 cm from the incisors. Histopathological findings of the biopsy specimens taken from the ulcer showed only infiltration of inflammatory cells, indicating neither infection nor malignancy. There was no retention of food residues in the esophagus, which could cause physical obstacles, nor any history of ingestion of corrosive substances by mistake. Various drugs were administered to control her chronic heart failure, but only potassium chloride was previously reported to cause DIEIs. The potassium chloride dose was increased during the patient's previous hospitalization to prevent atrial fibrillation attacks and most likely induced ulceration. Chest radiography showed cardiomegaly with a cardiothoracic ratio of 56% and scoliosis. A transthoracic echocardiogram revealed the presence of mild mitral regurgitation and LA enlargement, with a LA dimension of 55 mm. CT showed that the enlarged LA and vertebral body compressed the esophagus, where a high-density area was noted and suspected to retain drugs. This high-density area likely contained potassium chloride because the drug was orally administered before CT and was radiopaque for several hours after administration. Collectively, these findings indicated that the ulcer was induced by potassium chloride lodged in the esophagus owing to the LA enlargement. In the upper gastrointestinal series, retention of contrast media was observed at the narrowing site of the esophagus, which is close to the LA, suggesting esophageal obstruction due to LA enlargement.\n\nTreatment with a proton-pump inhibitor was initiated, and potassium chloride administration was discontinued. Follow-up endoscopy 2 weeks later showed that the ulcer was healing, and epigastric distress and odynophagia were alleviated. However, conservative treatment with cardiovascular drugs did not effectively control the patient's heart failure, and therefore, she underwent left ventricular assist device implantation and waited for a heart transplantation. Follow-up endoscopy 2 months later showed that the ulcer had scarred, and an esophageal stricture had developed. The patient complained of dysphagia and vomiting after ingestion of solid meals, but she managed to maintain nutrition on a soft diet without intravenous nutrition and was observed without endoscopic therapy due to severe cardiac dysfunction.\n\nTwo years after the development of the esophageal ulcer, the patient underwent heart transplantation. Surgery was completed without any serious complications. Her general condition improved, but her dysphagia worsened as her medications such as immunosuppressive agents increased. Four months after the heart transplantation, endoscopic balloon dilation was performed for the esophageal stricture. Thereafter, her dysphagia improved during meals and while taking medicines. The patient was discharged 5 months after the heart transplantation. No ulcer recurrence has been observed for 10 months since her discharge.\n\nWe obtained written consent from the patient for publication of this case. Ethics committee approval is not included, as it is accepted in our hospital that case reports do not require such approval. In this work, we did not use patient data that would allow identifying her.",
    "summary": "Patient concerns:\nWe present a case of a drug-induced esophageal ulcer caused by left atrial enlargement in a 44-year-old woman with end-stage hypertrophic cardiomyopathy. Upper gastrointestinal endoscopy showed a deep, circumferential ulcer in the middle thoracic esophagus. CT revealed that the esophagus was compressed between the enlarged left atrium (LA) and the vertebral body. In the upper gastrointestinal series, retention of contrast media was observed in the esophagus near the LA.\n\nDiagnosis:\nThe ulcer was a result of potassium chloride retention in the esophagus, which was compressed by the enlarged LA.\n\nIntervention:\nAfter cessation of potassium chloride administration for 2 months, the ulcer healed and a stricture developed. Two years after the ulcer development, the patient underwent heart transplantation, and subsequent endoscopic balloon dilation was performed for the esophageal stricture.\n\nOutcomes:\nThe patient's oral intake recovered completely without any ulcer recurrence."
  },
  {
    "id": "multiclinsum_gs_en_389.txt",
    "fulltext": "We report the case of a 26-year-old woman who started work in a company that recycles batteries in October 2018. The employee reported palpitations in February 2019, for which she sought medical attention. She had no relevant medical history and was not taking any regular medication. She underwent a 24-hour Holter monitor that showed sinus rhythm alternating with junctional rhythm, occasional supraventricular extrasystoles (1/23 h), very frequent ventricular extrasystoles (9256/23 h) and nonspecific changes in the ST-T segment. The echocardiogram did not reveal any significant changes. The analytical study revealed anemia (Hb 11.9 g/dL) with no other changes, particularly in the thyroid function or in the ionogram. The value of lead quantified in the blood was 59 μg/dL (> 5 μg/dL). She was treated with bisoprolol 5 mg/id. In the following three months, she presented a progressive worsening of the symptomatic picture, with the appearance of dyspnea, thoracic pain aggravated in the supine position, dizziness, headaches, fatigue, insomnia, diarrhea, significant weight loss (14 kg in four months), changes in motor coordination and vertigo. In May 2019 she ceased work in the company, with a subsequent progressive decrease in symptomatology. One month after leaving the company, she reported recovery of the quality of sleep, a decrease in palpitations and fatigue. The analytical study of June revealed a normalization of the hemoglobin values (12.2 g/dL) and a decrease in the value of plumbemia to 23.4 μg/dL.\n",
    "summary": "A 26-year-old woman who started to have palpitations associated with headaches, fatigue and insomnia about four months after starting work at a company that recycled batteries is described. Anemia (Hb 11.9 g/dL) and a plumbemia of 59 μg/dL were observed. She stopped working at the company and after a month, she reported a progressive decrease in symptoms. The analytical study revealed a normalization of the hemoglobin values (12.2 g/dL) and a decrease in the value of lead in the blood to 23.4 μg/dL.\n"
  },
  {
    "id": "multiclinsum_gs_en_264.txt",
    "fulltext": "40-year-old male who presented to the emergency department with precordial pain. His medical history included overweight, non-alcoholic steatohepatitis, sleep apnoea hypopnoea syndrome with no requirement for continuous positive airway pressure, and coronary artery disease in his grandfather. His symptoms began 6 days prior to the appointment with precordial pain in functional class II (1000 metres), intensity 5/10, burning, no irradiation, lasting 15 to 20 minutes, which improved with rest and was not associated with dyspnoea, palpitations or sweating. He repeated similar episodes in the days following the appointment, in the same functional class, 2 hours prior to admission, when the pain started in functional class IV, postprandial, of greater intensity, 8/10, associated with dyspnoea, so he decided to seek medical attention.On admission, he presented the following vital signs: blood pressure 150/80 mmHg, heart rate 85 LPM, respiratory rate 16 RPM, oxygen saturation 98% (0.21), fever. Pre-existing residual chest pain of intensity 4/10, with no signs of heart failure. An electrocardiogram was performed, which showed negative T waves, symmetrical in precordial leads and a ST elevation of less than 1 mm with bifasic T waves in V3, without Q waves and good progression of R in precordial leads (not seen in the previous electrocardiogram). Laboratory: HtO 43%, Cr 0.8 mg/dl, ultrasensitive troponin of 132 pg/ml with subsequent elevation to 172 pg/ml. Acute myocardial infarction without ST elevation, TIMI score of 3 points, GRACE score of 66 points was interpreted. Aspirin loading, high intensity statins and anticoagulation with low molecular weight heparin were administered. Nitroglycerine was initiated intravenously, with improvement of pain. In a new electrocardiogram, the reversal of negative T waves in precordial leads was observed, but persistence of the ST elevation with bifasic T waves in V2-V3 persisted. In the echocardiogram, good ventricular function and anterolateral, basal and medial hypokinesia were observed. In the coronary angiography, severe lesions were observed in the proximal third, middle of the descending anterior artery and severe lesion in the middle third of the first diagonal, so three drug-eluting stents were placed in these lesions. A new electrocardiogram was performed after the stents were placed, in which the absence of changes was observed. The patient was discharged without complications.\n",
    "summary": "A 40-year-old man with no previous cardiovascular history presented to our center with precordial pain. The electrocardiogram showed a typical pattern, already described, known as Wellens syndrome type 1 or A, characterized by supradesnivel of the ST < 1 mm and bifasic T wave in the V3 derivation. Acute myocardial infarction without elevation of the ST was diagnosed, TIMI 3 and GRACE score 66 points. This electrocardiographic pattern is of high risk, beyond the stratifying scores, given that it correlates with severe injury in the proximal level of the anterior descending artery and requires percutaneous intervention without delays. In the coronary angiography, 3 severe lesions were evidenced: proximal and middle third of the anterior descending artery and first diagonal.\n"
  },
  {
    "id": "multiclinsum_gs_en_138.txt",
    "fulltext": "Patient, 10 months old, female, admitted to HCPA nine months ago, remained in the Neonatal Intensive Care Unit (NICU) for four months for genetic investigation, requiring invasive mechanical ventilation (IMV) for respiratory stability. During the admission, she required tracheostomy (TQT) and IMV for home use. For this, the patient was adapted in the NICU to the Trilogy 100 mechanical ventilator (Philips Respironics, United States), ventilatory mode with controlled pressure, inspiratory pressure (IPAP) of 25 cmH2O, expiratory pressure (EPAP) of 6 cmH2O, respiratory frequency (FR) of 22 irpm, auto-track sensitivity and inspiratory time of 0.8 seconds.\n\nAfter his adaptation, he was discharged to the pediatric inpatient unit, where he was clinically stable, without the need for oxygen therapy, awaiting judicial release for home care. However, in the ninth month of hospitalization, he started with fever and hypoxemia [partial oxygen saturation (SpO2): 90%], requiring the placement of oxygen (2 L/min) and the transfer to an isolation bed, where he performed the polymerase chain reaction (PCR) test for COVID-19, which was positive.\n\nThe unit's physiotherapy team installed a closed suction circuit to prevent aerosol dispersion, although it was ineffective because the child was active and often disconnected the circuit. They also inserted a high efficiency particulate air (HEPA) filter into the ventilator's outlet, followed by a heat and moisture exchanger filter (HMEF) near the TCV. They used the HMEF in the manual resuscitator for the performance of bronchial clearance techniques and a HEPA filter in the outlet of the compressed air, with the aim of reducing aerosol dispersion during the aspiration of the airways.\n\nIn the initial chest radiograph, no changes were observed. The venous blood gas indicated the presence of respiratory acidosis (pH = 7.27; pCO2 = 69.9; HCO3 = 31.7), with the need for adjustments in ventilatory parameters (IPAP = 28 cmH2O; EPAP = 5 cmH2O; FR = 25 irpm), and the use of oxygen therapy (1 L/min). After seven days of the onset of symptoms, a new chest radiograph was performed, with the presence of a peri-hilar infiltrate and apparent consolidation in the middle lobe.\n\nDuring the physiotherapy sessions, manual techniques were performed to maintain pulmonary expansion and promote bronchial hygiene. The most used techniques were: compression/decompression, prolonged slow exhalation (ELPr), manual hyperinflation (HM) with self-inflating bag and bag squeezing. In order to keep the patient active and prevent the regression of the motor picture, daily motor stimulation was maintained through the guidance of the family member.\n\nAfter 19 days from the onset of COVID-19 symptoms, the patient was discharged from hospital, clinically stable, with negative SARS-CoV-2 counter test, blood gases without alterations and return to ventilatory parameters used prior to infection. A few days before discharge, the genetic investigation was completed, confirming Ondine's syndrome. Despite a prolonged hospitalization (300 days), the patient presented head control, sat without support, rolled and reached for objects without difficulty. In addition, the functional evaluation through the Functional Status Scale (FSS-Brasil) indicated moderate degree of dysfunction (12 points), and the motor and respiratory physiotherapy was continued at home.\n",
    "summary": "Female, 10 months old with pre-existing chronic disease, admitted since birth, used mechanical ventilation via tracheostomy, evolved with hypoxemia, need for oxygen therapy and increased ventilatory parameters, and COVID-19 was confirmed. Bronchial clearance techniques and maintenance of pulmonary expansion were performed. In addition, the child during admission acquired cephalic control, sitting without support, rolling and reaching for objects, and during coronavirus infection, guidelines were passed to the family for maintenance of acquired motor milestones.\n"
  },
  {
    "id": "multiclinsum_gs_en_526.txt",
    "fulltext": "The patient comes to our pharmacy for the first time to pick up her medication in January 2020. The pharmacist who attends her, seeing the amount and complexity of medication (aerosols, narcotics...) makes her the short Morisky-Green test during the conversation at the counter to assess her adherence to the treatment and finds that she is not adherent. In this situation, she explains to the patient the personalised dosage service (PDS) and the advantages it would bring to her treatment. The patient thanks her for the explanation and says that she will consider the proposal.\n\nAfter about a month, the patient requested the SPD service, we informed her of the steps to follow and arranged an initial appointment.\n\nInitial interview (21 February 2020): The patient explains that she tries to take the medication according to the schedule, but she admits that she often either does not take it, or takes all the tablets together at dinner time. We took the patient's anthropometric data and pathologies, her medication and the extended Morisky-Green test.\n\n36-year-old female. Date of birth: 18/05/1984. Height: 152 cm. Weight: 83.3 kg. BMI: 36.\n\nChronic diseases and relevant health problems (the patient provides various clinical reports, from different dates, with the following diagnoses):\n\nCongentinal kyphoscoliosis\n\nSubclinical hypothyroidism\n\nMultiple sclerosis\n\nMigraine\n\nEhlers-Danlos syndrome (EDS)\n\nIntraaural Communication (IAC) surgery\n\nTonsil Surgery\n\nLumbosacral and dorsal arthrodesis\n\nContinuous Positive Air Pressure (CPAP) sleeper\n\nAllergies/intolerances:\n\nLipid Transfer Proteins (LTP) allergy\n\nLatex allergy\n\nAllergy to pollen\n\nAAS intolerance\n\n\nDischarge medication in the SPD service.\n\nMEDICINE  DOSE  ROUTE  BEFORE  SPD  ROUTE  SPD\nOmeprazole 20 m 28 caps.  1 c/24 h  0 - 0 - 1 - 0  1 - 0 - 0 - 0 FASTING\nAmitriptyline 25 mg 24 comp.  1 q.d.  0 - 0 - 0 - 1  no change\nPregabalin 75 mg 56 pills  2 q/24 h  0 - 0 - 2 - 0  0 - 1 - 0 - 1\nZolpidem 10 mg 30 comp.  1 c/24 h  0 - 0 - 0 - 1  no change\nHydromorphone 8 mg 56 pills  2 pills/24 h  0 - 0 - 0 - 2  0 - 2 - 0 - 0\nLevothyroxine 75 mcg 100 comp. 1 comp/24 h 1 - 0 - 0 - 0  unchanged  FASTING\nTopiramate 50 mg 60 comp.  2 comp/24 h  0 - 0 - 2 - 0  no change\nThiamine 300 mg 20 comp.  1 comp/7 days  1 - 0 - 0 - 0  no change MONDAY\nBeclomethasone/Formoterol 100/6 mcg inh.  1 inh/12 h.  Excluded from SPD\nCyanocobalamin 1000 mcg 8 ampules 1 ampoule/0 days\t\tExcluded from SPD\nCalcifediol 0'266 mg 10 caps. 1 cap/30 days.\t\t Excluded from SPD\nFluticasone 27.5 mcg/pulv.  2 pulv/24 h  Excluded SPD\nEbastina 20 mg 20 comp. 1 comp/24 h.\t\t Excluded SPD\nFentanyl 133 mcg 30 comp sublin. 1 comp/24 h.\nFentanyl 200 mcg 30 comp suck. 1 comp/24 h.\nEpinephrine 300 mcg injection\nTerbutaline turbuhaler 500 mcg/inh. 1 inh/24 h.\t\t Excluded SPD\nParacetamol 1 g 40 comp. 1 comp/12 h.\t\tExcluded SPD\nEletriptan 40 mg 4 pills 1 p/24 h\t\t Excluded from SPD\n\nThe patient lives with her parents, does not work, is usually tired, in pain and wants to sleep. She is sad and irritable. She often argues with her mother about health issues.\n\nHis physical activity is poor, as he hardly leaves the house and spends his time between the couch and the bed.\n\nThe patient explains that she has an appointment with her doctor in early March and we agree that we will prepare the discharge documentation for the SPD Service so that she can hand it over to her doctor on that day.\n\n\nEVALUATION AND INTERVENTION\n10 interactions of moderate clinical significance are detected. (1, 2)\n\nActions taken in response to detected interactions:\n\nOf the 10 interactions detected, 8 can produce excessive sedation and/or impairment of cognitive and motor function which fully coincides with the clinical situation of the patient, so we assess these interactions as manifest.\n\nThe medicines involved are: amitriptyline, ebastine, beclomethasone/formoterol, terbutaline, hydromorphone, fentanyl, zolpidem and pregabalin.\n\nIn some, the prescriber is proposed to change the medication (hydromorphone and pregabalin) and in others a change of active principle (ebastine) is proposed.\n\nHydromorphone: Patient is warned and a change in schedule to 0-2-0-0 is proposed to the prescriber. Change accepted by the prescriber.\n\nPregabalin: Patient is warned and a change of schedule to 0-1-0-1 is proposed to the prescriber. Change accepted by the prescriber.\n\nEbastine: The patient was warned and the prescriber was advised to change to an antihistamine that does not cross the blood-brain barrier (cetirizine, levocetirizine and bilastine). The change was not accepted by the prescriber.\n\nRegarding the unstated interaction between beta-2 adrenergics and amitriptyline: the patient is warned and the prescriber is informed of the increased risk of cardiotoxicity due to QT interval prolongation. The prescriber did not change the treatment.\n\nWe also changed the schedule of Omeprazol to be taken on an empty stomach in the morning.\n\nActions taken in response to detected interactions:\n\nOut of 19 prescribed medicines, we excluded 11 from the SPD device for the following reasons: non-oral route, take if necessary and not conditional.\n\nThe table shows the patterns of each medication before and after evaluation and intervention.\n\nRESULTS\n6 months from the start of the service (September 2020):\n\nOn medication\n\nThe patient went from taking three opioid painkillers to just one. She tapered off oral fentanyl because the pain was subsiding, until the prescriptions were permanently removed from her medication plan.\n\nIt also requires less paracetamol and less eletriptan.\n\nIn clinical and personal situation:\n\nThe patient reports feeling much better both physically and mentally because:\n\nThe intensity of the pain has decreased significantly.\n\nThe frequency of migraine attacks has decreased.\n\nI no longer feel tired all the time as I did before.\n\nher social interactions have improved and she no longer spends her days locked in the house.\n\nrelationship with her parents has improved (she used to argue often with her mother about why she didn't understand why she never left the house).\n\nMorisky-Green test results at 6 months.\n\n12 months from the start of the service (March 2021):\n\nHydromorphone 8 mg treatment was continued until March 2021, when it was replaced with fentanyl 25 mcg patches (1 patch/72 h).\n\n20 months from the start of the service (October 2021)\n\nOn medication:\n\nThe patient has gone from using 19 drugs routinely at the beginning of the service to currently taking only 10 drugs (7 included in the DSP and 3 excluded due to their pharmaceutical form).\n\nThe rest of the medication is available in his medication plan, but he does not use it regularly, only in case of need for migraine and allergy attacks.\n\n\nMedication at 20 months follow-up\n\nMEDICINE  SPD\nOmeprazole 20 mg 28 caps. Included\nAmitriptyline 25 mg 24 comp. included\nPregabalin 75 mg 56 comp. included\nZolpidem 10 mg 30 comp. included\nLevothyroxine 75 mcg 100 comp. included\nTopiramate 50 mg 60 comp. included\nThiamine 300 mg 20 comp. included\nCyanocobalamin 1000 mcg 8 ampules  Excluded - regular use\nCalcifediol 0'266 mg 10 caps. Excluded - regular use\nFentanyl matrix 25 mcg/h 5 p  Excluded- regular use\nBeclomethasone/formoterol 100/6 mcg  Excluded - Occasional use\nEbastina 20 mg 20 comp.  Excluded - Occasional use\nEpinephrine 300 mcg injected. Excluded - Occasional use\nSalbutamol 100 mcg/dose  Excluded- Occasional use\nParacetamol 1 g 40 comp.  Excluded - Occasional use\nEletriptan 40 mg 4 pcs.  Excluded - Occasional use\n\n\nIn clinical and personal situation:\n\nThe patient is happy and encouraged because she has been taking her medication correctly for a year, has been able to start going to the swimming pool regularly to increase her physical activity and has started to lose weight. (Current BMI: 35).\n",
    "summary": "36-year-old woman with several diseases of varying complexity, with 19 active medicines in her medication plan and a Morisky-Green test result of a non-adherent patient, to whom we offer the follow-up service with personalised dosage service (SPD).\n\nFrom the initial interview, we obtain the following information about her state of health: she usually feels tired, sleepy, sad and with no desire for anything. She lives with her parents and hardly ever leaves her home.\n\n10 interactions of moderate clinical significance are detected, 8 of which may produce clinical situations that coincide with the situation described by the patient.\n\nAfter 6 months, the patient required only 1 opioid analgesic instead of 3, the use of other drugs was reduced and her health status improved significantly.\n\nAt 20 months, she has gone from taking 19 drugs routinely to taking only 10. She has also improved her social interactions and is no longer spending her days locked in the house.\n\nThe patient is very grateful to the pharmacy, and we are happy to offer this service and help so many patients to improve their adherence to their treatments and consequently their state of health.\n"
  },
  {
    "id": "multiclinsum_gs_en_570.txt",
    "fulltext": "The case of a 100-year-old man is presented. He had a stroke that has left him paralysed on the right side and, therefore, has significant mobility problems. He smoked for a few years when he was young, but this has caused COPD. He also suffers from dysphagia, which causes bronchial aspiration that, together with COPD, leads to frequent respiratory crises. Despite his age, his cognitive state is perfect. He is conscious and oriented at all times, and only if he wakes up at night does he have an episode of delirium and agitation. He is permanently accompanied by a carer.\n\nHe had a profound bradycardia episode that required an emergency call. He was taken off bisoprolol and the bradycardia resolved, but his son is asking us if any of his medications were responsible.\n\nWe have no reports of clinical or diagnostic data, as well as the chronology and severity of the same, so the status of the situation makes an approximation of the patient's diseases through the medicines he uses. Nor is there information available on start dates or last changes in the medicines, except the withdrawal of bisoprolol as a possible cause of bradycardia.\n\nStudy and evaluation\nThe bradycardia episode has been controlled, but we took the opportunity to review all of his medication for PRM/RNM. The state of the situation prior to the bradycardia is studied, therefore, bisoprolol is present.\n\nWe use the CheckTheMeds® app to help us with the analysis and we supplement it with the data sheets.\n\nBisoprolol was probably the main cause of bradycardia. Besides bisoprolol, there are other medicines that can also alter heart rate and rhythm by different mechanisms.\n\nAltered potassium levels, both hyper and hypokalemia, can alter heart rate producing tachy or bradycardia. Medicines that can produce hypokalemia are furosemide, budesonide and β2 agonists, salbutamol and formoterol. On the other hand, eplerenone will retain it, and take a potassium chloride supplement. In addition, there is an interaction between amiodaron and eplerenone that increases the effect of the latter.\n\nThe QT interval prolongation may also have influenced the heart rhythm. Medicines that may prolong it are salbutamol, amiodaron, trazodone, pantoprazole and furosemide. All of these medicines are important for the patient's heart problems, except trazodone which is used as a hypnotic and pantoprazole. Since you are taking apixaban, it may be convenient to maintain an IPP. The only IPP that does not prolong the QT interval is rabeprazole.\n\nThe anticholinergic burden was measured using the Crideco scale and the Anticholinergic Burden Calculator. Both scales showed a relevant anticholinergic burden, with the medicinal products ipratropium, glycopyrronium, furosemide, trazodone and zolpidem being involved.\n\nOther problems that appear are:\n\nSalbutamol and ipratropium inhaled in a scheduled manner 2 puffs every 12 hours when the recommended administration is on demand. In addition, salbutamol can have cardiac effects.\n\nParacetamol 1 g once daily. He takes it chronically at night because he has some pain. In patients of this age this dose can be very high. The dose of 650 mg is recommended so as not to saturate the hepatic metabolism.\n\nLatanoprost to control intraocular pressure and prevent glaucoma. With 100 years, the likelihood of this becoming a problem is low and latanoprost can cause discomfort to the patient.\n\nZolpidem 10 mg ½ tablet daily. It is advisable to use the 5 mg presentation so as not to manipulate the medication.\n\nIntervention\nTrazodone is proposed to be withdrawn because it is being used in an unauthorised indication, is arrhythmogenic and has anticholinergic burden.\n\nSubstitute pantoprazole with rabeprazole.\n\nCheck with your pulmonologist if the dose of salbutamol 2 puffs every 12 hours is correct, as it can also have effects on the heart.\n\nChange to paracetamol 650 mg and check if the pain control is maintained.\n\nChange to zolpidem 5 mg 1/day. Chronic treatment with zolpidem or benzodiazepines is not recommended, but in this patient it will give few problems and if he wakes up at midnight he has episodes of agitation with alterations in heart rhythm. If the trazodone is withdrawn, it may be necessary to increase the zolpidem dose. That would increase the anticholinergic load but does not seem to be a problem in this patient. The main limitation could be the respiratory depression that could appear and that would require very good adjustment of the dose or search for other solutions.\n\nConsult with the ophthalmologist about the need to maintain latanoprost.\n\nResults/Follow-up\nHe is a MUFACE patient, so he has easy access to specialist doctors. A report was issued for the patient and it was the son (very high cultural level) who spoke to all the doctors. The response from them is known through the son. The intervention does not comply with the protocols for communication with doctors because the son's decision to be the one to transmit the information is respected.\n\nThe cardiologist confirms that trazodone prolongs the QT interval, but considers that its effect is negligible compared to the patient's cardiac problems. Neither trazodone nor pantoprazole is withdrawn.\n\nSalbutamol was discontinued. The patient remains under observation.\n\nParacetamol 650 mg was changed and the pain was kept under control.\n\nZolpidem 5 mg 1/day is changed.\n\nThe ophthalmologist maintains the latanoprost.\n",
    "summary": "A 100-year-old man presents with a profound bradycardia episode. The patient's caregiver calls emergency services and they withdraw bisoprolol and monitor the bradycardia. After the problem is resolved, they ask us if any of their medications could be related to the bradycardia.\n\nInvestigation and evaluation: When reviewing the patient's very complex treatment, we cannot establish a clear relationship between any of his 19 medications and bradycardia, except for bisoprolol, which has been discontinued, but we found 6 other problems that we are trying to solve.\n\nResult: Of the 6 proposed changes, 3 are accepted.\n"
  },
  {
    "id": "multiclinsum_gs_en_38.txt",
    "fulltext": "A 1-day-old, Black Bantu African preterm female baby weighing 1000 g was born to a Gravida 3, Living 2 mother via spontaneous vaginal delivery. Soon after delivery, she was referred to our neonatal intensive care unit owing to multiple congenital anomalies and moderate respiratory distress. The mother is 32 years and is in a non-consanguineous marriage. The mother did not seek any medical attention until her early third trimester of pregnancy, due to abruptio placenta. The first antenatal ultrasound revealed severe oligohydramnios. She was not diabetic (random blood glucose was 5.1 mmol/L) and did not receive folic acid supplementation during pregnancy.\n\nAt admission, the baby was alert with mild features of respiratory distress syndrome. She had multiple dysmorphic features that included microcephaly (head circumference < 10%), prominent occiput, low-set ears, right cleft palate and lip, micrognathia, elbow contracture bilaterally, and shorter lower limbs.\n\n\nThe birth weight was 1000 g, the length of the baby was 40 cm, and the occipitofrontal circumference was 30 cm.\n\nInvestigations\nSkeletal X-ray showed rib flattening, right femur aplasia, and left femur hypoplasia. Laboratory workout included: complete blood counts, c-reactive protein, creatinine, blood urea, and electrolytes, which were all within the normal range. Cranial ultrasound was normal, but echocardiography revealed a small patent ductus arteriosus.\n\nDifferential diagnosis\nThe patient had bilateral femoral aplasia and unusual facies. These clinical entities led to the diagnosis of femoral–facial syndrome.\n\nThe similarity in etiopathogenesis makes caudal regression syndrome the common differential diagnosis. Both can be caused by poorly controlled maternal hyperglycemia. However, facial defects are absent in caudal regression syndrome, the key diagnostic feature.\n\nProximal focal femoral hypoplasia and craniofacial anomalies are usually absent.\n\nDisruption conditions that can cause cleft palate include severe amniotic band syndrome.\n\nTreatment\nThe infant was kept on respiratory support and empirical antibiotics. An orthopedic surgeon, an ear, nose, and throat surgeon, and a physiotherapist were involved. Surgical repair of the cleft palate is planned at age of 6 months. Functional rehabilitation is planned before the patient starts ambulation. Limb lengthening surgery is currently not done in our setting.\n\nOutcome and follow-up\nAt the age of 1 month, the patient died from complications of severe late-onset neonatal sepsis.",
    "summary": "A 1-day-old Black Bantu African female baby was admitted to the neonatal unit owing to multiple congenital anomalies. The mother did not seek any medical attention until her early third trimester when she had an abruptio placenta. The mother has never received antenatal folic acid supplementation. The baby had microcephaly, low-set ears, right cleft palate and lip, micrognathia, contracture, and shorter limbs. A skeletal X-ray showed femoral hypoplasia. We report this rare case and highlight the challenges in diagnosis and treatment."
  },
  {
    "id": "multiclinsum_gs_en_62.txt",
    "fulltext": "22-year-old male from Dolores, Buenos Aires, Argentina, who consulted the Otorhinolaryngology Service of our institution for a three-week old case, characterized by a right nasal cavity tumour, which caused homolateral nasal respiratory insufficiency, rhinorrhea and intermittent epistaxis. On examination, the patient denied relevant antecedents, such as underlying diseases, similar lesions and regular medication. As antecedent occupational activity, he worked in rural areas, in close contact with dogs and farm animals (sheep, horses and cattle), which drink from a nearby water source. On physical examination, with relevant anterior rhinoscopy, a friable, bleeding, polypoid mass was evident, which occupied the entire right nasal cavity, with implantation at the level of the septum. The patient came with a computed tomography scan performed two weeks earlier (few cuts), in which a right nasal tumour, posterior septal deviation to the right and free paranasal sinuses were observed. It should be noted that, although the tomography was not too old, it did not allow the size of the lesion to be determined with accuracy at the time of the consultation, given the rapid growth of the lesion. Surgical treatment was opted for, and the total resection of the tumour from the septum was performed by endoscopic surgery. The same was sent to the Pathology Service for subsequent evaluation. The total material was received, fixed in 10% formol. On macroscopic inspection, a brown-red, scaly fragment was identified, with whitish areas, 2.3 × 2.2 × 1.1 cm. The sample was processed routinely and stained with hematoxylin and eosin. Histologically, the polyp presented respiratory and squamous epithelial lining, marked chronic granulomatous inflammatory process at the stromal level, with the presence of abundant thick-walled cystic structures between 100 and 500 µm (sporangios), which contained abundant endospores in different evolutionary stages. In view of the findings described, techniques of periodic acid Schiff (PAS) and Grocott were performed in a second time, which were positive, allowing the diagnosis of nasal cavity rhinosporidiosis. 100 mg of dapsone was indicated three times a week for three weeks. The patient, almost two years after the onset of the case, did not present recurrences or other complications.\n",
    "summary": "We report the case of a 22-year-old male native of Argentina who presented with nasal respiratory insufficiency, rhinorrhea and epistaxis. Rhinoscopy showed a polypoid formation arising from the septum and occupying the entire right nasal cavity. Microscopically, the polyp was covered by respiratory and pavement epithelium and at the stromal level there was evidence of a chronic granulomatous inflammatory process with the presence of abundant cystic structures of 100 to 500 microns thick (sporangia), containing within them abundant endospores. Periodic acid-Schiff and Grocott's stains highlighted these structures. Given the clinical and epidemiological background and the morphological picture, the diagnosis of rhinosporidiosis was reached.\n"
  },
  {
    "id": "multiclinsum_gs_en_592.txt",
    "fulltext": "A 33-year-old previously healthy woman presented in December 2017 with progressive dyspnoea, high fever, night sweats and weight loss. After a month of evolution, she was admitted to a general hospital with frank respiratory failure and septic shock with diffuse alveolar infiltrates, jaundice, haemoptysis and petechiae in the lower limbs. She was intubated and required haemodynamic support. A mild systolic mitral murmur was identified on precordial auscultation. There was marked leukocytosis with left shift, plateletopenia, hepatic and renal dysfunction associated with subnephrotic proteinuria and consumption of complement. The result of antinuclear antibodies was 1/80, despite normal anti-double strand DNA, anti-SM and anti-PR3 levels. After administration of ceftriaxone, she improved clinically. Yellow fever, dengue, chikungunya, leptospirosis, HIV and viral hepatitis were ruled out. The blood cultures were positive for Haemophilus spp. in all six samples collected. The transthoracic echocardiogram (ETT) demonstrated a diffuse, amorphous, echogenic mass with irregular surface and some mobile elements that involved both leaflets of the mitral valve, measuring 20x17 mm in the anterior leaflet and 19 mm in its greatest diameter in the posterior leaflet, resulting in severe flail mitral regurgitation and perforation. The magnetic resonance imaging showed small splenic abscesses, treated conservatively. A non-complicated fungal aneurysm of the left middle cerebral artery was treated by percutaneous embolisation. Thirty days after admission, she underwent mitral valve replacement with a size 29 mm Sorin® biological valve prosthesis and after extensive resection of the tumour. Moderate aortic regurgitation due to fibro-intervalvular mitro-aortic fibrosis and non-coronary cusp retraction was treated conservatively. The pathological examination confirmed the presence of an infected mitral valve myxoma. The patient completed 28 days of ceftriaxone and gentamicin, and was discharged asymptomatically. After one year of follow-up, there was no evidence of recurrence and only mild aortic regurgitation was observed. Infected myxomas present a higher risk of embolic events, although the clinical manifestations are indistinguishable from non-infected tumours.2 The present case appears to be the sixth reported case of infected mitral valve myxoma in the literature, fulfilling definitive criteria for diagnosis, and the third caused by a HACEK group microorganism.3 - 8 Of the 64 published mitral valve myxomas from 2006 to 2012, the symptoms were cardiovascular in 36.7%; 9.5 to 21.6% of the mitral valve myxomas underwent valve replacement and the time from diagnosis to surgery ranged from a few hours to 42 days.2 , 9 The mortality rate was reported as 2.6 to 3% and 5.1 to 21%.2 , 10 In the present series, the majority of patients presented symptomatic heart failure, underwent mitral valve replacement and all had good results in the follow-up.\n",
    "summary": "A 33-year-old woman presented with a history of fever and dyspnoea of a few days' duration. On admission, she presented with a lupus-like syndrome with positive blood cultures for Haemophilus spp. An echocardiogram revealed a giant mass involving both mitral leaflets associated with severe regurgitation requiring a biological mitral valve replacement. Microscopy revealed an infected myxoma and the patient was discharged asymptomatic after completion of the antibiotic therapy. She has had a good follow-up.\n"
  },
  {
    "id": "multiclinsum_gs_en_193.txt",
    "fulltext": "An 18-year-old Caucasian, female patient presented at our clinic with complaints of multiple palpable lumps in her breasts bilaterally. On physical examination the patient had multiple pigmented lentiginous lesions on her face, body and her sclerae bilaterally, blue nevi on her trunk and upper extremities and a round moon-shaped face.\n\nUpon ultrasonographic evaluation multiple compact nodules-fibroadenomas were found in both breasts, with the largest being in the upper outer quadrant of the left breast with diameter of 7.8 cm.\n\nShe had previously undergone total thyroidectomy in 2018 with the diagnosis of follicular adenoma and a removal of a large nodule of the left breast, due to its large size and pain, with a histopathology report suggesting fibroadenoma with myxoid stroma.\n\nAn excision biopsy of two nodules of the right breast was performed with myxoid fibroadenoma diagnosis, supporting our diagnosis of Carney complex.\n\nOn magnetic resonance imaging, multiple compact fibroadenomas were found on bilateral breasts, with high signal intensity on T2 and T2/FS images, with internal septations without restriction of diffusion, compatible with multiple myxoid fibroadenomas.\n\nFurthermore, there were a couple of axillary lymph nodes and prominent internal mammary lymph nodes bilaterally.\n\nIn addition, there was an abnormality of soft tissue density at the anterior mediastinum, measuring 11 mm in maximum thickness, suggesting a prominent thymus.\n\nAll the above findings suggested a possibility of Carney complex. Further laboratory evaluation took place. Hormonal testing showed no abnormalities in testosterone, prolactin, PTH and DHEA-S levels.\n\nGene analysis was then performed with findings of PRHAR1A gene mutation, heterozygous for a missense variant of uncertain significance in exon 3 of this gene. This mutation has never been reported in the gnomAD database.\n\nGenetic testing was performed to the parents as well, finding only the father positive to the same gene mutation.\n\nVarious conservative treatment plans were discussed with the patient, but none proved to provide a definite solution/treatment. Excision of big lobules was performed in the past with temporary alleviation of the patients’ pain symptoms and the recurrent surgeries were affecting her quality of life. The patient had also several sessions with our clinic psychologist and was assessed thoroughly before deciding upon the final solution of a bilateral mastectomy.\n\nThe patient underwent a bilateral skin-sparing mastectomy and placement of tissue expanders (smooth, Motiva Flora®) subcutaneously. Histopathology reported multiple myxoid fibroadenomas in both breasts, compatible with Carney complex syndrome, with disruption of normal breast parenchyma architecture. Figures show macroscopically and histologically the fibroadenoma.\n\nWound care was minimal, the patient was advised to wear a medical bra and regular visits to the outpatient clinic for follow-up and further filling of the tissue expanders at regular intervals until the desired size was achieved. Patient prior and post-mastectomy. After one year a second surgery took place and the expanders were replaced with permanent silicone implants (smooth, Motiva Ergonomic®) submuscular, with again the same minimal wound care requirements and bra placement.",
    "summary": "An 18-year-old female patient presented at our clinic with complaints of multiple palpable lumps in her breasts bilaterally. On physical examination the patient had also multiple pigmented lentiginous lesions on her face, body and her sclerae, blue nevi on her trunk and upper extremities and a round moon-shaped face. The diagnosis of Carney syndrome was decided upon imaging, biopsies and genetic analysis. The patient underwent a bilateral mastectomy as a prophylactic treatment plan with tissue expanders' placement."
  },
  {
    "id": "multiclinsum_gs_en_484.txt",
    "fulltext": "68-year-old male patient with a history of chronic degenerative type 2 diabetes mellitus and systemic arterial hypertension. As surgical history, he reported a hemorrhoidectomy 30 years ago. The rest of the history was denied.\n\nHe presented to the emergency department of our unit, reporting clinical symptoms that had started 48 hours earlier, with abdominal pain in the hypogastrium, intense, without irradiation, accompanied by nausea and multiple vomits of gastrointestinal content, fever and tachycardia. On physical examination, the abdomen was with present air-water sounds, soft, depressible, painful to superficial and deep palpation in the right hypochondrium, positive Murphy's sign. Due to the symptoms described, he was admitted to the Gastro-surgery department. An ultrasound of the liver and biliary tract was performed, finding a gallbladder of 6 x 4.7 x 4.2 cm, wall of 2.5 mm, multiple anechoic images of approximately 0.5 mm with projection of acoustic shadow, suggestive of vesicular lithiasis, with extrahepatic dilation of the biliary tract of 9 mm. In the laboratory examinations performed, creatinine values of 3.6 mg/dL, bilirubins, AST and ALT without alterations, GGT: 224 IU/L, alkaline phosphatase: 231 U/L, LDH: 122 U/L, leukocytes: 15.58 mm3, neutrophils: 86%, haemoglobin: 10.2 g/dL, haematocrit: 30.3% and platelets: 279 x109/L.\n\nFollowing the hydration resuscitation and the management of the acute renal injury through a hydration plan performed by the Nephrology department, a contrasted abdominal computed axial tomography was performed as a complementary diagnosis. It reported a bile duct with a diameter of up to 10 mm in its pancreatic and intraduodenal portion with multiple ovoid images, the largest one with a diameter of 9.3 mm. For this reason, a magnetic cholangio-resonance was requested with a report of vesicular lithiasis associated with bile sludge and choledocholithiasis, conditioning a hydrocole-cyst, dilation of intra- and extrahepatic bile duct, and duodenal diverticulum without suggestive data of inflammation.\n\nBased on the findings described above, and according to the 2018 Tokyo Guidelines, a diagnosis of severe cholangitis/grade III (acute renal and neurological failure) secondary to choledocholithiasis was made. Antibiotic treatment with carbapenem was prescribed. The patient had significant clinical and neurological deterioration, so it was decided to perform ERCP, finding a duodenum of normal shape, calibre, distensibility and mucosa of normal appearance; in the second duodenal portion, a major papilla was identified within a diverticulum of 30 mm in diameter, with opacification of purulent material at its ostium. An intrahepatic dilated bile duct, extrahepatic up to 12 mm, could be seen inside with four 10-14 mm stones. The pancreatic duct was not opacified. A short sphincterotomy and 12 mm transpapillary dilation with a balloon were performed, and the stones and fragments were removed. The clearance of the bile duct was corroborated. The conclusion was: cholangitis, resolved choledocholithiasis, short sphincterotomy, 12 mm transpapillary dilation, biliary balloon sweep, intra-diverticular papilla.\n\nThe patient subsequently had a favorable evolution, with no data of complications associated with the endoscopic procedure, with evident clinical improvement and normalization of laboratory studies. Resolution of the acute renal injury and neurological status was also reported. Laparoscopic cholecystectomy was performed seven days after ERCP, which was performed without incident, so the patient was discharged to home after 16 days of hospital stay.\n",
    "summary": "68-year-old man with a history of diabetes and hypertension, who comes to the emergency department with abdominal pain, fever and tachycardia. Acute renal injury and alterations in liver function tests, ultrasound with dilated common bile duct and vesicular lithiasis are identified. A cholangioresonance is performed that shows duodenal diverticulum and choledocholithiasis. Antibiotic treatment is given and an endoscopic retrograde cholangiopancreatography is performed, showing a duodenal diverticulum with stones and pus inside. A sphincterotomy, transpapillary dilation and multiple scans are performed. A cholecystectomy is performed seven days later and the patient is discharged home after improvement without complications.\n"
  },
  {
    "id": "multiclinsum_gs_en_104.txt",
    "fulltext": "A 34-year-old female with no past medical or surgical history was presented to the emergency department (ED) with a five-day history of progressively worsening fatigue, heat intolerance, sweating, and palpitations. Her symptoms did not have a diurnal variation. The patient described fatigue and palpitations present with milder intensity for the last two years but was never bothersome enough to seek medical attention. Upon further questioning, the patient reported five kilograms of unintentional weight loss over the past five months. She did not report diarrhea, respiratory symptoms, or chest pain. Her menstruation was regular. The patient quit smoking three months before her presentation and never consumed alcohol. The patient denied any excessive use of caffeine in her diet.\n\nA physical exam revealed euthermia (36.6 °C), tachycardia with heart rate (HR) up to 120 beats per minute (BPM), raised blood pressure (140/100 mmHg), a respiratory rate of 20 breaths per minute, oxygen saturation at 99% on room air and a body mass index (BMI) of 23.5 kg/m2. Further examination revealed a diffuse goiter, fine bilateral tremors on outstretched hands, bilateral proptosis, bilateral lid lag and retraction, more on the right side. An electrocardiogram showed sinus tachycardia (ST) without ischemic changes or signs of chronic hypertension. A chest X-ray and bedside transthoracic echocardiogram did not reveal of any pathology. A complete blood profile and kidney and liver function tests were unremarkable.\n\nFurther blood investigations revealed thyrotoxicosis with fully suppressed thyroid stimulating hormone (TSH) (<0.01 mIU/L, normal range: 0.3–4.2), with raised T3 (17.8 pmol/L, normal range: 3.7–6.4) and T4 (52.5 pmol/L, normal range: 11–23.3). Her TSH receptor antibody (TRAB) was positive (16.5 IU/L, cut off 1.75 IU/L), hence confirming a diagnosis of Grave’s disease (GD). The patient was educated about GD and the effects and side effects (especially agranulocytosis) of CBZ. She was then started on CBZ 20 mg once daily (OD) and Propranolol 80 mg sustained release (SR) OD with an outpatient follow-up for repeat TFT and further dose adjustment. However, after four weeks, the patient revisited the ED with a three-day history of palpitations associated with chest discomfort and dizziness. The physical exam revealed ST (HR 137 BPM) and a thyroid exam similar to her initial visit. A repeat TFT panel showed TSH <0.01, T3: 17.5, and T4: 64.1. She denied non-compliance with the medication. CBZ was increased to 20 mg twice daily (BD), and Propranolol 80 mg SR was continued. The patient was seen in the endocrine clinic after two weeks. She still complained of palpitations and heat intolerance; however, ST had settled.\n\nTwo weeks post-clinic visit, the patient visited the ED for the third time with a 1-day history of bothersome palpitations. Examination revealed ST (HR140 BPM), and her BMI had increased to 24.5 kg/m2. TFTs showed persistent hyperthyroidism (TSH <0.01, T3: 12.1, T4: 54.1). The patient was admitted and given CBZ 20 mg thrice daily (TD) and propranolol 160 mg SR OD under supervision. Her TFTs were repeated after five days, showing persistent hyperthyroidism with only a marginal improvement in T4 (39 pmol/L). Medication non-adherence as a possibility was discussed in a detailed interview with the patient. The patient insisted on strict compliance to the treatment. She was bothered by persistent symptoms, with no underlying stress or depression, and wanted to get the symptoms treated. She had gained some weight and had a reduction in her absolute neutrophil count, hinting toward compliance with the medications.\n\nAdditionally, her TRAB reduced from 16.5 to 6.9. She was discharged (on CBZ 20 mg TD and propranolol 160 mg SR OD) with a close follow-up plan.\n\nAt the follow-up visit after four weeks, she remained hyperthyroid (TSH: 0.01, T3: 11.1, T4: 43.9) with a normal heart rate. The patient was asked to bring empty bottles of her medicine to check her compliance, which strengthened the possibility of taking the medicines as prescribed. Malabsorption was ruled out with a negative celiac screen (negative anti-tissue transglutaminase antibodies) and normal cyanocobalamin and albumin levels. CBZ resistant GD was considered at this point and was shifted to PTU 100 mg TD with propranolol 160 mg SR OD and prednisolone 20 mg daily for two months with a tapering regimen. At the four-week follow-up, she had no improvement in her TFTs (TSH: <0.01, T3: 11.3, T4: 40.1). After another four-week follow-up, her steroids were stopped, and PTU was increased to 150 mg TD due to persistently deranged TFTs (TSH: <0.01, T3: 12, T4: 40.4). Patient had a partial response to the increased dose of PTU with repeat TFTs after one month showing TSH <0.01, T3: 7, T4: 25.5. The TFT trend of the patient from diagnosis to the last follow-up is graphed.\n\nGiven only a partial response to increasing doses of PTU, patient was referred to surgical team to get definitive treatment via thyroidectomy, avoiding possible hepatotoxic and hematologic complications of long-term higher doses of PTU. The patient tolerated total thyroidectomy well without any complications. Her last thyroid profile was normal (TSH 3.42) on replacement levothyroxine 75 mcg daily.",
    "summary": "A 34-year-old female presented with a 5-day history of progressively worsening fatigue, heat intolerance, sweating, and palpitations. She was diagnosed with GD based on her thyroid function tests (TFTs) and started on CBZ and propranolol. Despite being compliant with CBZ 20 mg once daily and then twice daily, her TFTs remained unchanged for 4 months. However, patient revisited the emergency with continued thyrotoxicosis and unchanged TFTs. Her dose was eventually increased to 20 mg thrice daily, and administration under supervision did not improve her TFTs. The patient was shifted to PTU 150 mg thrice daily with steroids, with minimal improvement. The patient eventually underwent thyroidectomy to avoid long-term PTU use."
  },
  {
    "id": "multiclinsum_gs_en_305.txt",
    "fulltext": "Mr S. was an 88-year-old patient, retired, construction worker, widowed, living alone in a first floor apartment with stairs. He had solely a daughter, his primary caregiver. He had no home help before his hospitalization.\n\nHis clinical history was marked by repeated arthritis described as gout, heart failure on a tight aortic valve stenosis that subsequently benefited from TAVI, moderate chronic renal insufficiency (clearance 45 mL/min/1.73m2), stenting bi-femoral aorto-bi-femoral stenting, high blood pressure, transient ischemic stroke, essential tremor and a right sural venous thrombosis. He had no toxic habits or allergies.\n\nThe 7th of November, this patient was admitted to the emergency department for cardio-renal decompensation consecutive to a pneumopathy. Patient recovered with antibiotic associate to diuretic therapy. After five days, he was transferred to a geriatric ward for a standardized geriatric assessment and for rehabilitation in front of exercise deconditioning.\n\nInitial blood samples of November 13th, found a calcium level of 2.55 mmol/L, corrected at 2.84 mmol/L. There was severe denutrition with a dosage of albumin measured at 28.3 mmol/L. A PTH increased to 94 ng/L and a collapsed 25-hydroxy-vitamin D at 15 nmol/L were found. Clinically, he showed no clinical signs suggestive of hypercalcemia. Chest x-ray showed no anomalies. In December, given the suspicion of secondary hyperparathyroidism due to hypovitaminosis D and not in line with standard recommendations, a parathyroid ultrasound revealed no suspicious nodules. Colecalciferol supplementation was introduced. In addition, nutritional management was started. M. S presented at the same time knees painful arthritis with joint effusion associate to biological inflammatory syndrome. Chondrocalcinosis was suspected but acid uric level was high 478 µmol/L. A puncture was realized: 920 nucleated cells per mm3 and sodium urate crystals were found in the joint fluid. Treatment with colchicine and then the addition of allopurinol improved the symptoms. The cardiac status and physical improvements allowed the patient to return home on the 2nd of January.\n\nUnfortunately, a new cardiac decompensation required re-hospitalization on January the 23rd. During this subsequent hospitalization, blood calcium levels remained slightly increased (2.64 mmol/L) and PTH was significantly increased (191 ng/L) despite vitamin D supplementation. In March, a 24-h urine sample was collected for calciuria measurement, which revealed a decreased urinary calcium concentration of 1.23 mmol/L. The fractional excretion of calcium was 1.2%. Due to these uncharacteristic results, a MIBI parathyroid scintigraphy revealed no abnormalities in favour of an adenoma or parathyroid hyperplasia. In April, a genetic analysis to detect the inhibitory mutation of the CASR gene coding for the calcium-sensitive receptor (gene 3q21.1) revealed a pathogenic variant classified as FHH type 1 according to ACMG guidelines. The patient’s family was informed and genetic screening was organized to avoid unnecessary additional tests. The patient was finally able to go home. Patient and his family gave their informed consent for this case report. Ethical Approval was not required for this manuscript. Consent for publication from daughter of the patient was obtained.",
    "summary": "We report the diagnosis of FHH in an 88-year-old polypathological patient with hypercalcemia discovered during a check-up for cardiac decompensation. Despite a confusing clinical presentation with gout symptoms, including repeated episodes of knee arthritis, persistent hypercalcemia conducted further investigations. Biological tests excluded primary or hyperparathyroidism and malignancy-related hyperparathyroidism, confirming the diagnosis of FHH through the detection of an inhibitory mutation in the calcium-sensing receptor gene."
  },
  {
    "id": "multiclinsum_gs_en_381.txt",
    "fulltext": "It is a seven-year-old male patient, native and from Popayán (Cauca). The parents denied consanguinity and exposure to teratogens. The father was a healthy 32-year-old man and the mother a healthy 23-year-old woman with a history of two pregnancies and two births; her first daughter was born healthy.\n\nThe patient was a product of a second pregnancy, unplanned, with no history of preconception care. She received early prenatal care from the fourth week, six check-ups in total; her micronutrient intake was adequate. She had four obstetric ultrasounds, with no abnormal findings.\n\nThe patient was born at 38 weeks of pregnancy by vaginal delivery in a health institution; his birth weight was 3,340 g, his height was 51 cm and the Apgar score was adequate. He presented non-haemolytic neonatal jaundice lasting 45 days, with bilirubin values between 5.4 and 12.8 mg/dl, for which he received phototherapy. However, he presented neonatal hypoglycaemia, cyanosis and hypotonia; and, in addition, respiratory difficulty due to pneumonia and early neonatal sepsis.\n\nOn the other hand, at 14 days of age, she presented dystonic movements in both hands, four to five times a day, without loss of consciousness, which were diagnosed as convulsive episodes. At the beginning of lactation, severe and frequent episodes of sleep apnoea were observed; there was also persistence of generalised hypotonia, several episodes of aspiration pneumonia and swallowing disorders.\n\nClinical findings\nAt the 6-year physical examination, anthropometric measures were: weight, 21 kg; height, 116 cm; height-for-age, 0 to -1 SD; BMI-for-age, 0 + 1 SD; arm span, 108 cm; expected minus total (E-T) score = -8; pubic-to-head segment, 58 cm; pubic-to-toe segment, 59 cm; SS/SI, 0.98; and head circumference, 52 cm.\n\nThe following morphological characteristics were observed: brachycephaly, right occipital plagiocephaly, low-set auricles, oval face, bilateral endoforia, pseudo-strabismus, bilateral epicanthal fold, ocular hypertelorism, intercanal distance of 40 mm, intercanal distance of 140 mm, photoreactive isochoric pupils, nose without deviation of the nasal septum, normal nasal bridge, 20 mm nasolabial filter or groove, tongue and uvula without alterations, high palate, dental diastema and dental enamel of regular quality. In addition, he presented: pectus excavatum, normal abdomen and right lumbar scoliosis; redundant foreskin and descended testicles; mobile, symmetrical and hypotonic limbs; right hand with single flexion fold, and bilateral flat foot.\n\nOn neurologic examination, the patient was alert with motor aphasia (speaking in gibberish); there was no evidence of hearing impairment and most cranial nerves were normal except for bilateral cranial nerve VI. There was convergent psuedostrabismus and axial predominant hypotonia with reflexes present (++); he required assistance with ambulation, had 3/5 strength in all limbs, had preserved sensation and had no urinary incontinence.\n\nMolecular diagnosis\nAt the age of five, the full exome was sequenced and a heterozygous, probably pathogenic variant was identified in exon 1 of the PURA gene: c.692T>C (p.Phe231Ser).\n",
    "summary": "The patient, a seven-year-old boy, began to develop dystonic hand movements at 14 days of age. At the age of six, he was diagnosed with neurodevelopmental delay, generalized hypotonia, frequent episodes of apnoea and swallowing difficulties. Although other conditions, such as Duchenne muscular dystrophy and neuronal ceroid lipofuscinosis, were initially considered, the full exome sequencing revealed the pathogenic variant c.692T>C (p.Phe231Ser) in exon 1 of the PURA gene, not previously reported in other patients. This finding allowed a comprehensive management approach, which addressed the patient's clinical characteristics and alterations.\n"
  },
  {
    "id": "multiclinsum_gs_en_401.txt",
    "fulltext": "The patient consented to utilization of blinded data concerning the case for publication.\n\nA 17-year-old female student suffered a fall when performing trampoline jumping. A loud noise, associated with inability to get up was experienced by the patient, followed by inability of mobilization and weight bearing.\n\nDiagnostic work up demonstrated a fracture close to the distal of the tibia and the fibula.\n\nThe tibial fracture presented as an oblique fracture and the fibular fracture at the same level as a spiral type with additional fracture spike.\n\nAfter preoperative testing, surgical stabilization was performed using i.m. nailing of the tibia. A tibial nail with a diameter of 10 mm was inserted and 3 interlocking screws were inserted distally, two from the medial to the lateral cortex and a third screw from the anterior to posterior cortex.\n\nProximally, an interlocking bolt was inserted using the targeting device from the medial to the lateral cortex. Since the strictly transverse fracture pattern of the tibia offered sufficient axial support, a compression screw was inserted and interfragmentary compression was applied. It was decided not to separately stabilize the fibular fracture, as the fibular reduction was considered sufficient.\n\nOn postoperative day 1, the patient was mobilized out of bed and for the left leg weight bearing was allowed as tolerated. Soft tissues were unremarkable and no significant swelling or any clinical sign of compartment syndrome was noted.\n\nDistal pulses of anterior and posterior tibial artery were repeatedly palpated. The perfusion of lower leg and foot was unremarkable, she was discharged home on postoperative day 5 on continuous prophylactic antithrombotic medication.\n\nOn postop day 13, the patient experienced pain sudden onset of symptoms and swelling of the left lower leg and presented at the ER. At the site of the fibular fracture, significant swelling and tenderness on palpation was noted. There was no sign of peripheral peroneal nerve compression or sensory or motor deficits.\n\nSelective ultrasound studies demonstrated an enlarged pseudoaneurysm of the left fibular artery. Clinically, no signs of imminent or acute compartment syndrome were present. In addition, using ultrasound studies, a deep vein thrombosis (DVT) was ruled out.\n\nTherapeutically, the diagnosis of an “aneurysm spurium” was treated by selective embolization the left peroneal artery using PTA and coil embolization of the backdoor arteries (4× fig. 8 coil 2 × 5 mm) as well as feeding vessel (peroneal artery, 4× complex helical 6 × 6 mm, 1× interlock 6 × 10 mm).\n\nThe consecutive course remained unremarkable.\n\nFollow up controls performed at regular intervals demonstrated timely and complete bony healing and no signs of perfusion deficits. The functional outcome was excellent and the young sportive patient was able to resume hockey and soccer team sports at a semiprofessional college level.\n\nAt the 2 year follow-up, the patient did not experience any long term signs of functional compartment syndrome or perfusion deficits when extensively performing extended sports activities.",
    "summary": "Briefly, a 17-year-old female suffered a traumatic lower extremity fracture and was treated by intramedullary nailing of the tibia. After an uneventful postoperative course, she noted a painful and pulsating swelling of the lateral aspect of the lower extremity about 2 weeks post op. Diagnostic ultrasound confirmed formation of traumatic pseudoaneurysm of the peroneal artery adjacent to the fibular fracture. Subsequent endovascular treatment using coil-embolization was successful. Bony healing occurred in a timely fashion and the patient returned to pain free semi-professional sports activities."
  },
  {
    "id": "multiclinsum_gs_en_136.txt",
    "fulltext": "History of Presentation\nA 77-year-old man presented to the emergency department with angina that had started 24 hours prior. His electrocardiogram was unremarkable, and laboratory tests showed a mild elevation in cardiac troponin I (3.72 ng/mL).\n\nPast Medical History\nHis medical history was notable for hypertension, hyperlipidemia, diverticulitis, and significant coronary artery disease, for which he had previously undergone quadruple coronary artery bypass surgery. One month earlier, he was admitted with unstable angina and underwent coronary angiography, which revealed patency in 3 of his 4 grafts, except for an occluded vein graft to the second obtuse marginal (OM2). PCI was performed on the native coronary artery, and 3 drug-eluting stents (DES) were placed in the proximal left circumflex (LCx) artery extending into the OM2. This procedure was complicated by a coronary artery perforation, necessitating the placement of a covered stent (Papyrus 20 × 3.5 mm, Biotronik) in the proximal segment of the LCx. Notably, the covered stent was optimized using intravascular imaging. The patient had a prolonged hospital course with pericarditis and atrial fibrillation (no significant pericardial effusion on serial transthoracic echocardiograms [TTE]) but was discharged without resuming anticoagulation, with a plan to start this as an outpatient.\n\nInvestigations\nUpon evaluation in the emergency department, a TTE demonstrated normal left ventricular function with basal inferior wall akinesis, moderate mitral and tricuspid regurgitation, and a hypoechoic, well-circumscribed mass in the posterior atrioventricular groove that could not be clearly interpreted. Given the resolution of symptoms and negative preliminary test findings, computed tomographic angiography was performed, revealing a 39 × 29 mm PSA of the proximal-to-distal segments of the LCx, just distal to the recently placed covered stent.\n\nManagement\nA heart team discussion deemed the patient to be at too high a risk for surgical intervention, leading to the planning for PSA closure. A 6-F right femoral access was obtained, and an EBU 3.5 guide catheter was used to engage the left main artery. A Hi-Torque Wiggle wire (Abbott) was used to navigate the LCx. Intravascular ultrasound (IVUS) was performed to identify the origin of the PSA. Subsequently, a PK Papyrus covered stent, 3.5 × 26 mm (Biotronik), was implanted within the LCx-OM2. After dilation with a 3.5-mm distally and 4.0-mm proximally noncompliant balloon, final IVUS and angiography confirmed successful sealing of the PSA, resulting in TIMI flow grade 3 to the distal vessel.\n\nOutcome and Follow-Up\nThe patient was discharged the following day with instructions to continue dual antiplatelet therapy with aspirin and clopidogrel. At the 6-month follow-up visit, the patient remained asymptomatic. Dual antiplatelet therapy was discontinued in favor of a direct oral anticoagulant because of his history of atrial fibrillation. Repeated TTE showed no significant changes.",
    "summary": "The authors report the case of a 77-year-old man in whom a large PSA developed in the left circumflex artery within 30 days of PCI, which was complicated by coronary perforation. During the original procedure, the perforation was sealed by a covered stent; however, anticoagulation was resumed because of atrial fibrillation 2 weeks later. The patient subsequently presented again with chest discomfort, and computed tomographic angiography showed a large PSA at the edge of the stent. Percutaneous closure using a second covered stent achieved complete PSA isolation."
  },
  {
    "id": "multiclinsum_gs_en_363.txt",
    "fulltext": "A 44-year-old man was admitted to our hospital with acute decompensated heart failure (HF). Seven years before the patient's admission, he had first been admitted for the treatment of acute decompensated HF. The patient had a history of hypertension. His blood pressure was 140/80 mmHg when he was not taking any medication.\n\nAn echocardiogram showed LV systolic dysfunction and dilatation with no significant valvular disease. The degree of mitral regurgitation at the diagnosis was mild. The LV wall thickness was 8.0 mm. Blood urine examinations did not reveal secondary or infiltrative cardiomyopathy, with the following measurements: white blood cell count, 9,900/μL; C-reactive protein, 0.28 mg/dL; thyroid-stimulating hormone, 0.57 μIU/mL; free thyroxine, 1.71 ng/dL; anti-nuclear antibody negative; immunoglobulin G, 1,363 mg/dL; angiotensin-converting enzyme, 6.8 IU/L; and urinary Bence-Jones protein negative. The patient had no history of drug or alcohol consumption that could have caused LV dysfunction.\n\nCoronary angiography demonstrated no significant coronary disease. 18F-fluorodeoxyglucose positron emission tomography and 67Ga-scintigraphy showed no abnormal uptake in the LV. CMR showed no high-intensity regions on T2-weighted imaging or late gadolinium enhancement (LGE). An endomyocardial biopsy showed myocardial degeneration and mild interstitial fibrosis, but secondary cardiomyopathy was not observed. Therefore, the patient was diagnosed with idiopathic DCM.\n\nTwo and a half years after the first admission, the LV diastolic diameter decreased from 60 to 51 mm, and the LV ejection fraction (LVEF) increased from 10% to 67% after the administration of medication, including beta-blockers (carvedilol, 10 mg/day) and RAAS inhibitors (perindopril, 8 mg/day; spironolactone, 25 mg/day).\n\nThree years after the first admission, the patient stopped taking medication of his own volition against medical advice. His LVEF decreased from 67% to 25%, and the LV diastolic diameter increased from 51 to 72 mm. After the patient discontinued medical treatment, his systolic blood pressure increased from 131 to 162 mmHg. A 12-lead electrocardiogram showed sinus rhythm with a ventricular rate of 99 bpm, which was not significantly different from the value before the discontinuation of therapy (97 bpm). We performed coronary angiography; however, no coronary stenosis was observed. In addition, secondary cardiomyopathy was investigated again by blood and urine examinations, but no significant observations were made. We also performed CMR imaging and an endomyocardial biopsy again. CMR at follow-up demonstrated an appearance of linear LGE in the ventricular septum, which was not observed at the baseline. An endomyocardial biopsy also demonstrated a significant increase in interstitial fibrosis and the development of replacement fibrosis compared with the baseline evaluation.\n\nAlthough medications were re-introduced and the patient's compliance was good, the LV performance gradually worsened, and the B-type natriuretic peptide concentration increased over several years. Because of first-degree atrioventricular block and temporal complete atrioventricular block, beta-blockers could not be up-titrated to the target dose (final dose of carvedilol: 10 mg/day).\n\nThe patient was repeatedly admitted to the hospital because of HF. Although adaptive servo-ventilation was introduced, the effect was poor. At this time point, the patient was considered to be indicated for cardiac resynchronization therapy (CRT) for the further up-titration of beta-blockers. However, a CRT device was not implanted since it was difficult to anticipate whether or not the patient might achieve reverse remodeling with the further up-titration of beta-blockers, causing biventricular pacing to potentially negatively affect his cardiac performance. A ventricular assist device and heart transplantation were repeatedly considered; however, the patient did not want to undergo therapy. The patient ultimately died four years later due to worsening HF.",
    "summary": "A 44-year-old man diagnosed with idiopathic dilated cardiomyopathy was admitted to our hospital with acute decompensated heart failure. Seven years before this admission, the first introduction of medication resulted in left ventricular (LV) recovery, which was sustained for several years. However, the patient stopped taking his medication, resulting in worsening of the LV function. Despite the second introduction of medication, the LV function did not improve. We performed cardiac magnetic resonance imaging and an endomyocardial biopsy, which revealed the significant development of cardiac fibrosis that had not been present at the time of the initial diagnosis."
  },
  {
    "id": "multiclinsum_gs_en_339.txt",
    "fulltext": "We describe a case of 18‐year‐old male patient, affected by DMD and in a wheelchair from the age of 11, who has always been followed up by a multidisciplinary team in our Institution. Since the age of six, he was treated by oral medication with deflazacort. During these years, the patient was regularly followed up by pneumologists by using with spirometry and by neurologists who monitored the evolution of the neuromuscular disease in terms of thoraco‐abdominal function and scoliosis. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and peak expiratory flow (PEF) were, respectively, 60%, 70%, and 70% of predicted values (FVC, 2.24 Lt; FEV1, 2.09 Lt; PEF, 4.07 Lt). The patient also underwent right‐heart catheterization to monitor pulmonary vascular resistances with evidence of values within normal range. When he progressively developed dilated cardiomyopathy in 2016, at the age of 14, he underwent HeartWare LVAD implantation, because of acute refractory heart failure. The heart transplant option had not been considered by paediatric cardiac surgeons, (i) because of the emergency the patient was in and (ii) because of the common scepticism towards heart transplant in these DMD patients. Weaning from mechanical ventilation occurred as a routine, and no post‐operative complications were encountered.\n\nDuring the following 47 months the patient was regularly followed up, and we only report an infection of the exit site, treated by antibiotics and surgical toilette, 30 months after LVAD implantation. The debridement of the drive line consisted of incision of the skin following the path of the cable, exteriorization of the cable more proximally, cleaning of the fistulous path, and re‐suturing of the skin. Although the recovery was excellent, seeing that the drive line exit was very close to the sternal wound, the patient became psychologically stressed enough to spontaneously ask for a radical solution to the problem. FVC, FEV1, and PEF were, respectively, 1.66 Lt, 1.62 Lt, and PEF 4.41 Lt. Based on the patient's good general conditions and patient personal motivation, our multidisciplinary team started to consider heart transplant as an option. Thus, in 12 February 2020, at the age of 18, the patient underwent heart transplant with no post‐operative complications. Weaning from mechanical ventilation occurred as a routine once more. In the first post‐transplant day, it was possible to extubate the patient. The discharge from the ICU was possible on the third post‐operative day. As far as mobilization is concerned, in our Unit, the patients are followed up by a specialized team of physiotherapists. The patient was trained by them from the first days; and as soon as he was transferred from the ICU to the ward, mobilization was started as soon as possible. As regards sternal stabilization, as we usually do, we suggested to use a tissue sternal band. Mobilization in a wheelchair was possible on the fifth post‐operative day. The total hospital stay was 3 weeks, the time needed to perform the three canonical biopsies for the evaluation of any myocardial rejection. A standard triple‐agent immunosuppressive therapy was administered (cyclosporine, mycophenolate mofetil, and steroid). At 3 months, FVC, FEV1, and PEF were unchanged than at the pre‐transplant.",
    "summary": "We describe the case of an 18‐year‐old male patient, affected by DMD and in a wheelchair from the age of 11. He progressively developed dilated cardiomyopathy, and in 2016, at the age of 14 years, he underwent HeartWare LVAD implantation, as destination therapy, without post‐operative complications. He has been followed up for 47 consecutive months; and 30 months after LVAD implantation, he developed an infection of the exit site, treated by antibiotics and surgical toilette. Following this event, on the basis of patient's good general conditions and willingness, we started to consider heart transplant as an option. Before the patient was listed, he underwent accurate workup, and we found higher values of forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow, compared with the predicted values of same‐age DMD patients. The patient have neither scoliosis nor need for non‐invasive mechanical ventilation, and finally, he was always treated with steroids with stable thoraco‐abdominal function over the years. According to these considerations, the patient was listed for heart transplant. In 12 February 2020, at the age of 18 years, the patient underwent heart transplant with no post‐operative complications. Cardiac transplantation is not considered a valid option for DMD patients, because of the shortage of donor availability and the systemic nature of DMD disease. Considering that this patient had already experienced an LVAD‐related complication and he had better general condition than his DMD peers, we listed him for a heart transplant. We described the case of a DMD patient who underwent successful heart transplantation after 47 months of HeartWare LVAD assistance. Three months' follow‐up is uneventful."
  },
  {
    "id": "multiclinsum_gs_en_529.txt",
    "fulltext": "A 3050-g full-term male neonate was born after an uncomplicated pregnancy to a 20-year-old primiparous woman at a gestational age of 39 weeks. The pregnancy was uncomplicated. The labor was not prolonged with uneventful spontaneous vaginal delivery. Apgar scores were 8 and 9 at 1 min and 5 min, respectively, with a normal grimacing response score of 2. His Apgar remained to be 9 at 10 and 20 minutes. He was alert with a good cry, pink color, a pulse rate of 134 and respiratory rate of 56. He was given vitamin K at birth. He presented to our hospital with failure to suck for three days at age of 29 days. The family also stated that he had intermittent vomiting since birth. Otherwise, there was no history of bleeding diathesis, fever, neck stiffness, or seizure. At presentation, he had a bulging anterior fontanelle. Moro was incomplete; sucking was not sustained but good muscle tone was noted in all extremities. His complete blood count (CBC) and coagulation profile were normal. Brain MRI showed bilateral cerebellar convexity T1WI and T2WI hyperintense hematoma measuring 2cm with supracerebellar and periaqueductal extension. Furthermore, obliteration of the fourth ventricle and dilation of the third and lateral ventricles was also noted. Under general anesthesia, the patient was placed in a prone position utilizing a midline skin incision, bilateral burrhole craniostomy was done. After the dura was opened in a cruciate incision, a well-defined thick membrane; with dark hemolyzed blood came out with pressure. Intraoperatively, the patient had a cardiac arrest for which one cycle of cardiopulmonary resuscitation (CPR) was done and a return of spontaneous circulation was achieved. Afterward, the skin was closed subdural drain was placed and the patient was extubated and transferred to the intensive care unit (ICU). Control CT scan done on 3rd post-op day showed complete evacuation of the hematoma and improvement of the hydrocephalus. The patient was discharged on the 7th post-op day improved. The first-month post-op follow-up was uneventful with normal developmental milestones achieved for his age.",
    "summary": "A twenty-nine-day-old male neonate presented with failure to suck for three days duration associated with vomiting. Imaging showed bilateral posterior fossa chronic subdural hematoma and obstructive hydrocephalus. Bilateral burrhole craniostomy and hematoma evacuation was done which resulted in an excellent outcome."
  },
  {
    "id": "multiclinsum_gs_en_402.txt",
    "fulltext": "Male patient, product of controlled pregnancy, without previously detected anomalies. He was born at 36 weeks of gestational age, in a basic level institution, with 2.5 kg. He presented neonatal multi-organ compromise and episode of cardiac arrest in the first 24 hours postnatal. He was transferred to a higher level institution where he was diagnosed with Dextro-TGA. After stabilisation, he was taken to atrio-septostomy at the second day of life. Due to clinical conditions, neonatal switch arterial correction was not performed. He evolved with multi-organ compromise and pulmonary hypertension, and required mechanical ventilation for two months with prolonged stay in intensive care. He progressed to the disfunctionalisation of the left ventricle in a sub-pulmonary position (left ventricle banana morphology), with severe tricuspid valve insufficiency in a systemic position. At 7 months of life, he underwent Mustard surgery and tricuspid valve plasty. In the postoperative period, he had severe biventricular dysfunction and terminal cardiac failure, so they considered transplantation as the only viable option, which is why he was referred to a higher level institution. In the admission studies, the banana-like morphology of the left ventricle and severe right ventricular dysfunction in a systemic position were confirmed, with moderate to severe tricuspid valve insufficiency. There was no evidence of a stenotic gradient in the tunnels of the Mustard or alteration of the coronary pattern. The patient was dependent on inotropic support and was on the list for transplantation without a donor available for 4 months, so it was decided to opt for pulmonary artery clamping for left ventricular re-training. At 11 months of life and with 6.9 kg, pulmonary artery clamping was performed, obtaining a peak gradient of 20 mmHg and a mass of 19.3 g/m2. Inotropic support was discontinued. Once stabilised, left ventricular failure management and ambulatory levosimendan boluses were continued. The atrial natriuretic peptide (BNP) changed from 330 pg/ml before the first clamping, to a nadir of 48 pg/ml after the procedure. Given the adequate clinical response, a new adjustment of the clamping was performed at 20 months of life with 9 kg, achieving a gradient increase to 50 mmHg, with a mass of 50 g/m2 and change in the morphology of the left ventricle. BNP increased to 272 pg/ml in the first year after the second clamping, although the trend was subsequently downward.\n\nThe last bolus of levosimendán was 4 months after the second cerclage. He was kept on oral medical management and strict clinical follow-up by the pediatric heart failure clinic for 6 years, with progressive and adequate response, meeting some of the criteria for left ventricular preparation of Stanford. (table 1). BNP decreased to a value of 104 pg/ml, which was considered quite acceptable for the physiology at that time and supported the decision to carry out the complete correction. With these data it was decided that he was a candidate for anatomical correction. Jatene surgery was performed with reimplantation of coronary arteries and Lecompte maneuver, dismantling of Mustard, atrial reconstruction, removal of the cerclage and reconstruction of the pulmonary artery. After this procedure, the patient continued in ambulatory follow-up for pediatric heart failure for 3 years, with functional class II and BNP normalized. He continued with an ejection fraction of the left ventricle of 53%, ejection fraction of the right ventricle of 45% and without fibrosis, although with criteria of alteration of diastolic relaxation. In that evaluation he was stable, schooled, performed activities and sports routinely, continuing in strict follow-up by the pediatric heart failure clinic. Without reconsidering cardiac transplant.\n",
    "summary": "Patient with diagnosis of Dextro-TGA, with multiple perinatal complications, operated with Mustard surgery at 7 months, who developed refractory heart failure in the postoperative period. Given the option of cardiac transplantation, pulmonary cerclage was decided at 11 months of age as a stabilisation measure, which subsequently allowed the left ventricle to be retrained and led to anatomical correction with removal of the Mustard and successful switch of large arteries at 6 years. Three years later, he maintains a good quality of life and functional class II.\n"
  },
  {
    "id": "multiclinsum_gs_en_225.txt",
    "fulltext": "A 23-year-old Japanese man was admitted to our hospital due to worsening exertional dyspnea. He had shown difficulty running at two years old and been diagnosed with EDMD with a LMNA (Lamin A/C) gene mutation at exon 1 from leucine 102 to proline. In accord with the typical EDMD manifestations, his elbows, knees, and Achilles tendons had become contracted at five years old, and his posterior cervical muscles became rigid; however, he continued to go about his usual daily life, albeit with mild exercise restriction. His father had also been diagnosed with EDMD and died suddenly in his 40s.\n\nWhen the patient was 19 years old, he was admitted to a hospital for the first time due to congestive heart failure. Signs of RV failure, such as leg edema and liver congestion, were prominent, as indicated by the high blood bilirubin level (2.5 mg/dL). Echocardiography showed that the tricuspid annular plane systolic excursion (TAPSE) was 5.7 mm, RV-s' 5.1 cm/s, and RV fractional area change (RVFAC) 19%, indicating marked RV dysfunction. High-dose diuretics in addition to carvedilol (10 mg/day) and enalapril (2.5 mg/day) were introduced. Despite those medications, he was readmitted due to worsening RV failure.\n\nAt 22 years old, an implantable cardioverter defibrillator (ICD) was implanted due to his non-sustained ventricular tachycardia (VT) and family history of sudden cardiac death. At this point, right heart catheterization (RHC) showed a pulmonary artery wedge pressure (PAWP) of 22 mmHg, right atrial pressure (RAP) of 17 mmHg, and right ventricular stroke work index (RVSWI) of 6.47, suggesting sustained severe RV dysfunction. As such, RV failure was likely to be the main pathological condition throughout his clinical course.\n\nHe had symptomatic heart failure with New York Heart Association class III under maximal doses of guideline-directed medication, and his electrocardiogram showed a regular sinus rhythm and left bundle branch block with wide QRS (150 ms). His LV ejection fraction (LVEF) was ≤35% on echocardiography. He was therefore considered to be indicated for CRT and was thus upgraded from ICD at 23 years old.\n\nOn admission, his blood pressure was 106/65 mmHg, and his heart rate was 60 beats/min with a regular rhythm. The physical examination revealed a third cardiac sound and pan-systolic murmur (Levine II/VI) at the apical region. Respiratory sounds were clear, whereas a distended jugular vein and lower-limb edema were evident. Chest X-ray indicated an increased cardiothoracic ratio (59%) with no pulmonary congestion.\n\nThe electrocardiogram showed all biventricular pacing due to CRT. Echocardiography revealed mild dilatation in both ventricles (LV end-diastolic diameter: 54 mm, RV diameter 50 mm) with a reduced LVEF (30%). The RV function was also diminished, as indicated by a decreased RVFAC (11%) and a low TAPSE (8 mm). Both enlarged ventricles caused leaflet tethering and coaptation loss that resulted in moderate mitral regurgitation and severe tricuspid regurgitation. The inferior vena cava was dilated to 23 mm with reduced respiratory fluctuation.\n\nIn the histological findings of posterior cervical muscles performed later at the autopsy, increased variation in muscle fiber size with moderate infiltration of connective tissue was observed, which was compatible with EDMD. Blood tests revealed brain natriuretic peptide (BNP) 196.1 pg/mL, total bilirubin 1.4 mg/dL, aspartate aminotransferase (AST) 39 U/L, alanine aminotransferase (ALT) 43 U/L, and γ-glutamyl transpeptidase (γ-GTP) 451 U/L, which suggested liver dysfunction. Although the coronary arteries were intact on angiography, an RV endocardial biopsy revealed cardiac hypertrophy with increased magnitudes of the nucleus and myocardium.\n\nElectron microscopy demonstrated typical findings of EDMD: a reduced number of myofibrils, necrosis, and the formation of pseudo- or true inclusion. Since other secondary cardiomyopathies were ruled out by these clinical and histological findings, we diagnosed EDMD-related cardiomyopathy.\n\n\nThe patient’s clinical course. Right heart catheterization (RHC) on day 11 showed severe LV/RV dysfunction and congestion, and some inotropes were started. Although the patient’s hemodynamics improved, his renal function progressively worsened on day 38. Concerned about the worsening of his renal function due to the blood pressure decline, dopamine and mechanical support (IABP and CRRT) were initiated, and the patient’s renal function and hemodynamics improved. However, he developed acute liver failure along with severe RV failure indicated by the RHC data on day 68. Although veno-atrial ECMO was introduced on day 71, liver dysfunction and DIC caused systemic hemorrhagic diathesis, and the patient died of multiple organ failure on day 100. CRRT: continuous renal replacement therapy, DIC: disseminated intravascular coagulation, ECMO: extracorporeal membrane oxygenation, IABP: intra-aortic balloon pumping, LV: left ventricle, RV: right ventricle\n\nRHC on day 11 showed that the cardiac index (CI) was 2.0 L/min/m2 (Fick method), and PAWP was 15 mmHg, indicating Forrester subset IV. The pulmonary artery pressure (PAP) was 29/12 (18) mmHg, and the RAP was 15 mmHg. The RVSWI, one of the hemodynamic parameters for the RV function, was calculated with the following formula: RVSWI (g·m/m2/beat)=[mean pulmonary artery pressure (mPAP)-mean right atrial pressure (mRAP)]×stroke volume index (SVI)×0.0136. His RVSWI was 1.36 g·m/m2/beat, indicating severe RV dysfunction. To compensate for the patient's low output syndrome and congestion, we started a continuous dobutamine (3.0 μg/kg/min) infusion and added milrinone (0.125 μg/kg/min) on day 16.\n\n\nOn day 32, the RHC data were improved, with an increased CI (2.48 L/min/m2), reduced PAWP (13 mmHg), and increased RVSWI (2.8 g·m/m2/beat). However, on day 38, the patient's renal function progressively worsened, possibly due to high central venous pressure (CVP) and hypotension because the blood pressure had been around 70/40 mmHg several days before the worsening of the renal function. To increase his blood pressure, a continuous dopamine (2.0 μg/kg/min) infusion was initiated; the milrinone was reduced, and enalapril and eplerenone were discontinued. In addition, intra-aortic balloon pumping (IABP) and continuous renal replacement therapy (CRRT) were temporarily needed. As the patient's hemodynamics improved in response to increase mixed venous oxygen saturation (SvO2, 70-80%) and CI (3.0-3.5 L/min/m2), the IABP and CRRT were withdrawn on day 45.\n\nOn day 68, however, the CI dropped to 1.25 L/min/m2 again, and the patient's lung congestion and fluid retention deteriorated; the PAWP was as high as the RAP, at 22 mmHg. Furthermore, the patient's serum bilirubin levels and liver transaminase dramatically increased, suggesting the development of liver failure. On day 71, VA ECMO through a femoral vein to the subclavian artery was initiated, but due to the systemic hemorrhagic diathesis accompanied by the disseminated intravascular coagulation (DIC), the patient died of multiple organ failure on day 100.\n\nAn autopsy performed under informed consent from the patient's family revealed efferent enlargement in both ventricles with a thin wall thickness. The histopathological examination revealed that mild to moderate myocardial hypertrophy and severe fibrosis were evident in the RV and LV. The weight of the liver was significantly increased to 2,298 g, and macroscopic liver congestion and cholestasis were detected. On microscopic images, the portal vein area was scarcely changed, and atrophy or loss of hepatocytes was observed around the central veins, indicating “shock liver.” In the lungs, extensive alveolar hemorrhaging was observed, and a collection of macrophages had ingested hemosiderin was noted, reflecting systemic hemorrhagic diathesis.",
    "summary": "A 23-year-old man had progressive muscle weakness and Emery-Dreifuss muscular dystrophy (EDMD) due to a LMNA (lamin A/C) mutation. Congestive heart failure diagnosed at 19 years of age. Maximal drug treatment/cardiac resynchronization failed to improve the cardiac function. He was therefore hospitalized due to heart failure. Despite extracorporeal membrane oxygenation, he developed severe right heart dysfunction and died (multiple organ failure)."
  },
  {
    "id": "multiclinsum_gs_en_499.txt",
    "fulltext": "The case of a 43-year-old woman with a history of breast cancer diagnosed before menopause is described. The patient began with nonspecific gastrointestinal symptoms, such as postprandial fullness, increased abdominal perimeter, intermittent abdominal pain with a predominance in the mesogastrium of 12 months of evolution. Subsequently, dyspnea of medium efforts was added. The patient went to a primary care doctor, who established the study protocol and requested an ultrasound of the abdomen and pelvis, which showed a tumor that covered the entire abdominal cavity, and complemented the study with a contrasted computed tomography of the thorax, abdomen and pelvis, which showed a 27.5 x 12.7 x 28.2 cm, heterogeneous, predominantly liquid tumor with the presence of septa.\n\nThe tumour markers presented Ca 125 at 84.16, ACE 10.07, AFP 1.83, B-HGC 0.1. The haematological biometrics showed evidence of liver function and coagulation times within normal parameters. The patient was sent to the Gynecological Tumour Service of the Oncology Hospital of the Siglo XXI National Medical Center, where we proposed laparotomy with transoperative study. Surgical intervention was carried out in which left salpingo-oophorectomy was performed, which was sent for transoperative study.\n\nThe surgical event was found to be mucinose, with a carcinomatosis index of 16 points, with mucin implants throughout the extent of the parietal peritoneum, Gleason capsule and spleen, in addition to a ruptured left ovarian tumor.\n\nThe left ovary was received in the study, weighing 3450 g, measuring 28 x 27 x 14 cm, with a broken capsule, a multilocular inner surface with mucous content, and a cystic area measuring 7 x 6.5 cm with sebaceous content and hairs. Histological sections showed an ectodermal tissue composed of squamous epithelium and hair follicles, as well as an endodermal tissue composed of intestinal epithelium, which in various sections showed marked atypia with complex architectural arrangement, up to the point where seal ring cells were found, corresponding to adenocarcinoma. No immature elements were identified in the tumor sample.\n\nOvarian staging and debulking surgery was continued, consisting of total hysterectomy + bilateral salpingo-oophorectomy + peritonectomy + appendectomy. In the presence of evidence of tumour activity, a cholecystectomy and splenectomy were performed and hyperthermic intraoperative chemotherapy with 45 mg of cisplatin in 1000 ml of 0.9% saline at 40 degrees C was added, resulting in optimal debulking, which was classified as stage IIIC. In the histopathological report, tumour implants (adenocarcinoma) were observed in the omentum, liver capsule and spleen capsule.\n\nThe patient was referred to the Medical Oncology Service and was considered a candidate for adjuvant treatment with carboplatin and paclitaxel in six cycles, which ended without incident. She is currently in good oncological condition with a disease-free period of seven months; she is being monitored by the Gynaecological Tumour Service.\n",
    "summary": "43-year-old female with a diagnosis of mature teratoma malignum with signet ring cells. Optimal primary debulking surgery was performed; total hysterectomy, bilateral salpingo-oophorectomy, peritonectomy, appendectomy, cholecystectomy and splenectomy, plus intraoperative hyperthermic chemotherapy (HIPEC).\n"
  },
  {
    "id": "multiclinsum_gs_en_286.txt",
    "fulltext": "This is the case of a 51-year-old female with a past medical history of IPAH. This had been diagnosed by right heart catheterization 16 years previously when the patient collapsed at home shortly after childbirth. The patient’s condition was stable for many years, being medically managed with intravenous iloprost at 1300 μg once daily. This allowed the patient an acceptable quality of life maintaining a WHO functional class II.\n\nA computed tomography pulmonary angiogram in 2013 diagnosed a 5.5 cm PAA, worst affecting the main and left pulmonary arteries. Right heart catheter performed at this time demonstrated pulmonary artery pressure of 90/39 mmHg (mean 31 mmHg), right ventricular pressure of 93/10, end diastolic diastolic pressure of 20 mmHg and a mean right atrial pressure of 13 mmHg. Due to the progression of the underlying pathology additional pulmonary antihypertensives were added to the treatment plan (sildenafil and ambrisentan). The patient was considered for bilateral orthotopic lung transplantation but after assessment was deemed too clinically well to list for transplant at that time and the patient continued to be monitored by their local hospital.\n\nClinical deterioration prompted review at our centre in 2019, which identified worsening symptoms of shortness of breath, causing severe limitation of daily function (WHO functional class III-IV), and left shoulder pain. Echocardiography revealed marked progression of the PAA causing dilatation of the pulmonary valve annulus and subsequent severe pulmonary regurgitation. There was also severe right ventricular impairment, moderate tricuspid regurgitation and a 4 cm pericardial effusion lateral to the left ventricular wall. Pulmonary artery pressure was estimated at > 65 mmHg.\n\nComputed tomography pulmonary angiography confirmed a 12 cm aneurysm of the pulmonary artery mainly affecting the main and left pulmonary arteries. There was also a 6 cm aneurysm of the right pulmonary artery. Cardiac magnetic resonance imaging confirmed a right ventricular ejection fraction of 23% (this had been 40% at the previous assessment). A chest x-ray demonstrated marked cardiomegaly, tracheal deviation, and an extremely widened mediastinum extending into the left hemi-thorax.\n\nDue to the presence of a giant PAA, severe pulmonary regurgitation and a 4 cm pericardial effusion, it was decided to list the patient for heart-lung transplantation. Episodes of right heart failure were managed with inotropes and the patient was maintained on pulmonary antihypertensive medications and diuretics whilst awaiting transplantation.\n\nApproach via median sternotomy revealed the large aneurysm sac which was translucent to blood. The space occupying effect caused lateral deviation of the aorta, as well as inferior displacement of the heart into the diaphragm. It also extended well into the left hemi-thorax, severely compromising the left lung. Cardiopulmonary bypass was established via aortic and bi-caval cannulation and the patient cooled to 34 °C. Dissection of the pulmonary artery allowed identification of the ligamentum arteriosus and safe dissection of the left recurrent laryngeal nerve. Following dissection and preservation of the phrenic nerves the recipient heart and lungs were explanted. The donor heart-lung block was prepared and implanted and after haemostasis was confirmed, primary chest closure was performed. The patient was started on an induction immunosuppressive regime and transferred to the cardiac intensive care unit in a stable condition. A post-operative chest x-ray was performed which was normal. The only significant post-operative complication was a below-knee deep vein thrombosis which was easily managed with enoxaparin. The patient was discharged 34d post-operatively and follow-up for 13 months since discharge has confirmed good progress.",
    "summary": "We report a case of a 51-year-old female who underwent heart-lung transplantation for IPAH and giant PAA. The extreme size of the PAA and underlying pathology encountered in this case precluded both lung transplantation and conventional aneurysm repair."
  },
  {
    "id": "multiclinsum_gs_en_422.txt",
    "fulltext": "A 62 year old male with a past medical history of non-ischemic cardiomyopathy resulting in heart failure, status post bridging left ventricular assist device underwent orthotopic heart transplant. While recovering in the surgical ICU he developed worsening abdominal distention, tenderness, and leukocytosis, prompting evaluation by the general surgery team 6 days post-transplant. The patient had not passed bowel movements or flatus since his surgery and had not responded to administered enemas or oral metoclopramide for presumed post-op ileus. CT of the abdomen and pelvis was performed which revealed multiple dilated loops of bowel with air-fluid levels and transition point at the proximal small bowel in the left upper quadrant, concerning for obstruction. Based on these findings as well as the fact that the patient had no prior abdominal surgeries, making bowel obstruction secondary to adhesions less likely, the patient was subsequently taken to the operating room for exploratory laparotomy. In the operating room, the bowel was found to be diffusely dilated without any areas of apparent ischemia. A portion of small bowel was found to be adhered to the anterior abdominal wall in the left upper quadrant. Upon further exploration, a retained LVAD driveline was found to be tunneled into the peritoneal cavity, strangulating a loop of small bowel in the left upper quadrant. The driveline was freed from the abdominal wall and removed, and the affected loop of bowel was released. It was found to be viable after a few minutes of reperfusion. The small bowel was examined in its entirety starting from the Ligament of Trietz distally to the cecum and found to be dilated but grossly normal. A small area of serosal tear at the point of adhesion to the driveline was repaired primarily. The bowel was then returned to the abdominal cavity and the fascia and skin closed with running sutures and skin staples.",
    "summary": "A 62 year old male with a past medical history of non-ischemic cardiomyopathy induced heart failure, status post bridging left ventricular assist device and orthotopic heart transplant presented with abdominal distention, tenderness, and leukocytosis six days post-transplant. CT abdomen and pelvis revealed dilated loops of bowel, air-fluid levels and a transition point in the proximal small bowel. The patient was diagnosed with small bowel obstruction and taken for exploratory laparotomy. He was found to have a retained intraabdominal LVAD driveline strangulating a loop of small bowel in the left upper quadrant. The driveline was removed and the section of bowel released with return of perfusion."
  },
  {
    "id": "multiclinsum_gs_en_328.txt",
    "fulltext": "A 26-year-old male patient was admitted to our hospital with a history of recurrent yellow skin and urine for over a year. On June 1, 2022, the patient presented with yellow skin and urine, without any obvious triggers. An ultrasound examination revealed the presence of multiple stones in the common and intrahepatic bile duct, with mild dilatation of the intrahepatic (diameter: 0.32 cm, reference: ≤ 0.2 cm) and common bile duct (diameter: 1.04 cm, reference: 0.6–0.8 cm). These findings supported the initial impression of obstructive jaundice. On June 15, 2022, the patient underwent laparoscopic choledocholithotomy, cholecystectomy and choledochoscopic lithotomy. However, there was no improvement in liver function nor symptoms of jaundice after surgery over the past year. In order to seek further medical assistance, the patient was admitted to our hospital with icterus of unknown origin on August 12, 2023. The patient denied a history of smoking, alcohol abuse, and long-term use of liver-damaging medication, including herbal and dietary supplements.\n\nThe physical examination revealed the presence of generalized yellowing of the skin and sclera, as well as a palpable spleen with 2 fingers below the rib cage. Additionally, the subject’s body mass index was recorded at 17.4 kg/m².\n\nThe results of vital laboratory examinations were presented in Table 1. Additionally, antinuclear antibody (ANA) 1:100, p-antineutrophil cytoplasmic antibodies (p-ANCA) positive, autoimmune liver diseases antibody profile were all negative; hepatitis A to E, Epstein–Barr virus, cytomegalovirus, coxsackie virus, herpes zoster virus, treponema pallidum and human immunodeficiency virus were all negative.\n\nMagnetic resonance cholangiopancreatography (MRCP) demonstrated the existence of dilated left intrahepatic and common bile duct, in the absence of a gallbladder, splenomegaly and multiple enlarged lymph nodes in the hilar region. The histological examination of the liver revealed that the structure of the hepatic lobules and the capillary bile duct network were not clearly discernible. Some capillary bile ducts displayed dilatation, accompanied by the formation of bile thrombus. There was also bridging fibrosis from the portal tracts to the central vein. Disappearance of bile ducts was observed in 10 of the 12 portal tracts. This phenomenon is most commonly attributed to vanishing bile duct syndrome (VBDS). The simplified Scheuer score indicated a grade 2 and stage 3 to 4. Whole exome sequencing revealed the presence of a heterozygous mutation in PKLR (NM_000298.5:c.119G > A) and UGT1A1 (NM_000463.2:c.–3275T > G).\n\nIn light of the aforementioned evidence, a revised diagnosis was rendered as VBDS with PLKR and UGT1A1 mutation, cholestatic cirrhosis. A dosage of 1000 mg/d ursodeoxycholic acid (UDCA) and 8 mg/d methylprednisolone was administered in order to improve cholestasis and hepatic inflammation.\n\nOver time, a contrast-enhanced magnetic resonance imaging (MRI) scan performed on September 10, 2023 revealed the presence of stones in the common bile duct, despite the absence of fever, abdominal pain, or other complaints. The patient refused to have the stones removed from the common bile duct. On October 25, 2023, an MRCP examination showed dynamic changes. The biliary system showed banded stricture and a pruned tree appearance, which was in consistent with the imaging appearance of sclerosing cholangitis. Further colonoscopy was performed with adequate bowel preparation, adhering to guidelines for patients with suspected mucosal damage, which revealed the presence of UC involving the terminal ileum and right hemicolon. This finding was consistent with the colonoscopic manifestations of PSC-UC. Moreover, PSC-UC is a unique subtype of UC, which makes it difficult to apply Montreal classification criteria to describe the disease’s topography. Consequently, the diagnosis was revised to PSC-UC with PLKR and UGT1A1 mutations, choledocholithiasis.\n\nOn November 25, 2023, transduodenoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) were performed. A 4 mm × 5 mm black irregular stone and a large number of sedimentary stones were successfully removed using endoscopic duodenal papillary sphincter dilatation (EPBD). Following resolution of the obstruction, a long-term regimen of 1000 mg/d UDCA in combination with 10 mg/d obeticholic acid (OCA) was prescribed to improve cholestasis. In addition, 8 g/d colestyramine was prescribed to facilitate the adsorption of excess bile acids, while 1.2 g/d rifaximin was administered to prevent biliary tract infection. Furthermore, given the fact that the patient’s UC was limited to the terminal ileum and right hemicolon, there was a paucity of mucopurulent and bloody stools, as well as diarrhea. Mesalazine tablets (2 g per day) was medicated with the objective of improving colonic inflammation. On July 30, 2024, the patent’s liver function was as follows TB/DB 33/25.9 μmol/L, alkaline phosphatase (ALP)/GGT 183/112 U/L, IgG 17.19 g/L. The patient’s condition remained stable.",
    "summary": "Patient concerns: A 26-year-old male patient complains a history of recurrent yellow skin and urine for over a year.\n\nDiagnoses: Following dynamic magnetic resonance cholangiopancreatography imaging, colonoscopic manifestation, liver biopsy and whole exome sequencing, the patient was finally diagnosed with PSC - ulcerative colitis with PLKR and UGT1A1 mutation.\n\nInterventions: Following resolution of the obstruction, a long-term regimen of 1000 mg/d ursodeoxycholic acid in combination with 10 mg/d obeticholic acid to improve cholestasis, 8 g/d colestyramine to facilitate adsorption of excess bile acids and 1.2 g/d rifaximin to prevent biliary tract infection were prescribed.\n\nOutcomes: The patient's liver biochemical parameters have improved significantly. His condition is stable and has not undergone liver transplantation at this time."
  },
  {
    "id": "multiclinsum_gs_en_580.txt",
    "fulltext": "23-year-old male patient from Itagüí, Colombia, with a family history of sudden death of unclear etiology in his grandfather at the age of 50, with no other significant family or personal history. He was undergoing external monitoring for repeated syncopal episodes with a diagnosis since childhood of symptomatic sinus node dysfunction, for which he was implanted with a pacemaker.\n\nDuring subsequent controls, there was no report of deterioration of functional class until 2012 in Guayaquil, Ecuador. During his hospitalization, the generator was changed; in the first postoperative month, he presented an early complication of a pacemaker pocket infection, which required the explant of the generator unit with subsequent abandonment of the previously implanted ventricular electrode. A new pacemaker implant was performed on the contralateral side without complications or new syncopal events in the following 10 years of follow-up.\n\nShe presented with NYHA III functional class impairment 6 months prior to admission with no other symptoms and no reports of electrophysiology service evaluations since the last pacemaker generator implant in 2012. During outpatient checks, discontinuation of beta blocker therapy was reported due to poor tolerability.\n\nThe physical examination found a systolic murmur in the aortic focus II/VI without irradiation, and no signs of central or peripheral congestion. There was no evidence of renal function, electrolyte or haematological profile alteration in the laboratory. The pacemaker was scheduled with evidence of depletion of the generator battery. A transthoracic echocardiogram was performed where severe concentric hypertrophy of the interventricular septum was found at the middle ventricular level, of 26 mm with intracavitary peak gradient of 117 mmHg and anterior systolic movement of the mitral valve (SAM) which generated a mild mitral regurgitation.\n\nHe was evaluated by the Heart Team due to the sudden death risk score (16.8%) and a family history of sudden death, considering EUROSCORE II 0.67%; as for the previously abandoned electrodes and the contraindication of performing cardiac magnetic resonance, given the incompatibility of the pacemaker, a tomographic study was performed and the performance of myectomy was considered due to symptomatology and documented variant.\n\nHe was scheduled for a transapical approach ventricular myectomy with electrode removal; a left ventriculotomy was performed at the apex, with subsequent resection of the septum from the middle ventricular part to the base, with subsequent removal of electrodes attached to the tricuspid septal velum. There were no intraoperative complications and subsequently there was a decrease in the intracavitary gradient without the presence of the SAM phenomenon. During his stay in the Intensive Care Unit, the patient had two documented episodes of ventricular tachycardia with haemodynamic instability, for which an implantable cardioverter-defibrillator (ICD) compatible with magnetic resonance (MRI) was placed. The patient did not have new episodes of VT. The patient did not have new intercurrences and outpatient genetic studies were initiated due to his family history.\n\nThe patient had a favorable postoperative evolution after the CDI implant. A variant, probably pathogenic, was found in heterozygosity of the FLNC, c 4636G>A consistent with autosomal dominant type 26 hypertrophic familial cardiomyopathy.\n\nThe patient is currently in functional class I, without arrhythmias detected in the telemetry and on regular treatment with Bisoprolol 5 mg. Genetic study of direct relatives was initiated, however, due to the difficult access to health services, its execution was limited.\n",
    "summary": "The case of a 23-year-old male patient with a diagnosis of hypertrophic cardiomyopathy with a mid-apical variant, in whom a variant of filamin C was documented, is presented. In view of the inadequate response and persistence of symptoms to medical management, the procedure of myectomy with a transapical approach was performed, with subsequent improvement of clinical symptoms and obstruction to the outflow tract.\n"
  },
  {
    "id": "multiclinsum_gs_en_49.txt",
    "fulltext": "A 31-year-old male patient, presenting with typical angina symptoms upon exertion, sought care at the emergency department. Notably, at the age of 14, he experienced an episode marked by persistent fever, painful cervical lymphadenopathy, and conjunctivitis. Despite elevated inflammatory markers and extensive diagnostic workups, no definitive diagnosis was made. He was treated for inflammatory pericardial effusion, which required drainage, and was given empirical antibiotics. After three weeks of supportive care and further investigation into potential Still’s disease, he was discharged on prednisolone. Over the years, he remained stable without further symptoms or complications.\n\nUpon admission, the physical examination was unremarkable, vital signs were blood pressure of 135/82 mmHg, pulse of 82 beats/min, respirations of 14 breaths/min, oxygen saturation (O2 sat) of 100%, and temperature of 37.1°C. Cardiac and pulmonary auscultation revealed no pathological findings, and the extremities were well-perfused without oedema.\n\nThe electrocardiogram showed dynamic changes, including inverted T waves in lead aVF and leads V5–V6. Blood tests revealed elevated high-sensitivity cardiac troponin T, peaking at 657 ng/L (normal < 34 ng/L). No other abnormalities were found in the blood tests, including a normal BNP (B-type natriuretic peptide) level. Echocardiography indicated preserved systolic function with no segmental alterations and no significant changes, including aortic dissection.\n\nThe patient underwent ICA that revealed left main trunk aneurysmal disease and chronic total occlusion (CTO) of the left anterior descending (LAD) artery, with a medial aneurysm of the left circumflex (LCx) artery 70% occluded, and a CTO of the mid right coronary artery (RCA) with several collaterals.\n\nGiven the aneurysmal disease, the patient underwent a computed tomography angiography (CTA) examination and was subsequently recommended for coronary artery bypass grafting (CABG). The coronary CTA scan revealed a significant aneurysm involving the distal left main trunk and the ostial portion of the LAD, with thrombosis causing subocclusive stenosis. Additionally, two sequential aneurysms were found in the LCx, with parietal calcification but no significant stenoses. The mid-segment RCA showed an ecstatic segment with mural thrombosis but remained patent, allowing for anterograde filling through collateral vessels.\n\nA CTA scan was conducted on the cranial, supra-aortic, and abdominopelvic vessels, demonstrating no aneurysms. Therefore, the CABG was promptly performed on the fifth day of admission. The surgical procedure comprised the following sequential anastomoses left internal mammary artery to the LAD artery, right internal mammary artery (RIMA) to the first obtuse marginal artery (OM1), and RIMA to the interventricular posterior artery. Showing a positive evolution, the patient was discharged from the intensive care unit and transferred to a general ward 2 days after surgery with dual anti-platelet and statin therapy (aspirin 100 mg/day, ticagrelor 180 mg/day, rosuvastatin 200 mg/day) and was discharged from the hospital one week later.\n\nThe patient is under follow-up in the cardiology consultation and, six months post-infarction, reports no cardiovascular symptoms, classified as NYHA (New York Heart Association) class I and CCS (Canadian Cardiovascular Society) class 0. Laboratory tests are unremarkable, and the echocardiogram shows preserved global systolic function with no kinetic changes.\n\n",
    "summary": "A 31-year-old patient with an unrecognized history of Kawasaki disease presented to the emergency department with symptoms of angina. Imaging revealed significant coronary artery aneurysms, and he successfully underwent coronary artery bypass grafting."
  },
  {
    "id": "multiclinsum_gs_en_294.txt",
    "fulltext": "A 9-year-old girl was admitted to our hospital with recurrent fever over 3 months despite receiving intermittent antibiotic therapy at a local hospital. She had a history of patent ductus arteriosus ligation and aortic valvuloplasty at age 3. Routine follow-up echocardiography indicated progressive aortic regurgitation, with the latest scan before admission showing severe aortic regurgitation accompanied by left ventricular dilation. However, the patient remained asymptomatic.\n\nA detailed workup was carried out to clarify the cause of fever. While blood culture results were negative, mNGS on blood samples identified Aggregatibacter actinomycetemcomitans, a gram-negative bacillus commonly found in oral flora, also a member of the HACEK group (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, and Kingella)—a significant cause of blood culture-negative IE. Additionally, transthoracic echocardiology (TTE) revealed vegetations on the aortic valve, with the largest measured 8 mm in length, leading to the diagnosis of IE. Empirical antimicrobial therapy with intravenous ceftriaxone 80 mg/kg/day was initiated, and dental caries were removed as a potential source of infection.\n\nAs part of routine screening for neurological complications, a cerebral magnetic resonance angiography (MRA) revealed the presence of an IIA on the right parietal lobe, measuring 8 × 6 mm. Unfortunately, the patient experienced an acute ICH 2 days after the examination, before any intervention could take place. An emergency cerebral CT scan confirmed haemorrhage on the right parietal-temporal lobe, measuring up to 48 × 40 mm, resulting from the rupture of the IIA. The patient was promptly referred to neurosurgeons, and an emergency craniotomy was performed for haematoma removal and aneurysm resection.\n\nThe patient experienced a full recovery without major neurological impairment after 4 weeks of neurological rehabilitation and antimicrobial therapy. As follow-up TTE revealed significant enlargement of the aortic valvular vegetation, measuring over 10 mm in length, cardiac surgery was rescheduled due to the lack of response to antimicrobial therapy and the increasing size of the vegetation, which posed a high risk of embolism.\n\nHowever, a repeat cerebral computed tomography angiography (CTA) revealed a recurrent aneurysm (7 × 7 mm) with haemorrhage at the previously operated site, adding further complexity to the condition. Despite the indication for early surgery due to enlarging vegetation and severe aortic regurgitation, the recurrent IIA and concurrent haemorrhage posed a significant challenge to performing cardiac surgery.\n\nFollowing a multidisciplinary consultation, a consensus was reached to perform a one-stage procedure. This operation was carried out in a hybrid theatre and involved the combination of transcatheter aneurysm embolization with sequential aortic vegetation removal and mechanical valve replacement. The procedure proved to be a resounding success, and postoperative recovery progressed without complications. Postoperative work-up showed good aortic prosthesis function and complete isolation of the aneurysm without further haemorrhage before discharge. Although both preoperative and postoperative blood cultures were negative, antimicrobial therapy was continued for another 4 weeks following cardiac surgery. Follow-up assessments indicated that the patient maintained good cardiac and neurological function 3 years after discharge.",
    "summary": "We report a complex case of IIA related to IE in a 9-year-old girl with a history of patent ductus arteriosus ligation and aortic valvuloplasty. The patient was admitted for recurrent fever over 3 months despite irregular antibiotic therapy. Transthoracic echocardiography identified IE with vegetations on the aortic valve, and cerebral magnetic resonance angiography revealed an IIA. The patient experienced a sudden intracranial haemorrhage while awaiting intervention, requiring emergency craniotomy with haematoma removal and aneurysm resection. After 4 weeks of neurological rehabilitation and antimicrobial therapy, she recovered well without major neurological impairment. However, a recurrent IIA with haemorrhage was detected at the previously operated site. Following a multidisciplinary discussion, a one-stage procedure combining transcatheter aneurysm embolization and mechanical aortic valve replacement was performed successfully. Three years post-discharge, the patient maintained good cardiac and neurological function."
  },
  {
    "id": "multiclinsum_gs_en_364.txt",
    "fulltext": "A 56-year-old male came to emergency room with chief complain of atypical bilateral chest pain and shortness of breath.\nThe chest pain was getting more persistent and increasing gradually without any radiating pain in the past 1 week. Shortness of breath was felt in the last 3 years due to chronic obstructive pulmonary disease (COPD) (spirometry test 1 month before was as follow: FEV1/FVC ratio of 0.48 with FEV1 of 40%) and worsened 5 days before admission to the emergency room. He had been diagnosed with tuberculosis infection 3 years ago and already completed the 6-month treatment. Furthermore, he suffered from heart failure 2 year ago but did not comply to routine check-up. He was an active smoker with daily consumption of 2 packs per day since he was young until he was admitted to the emergency room.\nOn physical examination, he was fully awake with the vital sign as follow: Blood pressure (BP) of 90/60 mmHg, pulse rate (PR) of 92 beats per minute with strong but irregular pulse, respiratory rate (RR) of 30 breaths per minute, oxygen saturation of 88%, and axillary temperature of 36.9oC. His lung examination revealed slight wheezing in bilateral basal region and coarse crackle on superior lobe of right lung. Cardiac examination showed early diastolic murmur at pulmonal valve and holosystolic murmur at tricuspid valve, shifting of cardiac border, and raised jugular vein pressure. Other examinations were within normal limit.\nElectrocardiogram (ECG) evaluation showed an occasional premature ventricular contraction (PVC) and premature atrial contraction (PAC) with right axis deviation (RAD), right bundle branch block (RBBB) and right ventricular hypertrophy (RVH), and spike P wave. Chest x-ray showed cardiomegaly and predominate pulmonal cone. There is also an infiltrate in upper lobe of both lung. Laboratory evaluation showed slight leukocytosis (12.800/mm3) and hyponatremia (124 mmol/L), while the CK-MB titer was normal (20 U/L).\nBased on the initial evaluation, the patient was diagnosed with congestive heart failure because of cor pulmonale with suspected PAA and pneumonia. He was then transferred to high care unit where he was given oxygen mask 6 L/min, treated with oral spironolactone 25 mg and bisoprolol 2.5 mg once daily. He also received intravenous levofloxacin 750 mg once daily, furosemide 20 mg thrice daily, and dopamine with dosage of 3 mcg per kg body weight (BW). Five hours later, his blood pressure drops to 80/60 mmHg with sign of cardiogenic shock.\nThe dopamine then was tittered up to 5 mcg per kg BW. He was scheduled for transthoracic echocardiography (TTE) and multi slice computed tomography (MSCT) on the following morning. TTE result showed normal kinetic on left ventricular segmental\n¡ analysis, normal left ventricular (LV) systolic function with ejection fraction (EF) of 89%, grade I diastolic dysfunction on LV, decreased right ventricular (RV) systolic function (TAPSE 1 cm) with right atrium (RA) and RV dilatation, severe tricuspid regurgitation (TR), mild pulmonary regurgitation (PR), and high probability of severe PH (TR peak velocity 5.21 m/s, estimated mean pulmonary artery pressure 68.99 mmHg), accompanied by main pulmonal artery (MPA) aneurysm (4.2 cm in diameter). No congenital or structural heart defect was found. Contrast-enhanced thorax MSCT showed an aneurysm on the main pulmonal artery (MPA) (4.39 cm in diameter) and bilateral pulmonal artery dilatation with wall adherent apposition thrombus.\nWith additional findings from TTE and MSCT, the patient was then diagnosed with heart failure with preserved EF and RV dysfunction secondary to suspected severe PH due to COPD and CTEPH along with MPA aneurysm. The given therapy was continued with addition of beraprost sodium 20 mcg twice daily and warfarin 2 mg once daily. On the fifth day, he became stable with blood pressure of 90/60 mmHg and the symptoms was improved. He was then scheduled to be referred to tertiary hospital for further evaluation with right heart catheterization (RHC), but he refused. Therefore, conservative treatment with oral therapy of furosemide 40 mg once daily, bisoprolol 2.5 mg once daily, spironolactone 25 mg once daily, beraprost sodium 20 mcg twice daily, and warfarin 2 mg once daily continued.\nSix months after regular monthly follow-up, the patient’s condition was improved with stable hemodynamic and without any significant complaint. TTE evaluation showed a decreased in the PH severity grading from severe to moderate PH and TR severity grading from severe to moderate. Moreover, the MPA diameter was not increased, with RA and RV dilatation and normal LV and RV systolic function.",
    "summary": "We report a 56-year-old male with chief complain of atypical bilateral chest pain and shortness of breath. Initial electrocardiogram (ECG) and laboratory evaluation showed no sign of ischemic heart disease. After the patient was stabilized, he was evaluated using chest x-ray, transthoracic echocardiography (TTE), and multi slice computed tomography (MSCT). The patient was then diagnosed with PAA secondary to suspicion of pulmonary hypertension (PH) with chronic obstructive pulmonary disease and heart failure. Conservative treatment was chosen because of the limited resources for surgery and patient’s refusal to be referred. The treatment aims to lower the pulmonary artery pressure while monitoring the aneurysm. His 6-month follow-up evaluation showed an improvement in pulmonary artery pressure and persistent of the PAA without any increasement of the diameter."
  },
  {
    "id": "multiclinsum_gs_en_298.txt",
    "fulltext": "A woman in her eighties, who was being evaluated for significant involuntary weight loss, was admitted to the emergency department due to vomiting and the sudden onset of acute pain in her right thigh. The pain was constant and worsened with movement. Clinical examination revealed a highly tender point in the proximal medial region of her right thigh. There was no indication of trauma.\n\nThe patient was referred for an X-ray of the right hip to investigate a possible pathological fracture. No fracture or misalignment was observed, and she was admitted to the orthopaedic department for pain management and mobilisation. She was discharged the next day despite persistent pain and vomiting. On day three, the patient was readmitted to the emergency department with the same symptoms. She was afebrile, but due to mildly elevated infection markers, leukocytes at 13.5 × 109/L (reference range 4.1–9.8 × 109/L) and CRP at 60 mg/L (< 5 mg/L), a chest X-ray was performed, revealing basal confluent consolidations in the right lung, raising suspicion of a pneumonic infiltrate. The patient was transferred to the medical ward for observation. Antibiotics were not initated due to minimal respiratory symptoms.\n\nOn day four, the woman's condition deteriorated, presenting with tachycardia (heart rate of 119 bpm), a respiratory rate of 28 breaths per minute (normal range: 12–16), and a fever of 38.1°C. Her CRP level also increased from 50 to 250 mg/L. Piperacillin-tazobactam was initiated intravenously at a weight-adjusted dose of 2 g x 4, and she was referred for a CT scan of the chest/abdomen/pelvis due to suspected sepsis from an abdominal focus. The CT scan revealed an incarcerated loop of small bowel protruding through the right obturator canal and pre-obstructive small bowel dilation, consistent with an acute, irreducible obturator hernia. The on-call surgeon was promptly consulted, and the patient was scheduled for emergency surgery.\n\nDuring laparoscopy under general anaesthesia, an incarcerated small bowel loop was found in the obturator canal, consistent with the CT findings. The bowel was carefully reduced, with no signs of necrosis or perforation. After the hernia was reduced, the patient experienced hypotension, with blood pressure of 98/37 mmHg. Intraoperative arterial blood gas analysis showed pH 7.22 (7.36–7.44), PCO2 (a) 7.0 (4.7–6.0 kPa), PO2 (a) 15.0 (> 8.7 kPa), HCO3 19 (22–26 mmol/L), base excess -6.6 (-1.9–4.5 mmol/L), Cl 104 (98–107 mmol/L), and lactate 1.0 (0.4–1.3 mmol/L), consistent with mixed respiratory and metabolic acidosis. The hypercapnia was presumed to be caused by perioperative absorption of insufflated CO2 gas from the peritoneum into the capillary network. Norepinephrine infusion was initiated at 0.04 mcg/kg/min, and minute ventilation was increased to correct the acidosis. The reduced small bowel segment was re-evaluated and was considered still viable, with no need for resection. The hernia defect was closed with primary sutures using non-absorbable, knot-free monofilament barbed suture (V-Loc) to minimise surgery time due to the patient's deteriorating condition.\n\nThe patient was extubated immediately after surgery and observed in the intensive care unit until the following day. Vasopressors and a decompression nasogastric tube were removed on the first postoperative day. She was then transferred to the surgical ward. Bowel function resumed on the second postoperative day. Antibiotics were discontinued on the third postoperative day. On the same day, she was also transferred back to the medical ward for further evaluation of her weight loss.",
    "summary": "A woman in her eighties with a history of involuntary weight loss presented to the emergency department due to acute pain in her right thigh, nausea and vomiting. On examination, the patient exhibited tenderness to palpation in the proximal and medial aspect of her right thigh. Abdominal computed tomography revealed a loop of small bowel protruding through the right obturator canal, consistent with an incarcerated obturator hernia. An emergency laparoscopy was performed, revealing that the affected small bowel segment was viable after reduction of the hernia. Due to development of respiratory acidosis and hypotension, the obturator defect was primarily sutured to reduce operating time. The patient made a good recovery and was transferred to the medical ward for further evaluation of her weight loss."
  },
  {
    "id": "multiclinsum_gs_en_20.txt",
    "fulltext": "A 72-year-old patient presented himself with chest pain radiating to his left arm and progressive dyspnoea over the past few weeks. He had a history of a deep vein thrombosis of the lower limb and controlled arterial hypertension. There were no other relevant comorbidities.\n\nOn physical examination, the patient presented himself in good general condition without signs of heart failure, a blood pressure of 156/101 mm Hg and a heart rate of 73 bpm. He was eupneic and the arterial oxygen saturation was 93%. Renal function was impaired with a serum creatinine of 115 μmol/L and an estimated glomerular filtration rate of 54 mL/min/1.73 m², high-sensitivity troponin T was slightly elevated at 29 ng/L and NT-proBNP significantly increased at 5463 ng/L. The ECG showed newly diagnosed atrial flutter with an irregular heart rate of 93 bpm, as well as anterior and inferior repolarisation disorders (T-wave inversion in II, III, aVF, V1–V4). CHA2DS2-VASc Score was of 4 points.\n\n\nTransthoracic echocardiography showed normal left ventricular ejection function (LVEF 55%), a slightly impaired right ventricular function (Tricuspid annular plane systolic excursion (TAPSE) 18 mm), and increased pulmonary arterial pressure (sPAP 47 mm Hg). A bicycle stress test was performed and showed a relevant blood pressure drop from 138/74 mm Hg at rest to 118/76 mm Hg at 67% of the age-predicted maximal heart rate.\n\nBased on these findings, relevant coronary disease was expected, probably with left main disease (based on the blood pressure drop in the stress test).\n\nPE was a possible differential diagnosis (Wells Score of 4.5 points predicted a moderate risk with a 16.2% chance of PE). Anticoagulation was already indicated due to atrial flutter.\n\nThe newly documented atrial flutter was seen as associated with the underlying disease. There were no signs of neurological abnormalities.\n\n\nInvestigations\n\nThe coronary angiogram revealed a coronary two-vessel disease followed by ad hoc percutaneous coronary intervention with complete revascularisation. Right heart catheterisation, performed because of the slightly increased sPAP, revealed an elevated mean PAP (mPAP) of 38 mm Hg of precapillary and postcapillary origin. Pulmonary angiogram showed thromboembolic occlusion of the subsegmental pulmonary artery of the right lower lobe. Arterial blood gas analysis showed respiratory alkalosis, partly metabolically compensated (pH 7.49, pCO23.4 kPa, pO211.7 kPa, HCO319.5 mmol/L, base excess −3.8 mmol/L).\n\n\nTreatment\n\nThe patient was then admitted to the coronary care unit (CCU) where dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, as well as oral anticoagulation with apixaban was started.\n\nHaemodynamic monitoring on the CCU was acceptable with a blood pressure of 140/100 mm Hg, heart rate of 85 bpm, respiratory rate of 17/min and SO294% in ambient air. CT of the thorax on the following day confirmed the PE with extensive, bilateral, central to peripheral PEs. These findings were progressed compared with the results of the pulmonary angiography from the day before. In a further assessment, the only additional change was a newly diagnosed right bundle branch block (RBBB) and a change of the heart axis in the ECG. The patient was still without any discomfort or signs of cardiopulmonary instability and the arterial blood gas examination was unchanged.\n\nDuring a falling after independent mobilisation on the CCU, the patient developed circulatory arrest with pulseless electrical activity (PEA). Immediate cardiopulmonary resuscitation was started. During resuscitation, right heart catheterisation was performed, which showed an occlusive thrombus in the right pulmonary artery and was found impossible to mobilise by interventional techniques.\n\n\nOutcome and follow-up\n\nAfter 45 min of mechanical resuscitation, the patient developed a flatline in the ECG. Based on the recent finding in the pulmonary angiogram and the already prolonged and unsuccessful mechanical resuscitation, return of spontaneous circulation was very unlikely and the resuscitation efforts were stopped, on which the patient died.",
    "summary": "We present a case of a 72-year-old man with submassive acute pulmonary thromboembolism. Pulmonary embolism severity index Score and common clinical risk stratification recommended systemic anticoagulation and a clinical course without complications was expected. A primary reperfusion strategy was not indicated by the current guidelines. Under established anticoagulation, the patient was found in cardiac arrest immediately after mobilisation from the bed the next morning. Right heart catheterisation under ongoing resuscitation revealed a complete obstruction of the right pulmonary artery by a big thrombus. Catheter-directed intervention trying to bypass the thrombus with interventional guidewires failed. Ultimately, the patient died from acute right heart failure."
  },
  {
    "id": "multiclinsum_gs_en_306.txt",
    "fulltext": "A 57‐year‐old woman with a previous 8‐year follow‐up of idiopathic dilated cardiomyopathy presented with worsening functional class and recurrent hospitalizations for heart failure New York Heart Association functional Class IV and Interagency Registry for Mechanically Assisted Circulatory Support Class V. She had been treated with guideline directed medical therapy at maximally tolerated doses—which included enalapril 10 mg b.i.d, metoprolol 50 mg b.i.d., spironolactone 25 mg, furosemide 40 mg b.i.d., and digoxin 0.125 mg daily—for at least 5 years. Comorbidities included active smoking and morbid obesity (body mass index of 37 kg/m2). She was mostly limited by exertional fatigue and dyspnoea, despite being mostly euvolemic not dependent on high doses of diuretics. Rest electrocardiogram (ECG) showed sinus rhythm at a rate of 70 bpm and a QRS duration of 80 ms. Left ventricular ejection fraction was 23%, with a dilated left ventricle (end‐diastolic diameter 6.7 cm) and diffuse hypokinesis. A cardiopulmonary exercise testing (CPET) demonstrated severely decreased exercise capacity, with a peak oxygen uptake (VO2 peak) of 12 mL/kg/min (or 16.46 mL/kg/min when corrected for lean body mass), along with other variables indicating adverse heart failure prognosis, including minute ventilation/carbon dioxide production (VE/VCO2) slope of 42 and periodic breathing. At the second minute of exercise, at a heart rate of 131 bpm, the patient developed LBBB with widening of the QRS to 200 ms. This finding persisted into the recovery phase. Of note, attenuated pressoric response was also observed during the CPET. A subsequent exercise stress echocardiography evidenced exertion‐induced intraventricular and interventricular dyssynchrony, with electromechanical delay from QRS onset to S wave onset from septal, lateral, anterior, and inferior walls of more than 65 ms and difference between left and right pre‐ejection intervals of more than 40 ms, respectively.\n\nAs the patient was not considered eligible for cardiac transplant, given her active comorbidities, a decision was made to implant a CRT (Etrinsa 8 HF‐T, Biotronik, Berlim, Germany) to approach the EI‐LBBB. Cardiac magnetic resonance imaging performed prior to CRT insertion showed only a small area of late gadolinium enhancement at the mesocardium basal septum, but no patterns suggestive of specific aetiologies other than non‐ischaemic dilated cardiomyopathy were noted. Initially, biventricular pacing was set at a minimal heart rate of 75 bpm with atrioventricular delay of 105–80 ms, and the ECG showed QRS duration of 145 ms.\n\nSubsequent to CRT implant, the patient improved to New York Heart Association II, and no recurrent heart failure hospitalizations occurred. Medical therapy was relatively unchanged after CRT, except for the introduction of amiodarone due to ventricular arrhythmias and a change from metoprolol to carvedilol and introduction of hydralazine, both to enhance hypertension management, as blood pressure levels increased and tolerance to medications improved after CRT. Pacemaker interrogation showed 94% atrial pacing and 100% biventricular pacing. A few months later, repeat CPET at 6 and 12 months demonstrated significant and sustained amelioration in exercise capacity. Biventricular pacing occurred at 100% of the exercise time, and periodic breathing was absent on both exams. Reverse cardiac remodelling and improvement in ejection fraction were also noticed.",
    "summary": "A 57‐year‐old woman with idiopathic dilated cardiomyopathy (ejection fraction 23%) presented with New York Heart Association Class IV and recurrent hospitalizations. During heart transplant evaluation, a new onset of intermittent left bundle branch block was observed on the cardiopulmonary exercise test. CRT was implanted, and 97% resynchronization rate was achieved. In 12 month follow‐up, both clinical and prognostic exercise parameters improved."
  },
  {
    "id": "multiclinsum_gs_en_210.txt",
    "fulltext": "We describe the case of a 52-year-old Caucasian female patient. Her cardiovascular risk factors were dyslipidemia and that she was overweight. She had no previous surgeries. She reported two full-term pregnancies and one abortion and had a negative family history of thrombophilia.\n\nShe had suffered an ischemic stroke three years prior to the admission, due to atrial fibrillation. On that occasion, transthoracic echocardiography revealed moderate/severe mitral regurgitation. Amiodarone-induced hyperthyroidism also occurred. In the following months, while presenting progressive and complete neurologic recovery she had a rapid progression of mitral regurgitation and dyspnea such that surgery was indicated.\n\nMedications prior to admission included warfarin, tapazole, furosemide, potassium canrenoate and bisoprolol.\n\nThe surgical procedure consisted of mitral valve repair with a Carpentier-Edwards Physio II annuloplasty ring, tricuspid valve repair with a Medtronic Contour 3D annuloplasty ring and left atrial appendage exclusion with atriclip pro device, performed via right mini-thoracotomy access.\n\nThe immediate postoperative course was regular. The patient was discharged from the intensive care unit on postoperative day (POD) 2 in excellent clinical condition.\n\nIn accordance with our anticoagulation protocol, 5000 IU of subcutaneous UFH three times a day was reintroduced on POD 1, while oral warfarin was also started on POD 2 aiming for a target international normalized ratio (INR) between 2 and 3.\n\nOn POD 6, subcutaneous heparin was discontinued because the INR was already within the therapeutic range (2.5). On the same day a fever occurred. Consequently, the central venous catheter was removed, and the tip and blood samples were collected for culture. A transthoracic echo ruled out endocarditis. A few days later, two blood cultures tested positive for staphylococcus epidermidis.\n\nOn POD 7, the patient had thrombocytopenia (34 × 109/L from 267 × 109/L on POD 5), and a 1 mg/dl decrease in her Hb level. Therefore, since the INR was already 2.6, warfarin was suspended, and vitamin K was administered (5 mg).\n\nOn POD 9, a floating mass on the mitral annulus became visible on both transthoracic and transesophageal echocardiography while PLT count reached the nadir of 21 × 109/L.\n\nThe urgent indication for redo surgery was decided upon. While antibiotics were started (piperacillin/tazobactam and vancomycin), HIT suspicion also arose because of a 4T score of 5.\n\nTherefore, an immunoglobulin (Ig)G-specific anti-PF4–heparin chemiluminescent immunoassay (CLIA) was ordered, and the alternative anticoagulant fondaparinux (7.5 mg once a day) was initiated and maintained until the day before surgery. CLIA test resulted positive for PF4/heparin antibodies (8.9 U/mL), and the heparin-induced platelet activation assay (HIPA) confirmed HIT diagnosis on POD 10.\n\nRedo operation was performed on POD 12. Bivalirudin was the anticoagulant of choice for cardiopulmonary bypass, as had been successfully done in the past in similar cases. Unexpectedly, a voluminous thrombotic mass was removed from the patient’s left atrium (further confirmed as a thrombus by histologic examination and by a negative culture exam). The diagnosis of HIT with thrombosis (HITT) was therefore clear, and alternative anticoagulation therapy with bivalirudin at therapeutic dose was resumed in the postoperative period as soon as bleeding became negligible.\n\nThe patient was weaned from the ventilator on POD 2. On POD 4, after removal of the chest tubes, bivalirudin was discontinued, and danaparoid was initiated. Two subcutaneous (750 U) doses were administered first; thereafter, endovenous infusion was started at 396 U/h for the first 4 hours, 297 U/h for the next 4 hours and then 198 U/h. Danaparoid was monitored daily through its plasmatic anti-Xa activity.\n\nOn POD 15, a right pleural effusion occurred, which was drained in the following days. Therefore, planning thoracentesis, danaparoid was temporarily discontinued. Danaparoid anti-Xa activity was monitored every 12 hours until it reached the prophylactic range target (0.1–0.2 U/mL).\n\nThoracentesis was performed on POD 17, 38 hours after danaparoid suspension when anti-Xa activity was 0.14 U/mL. The drug was resumed 2 hours after the uncomplicated procedure (180 U/h and 162 U/h the following day) once procedural complications were excluded. The anti-Xa activity target was then set at the lowest level of the therapeutic range (0.45 U/mL).\n\nOn POD 18, when the anti-Xa activity was 0.39 U/mL, and the platelet (PLT) count had substantially recovered (160 × 109/L), the switch from danaparoid to vitamin K antagonist (VKA) was initiated. The first warfarin dose (5 mg) was administered starting from an INR 1.1. Over the next five days, the INR and the administered warfarin dose were as follows: 1.2 and 6.25 mg, 1.4 and 6.25 mg, 1.9 and 6.25 mg, 2.1 and 6.25 mg, and 2.8 and 3.75 mg, respectively.\n\nOn POD 20, after 66 hours from warfarin initiation, danaparoid infusion was stopped while plasma anti-Xa activity was 0.54 U/mL. Two days after discontinuation, the measured danaparoid activity was 0.09, while INR was 2.8.\n\nThe patient was successfully discharged from the hospital on postoperative day 35 (POD 48 from the first operation) in good clinical condition. The PLT count was then 173 × 109/L. The INR was 3.2. The serum creatinine concentration was 0.64 mg/dl.",
    "summary": "Here, we present a case in which HIT occurred six days after cardiac surgery. Warfarin was initiated two days after surgery but was stopped five days later, given the high risk of bleeding due to concomitant thrombocytopenia. HIT probability was initially underestimated, because a misleading diagnosis of endocarditis was made. When redo surgery was performed, no infectious masses were found, but a large thrombus was removed from the left atrium. Bivalirudin and danaparoid were used as alternative anticoagulants during the subsequent postoperative course."
  },
  {
    "id": "multiclinsum_gs_en_239.txt",
    "fulltext": "A 31-year-old Vietnamese female who presented with seizures was transported to our hospital by ambulance. The patient had been in her usual state until a week before the current presentation when she developed fever, vomiting, and abdominal pain. Two days before her first visit, a nasopharyngeal swab performed at a clinic returned a positive result for COVID-19. She had been vaccinated twice against COVID-19, and this was her first infection. On the day of the first visit, she experienced two episodes of generalized tonic-clonic seizures (GTCS) and was transported to our hospital in a coma. Her past medical history was unremarkable, and she had never experienced GTCS and severe gastrointestinal symptoms before. Her family history was marked by episodes of vomiting, seizures, and abdominal pain in her mother that lasted several months at the age of 31. This information was carefully collected at the time of admission. She had persistent hypertension and tachycardia. Her physical examination was unremarkable and she had no dermatologic abnormalities. Laboratory tests revealed severe hyponatremia (121 mEq/L) and mild hypomagnesemia (1.7 mg/dL). Her chest X-ray and head CT scans revealed no abnormalities. Despite her hyponatremia being resistant to hypertonic saline, she regained consciousness on the second day of hospitalization. On her 10th day of hospitalization, she had another episode of GTCS and transient mild left hemiparesis despite her hyponatremia having been corrected to 128 mEq/L. She became mildly agitated and depressed after the GTCS episode, and she still had hypertension (177/99 mmHg), tachycardia (141 bpm), and generalized myalgia. Magnetic resonance imaging (MRI) revealed a T2 shine-through lesion in the bilateral parietal and right occipital lobes, encompassing both subcortical and cortical regions, indicative of PRES. Her hypertension was successfully managed with a maximum dosage of 10 mg of amlodipine, and the follow-up MRI showed improvements in the abnormal findings. Given her female sex, young age, high blood pressure, tachycardia, and prior COVID-19 infection, we considered COVID-19-associated PRES, AHP, systemic lupus erythematosus, and pheochromocytoma as possible etiologies of PRES. Among these, we considered AHP the most likely diagnosis based on a constellation of characteristic manifestations including PRES, neuropsychiatric symptoms (agitation, depression), and gastrointestinal symptoms (vomiting, abdominal pain). First, we exposed the patient’s urine to sunlight and observed its discoloration. Second, urinalysis demonstrated elevated delta-aminolaevulinic acid (158.4 mg/g·Cre), coproporphyrin (1,170 mcg/g·Cre), and uroporphyrin (10,168 mcg/g·Cre). Her antinuclear antibody titer was 1:160; however, both anti-dsDNA antibodies and anti-Sm antibodies tested negative. Plasma epinephrine (196 pg/mL [< 100]), norepinephrine (823 pg/mL [100–450]), and dopamine (48 pg/mL [< 20]) levels were elevated. Catecholamine levels were measured using a standard protocol after 30 min of supine rest. The 24-hour urinary excretion assay revealed that her metanephrine (0.66 mg/day [0.04–0.19]) level was markedly elevated. The patient had not consumed any foods, beverages, or medications known to elevate catecholamine or its metabolite levels in plasma and urine samples. However, a torso CT scan did not reveal pheochromocytoma or extraadrenal paraganglioma. Furthermore, genetic analyses demonstrated a heterozygous missense mutation of c.517 C > T in HMBS, confirming the diagnosis of AIP. She received hemin from day 30 to day 33 of hospitalization. Following hemin administration, all her symptoms (e.g., depression, agitation, myalgia, and tachycardia), as well as electrolyte disturbances including hyponatremia, showed significant improvement. Simultaneously, her amlodipine was tapered off without any recurrence of hypertension.",
    "summary": "A 31-year-old Vietnamese female initially presented with seizures, severe hyponatremia, and hypertension after COVID-19. Despite the initial treatment, she had recurrent seizures and developed PRES as confirmed by magnetic resonance imaging. Further investigations revealed a genetic mutation of c.517 C > T in HMBS, leading to a diagnosis of AHP. Treatment with hemin significantly improved her symptoms and corrected her electrolyte imbalance."
  },
  {
    "id": "multiclinsum_gs_en_78.txt",
    "fulltext": "A 23-month-old girl with a personal history of non-compacted dilated cardiomyopathy that had progressed unfavourably. She was included in the cardiac transplant programme, needing a Levitronix Centrimag ventricular assist device. As in the previous case, she was on double antiplatelets and anticoagulants. When she was 23 months old she presented with irritability and an acute right hemiparesis suggestive of occlusion of the left internal carotid artery, which was confirmed on the CT and later on the angiography. Her blood analysis showed: red cells 3.41 × 106  µ/L; haemoglobin 9.2 g/gL; APTT 134 seconds and INR 1.2. As in case 1, intravenous fibrinolytic treatment was contraindicated due to double antiplatelet and anticoagulant treatment with heparin at full dose, so intra-arterial treatment was planned. Although she was 23 months old, she was in approximately the third percentile in the weight curve (9.3 kg).\n\nThe same technique was used as the one described for the previous case. The vessel was opened in one pass. A disseminated embolus in segment A2 of the left anterior cerebral artery was observed in the angiographic control series. The CT scan at 24 hours showed an established infarct of the territory of the anterior division of the MCA and of the left anterior cerebral artery. The neurological examination showed right hypertonia. When she was 30 months old she received her transplant with a good immediate postoperative result. Three weeks after the transplant, a right ventricular dysfunction was detected, so at the time of writing this article she was still in the intensive care unit.",
    "summary": "An 18-month-old girl with non-compacted dilated cardiomyopathy included in the cardiac transplant programme and in need of a Levitronix Centrimag ventricular assist device presented with an acute left hemisphere stroke at 23 months. An intra-arterial procedure was carried out leading to positive clinical results except for residual right hypertonia. Seven months later she received her transplant."
  },
  {
    "id": "multiclinsum_gs_en_585.txt",
    "fulltext": "36-year-old male patient, HIV positive since 2017, on treatment with bictegravir/tenofovir/emtricitabine, with a history of Kaposi's sarcoma, previously treated with emtricitabine/tenofovir/efavirenz.\n\nInitiated in March 2021 with electric-like pain in the lower back radiating to the pelvic limbs, 24 hours later weakness and numbness of the pelvic limbs followed by urinary incontinence and abdominal distension.\n\nThe patient reported bilateral blurred vision with a predominance in the right eye.\n\nComplete spinal syndrome with level at T8-T9 was integrated into the exploration.\n\nIn the magnetic resonance imaging at the level of optic nerves, a decrease in bilateral diameter of right predominance was observed, being 2 mm right and 3 mm left. In the magnetic resonance imaging of the spine, a hypointense lesion at T8 to L1 level was observed in T1 and hyperintense in T2, of central predominance that produced an increase in diameter in T12-L1 of up to 8 mm. In his paraclinical studies, a negative TORCH profile was obtained, vitamin B12 levels (912 pg/mL) and negative tumour markers. A lumbar puncture was performed (leukocytes: 2 cel/uL, 100% mononuclear, glucose: 51 mg/dL, lactate dehydrogenase: 42 U/L, chloride: 128 mEq/L, microproteins: 82.9 mg/dL) suggesting an inflammatory pattern, so it was decided to initiate treatment with intravenous methylprednisolone with a total dose of 5 grams. On admission, he presented an expanded scale of disability status (EDSS) of 4 (severe relative disability), at the expense of motor symptoms and involvement of sphincters. Anti-AQP4 antibodies were requested in cerebrospinal fluid (CSF), which were positive, meeting Wingerchuk criteria for AQP4+ neuromyelitis optica. Rituximab was initiated in June 2021. In the follow-up after one year, the patient showed symptomatic improvement with EDSS 1 (present signs, without disability) at the expense of distal paresis.\n",
    "summary": "36-year-old man with a history of HIV diagnosed in 2017, on antiretroviral treatment and a history of Kaposi's sarcoma. He began his condition in March 2021 with pain in the lower back, accompanied by weakness and anesthesia in the pelvic limbs, with bladder incontinence and abdominal distension. A complete medullary syndrome with a level at T8-T9 was integrated into the exploration, corroborating a longitudinally extensive lesion from T8-L1 in the MRI, with CSF with proteinohraquia and seropositivity to AQP4. A diagnosis of NMO was integrated by Wingerchuk criteria and treatment with rituximab was initiated with symptomatic improvement, objectified with an expanded scale of the state (EDSS) of 4 to 1.\n"
  },
  {
    "id": "multiclinsum_gs_en_282.txt",
    "fulltext": "68-year-old man with a history of insulin-requiring type 2 diabetes, coronary artery disease managed with coronary bypass (1996) and coronary stent (2005), and smoking stopped at 38 years of age. He has a history of portal hypertension syndrome characterized by variceal hemorrhage on 4 occasions since 2019, despite medical management with beta blockers and esophageal variceal ligation on 5 occasions, associated with gastric varices and portal thrombosis in 2022. The picture was attributed to a liver cirrhosis secondary to steatohepatic disease associated with metabolic dysfunction.\n\nHe presented to our service for a new episode of upper gastrointestinal bleeding. Emergency upper endoscopy was performed which showed scars from an old ligation at the level of the distal esophagus, without current varices, stomach without blood stains, normal fundal mucosa, body and antrum, and gastric fundal varices (GOV 2); pylorus, bulb, duodenal to 3 without lesions, no blood stains. Liver tests at admission showed total bilirubin (TB) of 0.74 mg/dL, alkaline phosphatase (AP) of 128 U/L, gamma-glutamyl transferase (GGT) of 119 U/L, aspartate aminotransferase (AST) of 38 U/L, alanine aminotransferase (ALT) of 29 U/L and an international normalized ratio (INR) of 1.2. A contrast abdominal and pelvic scan showed a liver of normal size, nodular contours, wide cissures, without focal lesions, associated with a moderately distended and thin-walled gallbladder.\n\nGiven the patient's history of recurrent upper gastrointestinal bleeding unresponsive to beta blocker therapy and endoscopic therapy, a transjugular intrahepatic portosystemic shunt (TIPS) was performed for management.\n\nA transient elastography (FibroScan®) was performed, which reports a liver stiffness with a median of 6.9 Kpa, with an IQR (interquartile range) of 13%, correlated with F1 stage of the METAVIR classification; and controlled attenuation parameters with a median of 241 dB/M with an IQR of 23%, compatible with absence of hepatic steatosis.\n\nThe finding of no liver cirrhosis on the non-invasive method of assessing fibrosis led to a liver biopsy, which reported liver tissue with dilation and perivenular non-zonal sinusoidal congestion, corresponding to a non-specific histological finding, but with a compatible picture with EVPS. No steatosis, necroinflammatory damage, or significant fibrosis was observed.\n\nIn the context of portal hypertension, absence of liver cirrhosis, and a compatible liver biopsy, EVPS is diagnosed.\n",
    "summary": "A 68-year-old man with a history of portal hypertension and recurrent variceal hemorrhage presented. Despite medical treatment and endoscopic procedures, the hemorrhages persisted. A transjugular intrahepatic portosystemic shunt (TIPS) was performed for management. Liver elastography showed an unusually low liver stiffness for cirrhosis, which led to a liver biopsy. Histologic findings supported the diagnosis of EVPS.\n"
  },
  {
    "id": "multiclinsum_gs_en_552.txt",
    "fulltext": "4-year-old boy with no relevant antecedents, who began with atonic focal crises from 16 months of age, characterized by hypotonia of the left upper limb, associated with disconnection and hypertonia of the lower jaw in wake and nighttime weakness, adding sporadic clonic spasms of the ipsilateral shoulder. He received multiple anti-seizure regimens (carbamazepine, clobazam, levetiracetam, topiramate, oxcarbazepine and sultimate) with no improvement. Physical examination evidenced mild left brachial plexus hemiparesis. Psycho-pedagogical evaluation reported a mild neurodevelopmental delay (mainly in the areas of language and fine motor skills). Assuming the case as a pharmacoresistant focal epilepsy with atonic crises, a video EEG was performed to determine the electroclinical pattern, monitored for 72 hours, while the treatment with oxcarbazepine and topiramate was maintained. Eight crises were recorded, seven in wake and one under sleep, characterized by a feeling of discomfort in the left upper limb, followed by immobility with hypotonia of the same limb, followed by mild clonic spasms of the ipsilateral shoulder. The interictal tracing evidenced left hemispheric slowing and brief waves of slow waves, with sharp waves generalized, sometimes with a generalized wave of the left. The crises appeared to be simple focal epilepsy with sensory aura, consistent with the right parietal area. After determining the electrical pattern, a brain MRI was performed with EV contrast, showing a perirolandic posterior right lesion, with loss of definition between white and grey matter, consistent with focal cortical dysplasia. Assuming the case as a pharmacoresistant structural focal epilepsy, a video EEG was performed with deep electrodes and cortical stimulation, in order to determine the relationship of the epileptogenic area with the lesion and the neighbouring eloquent areas, as well as its extension. The deep electrodes were located in the lesion antero-superior and posterior to the lesion. Then in the primary motor and sensory areas at the superior, middle and inferior levels. The ictal EEG revealed repetitive activity of sharp waves in corresponding electrodes to the lesion and superior to the lesion, then diffuse disorganisation of the basal activity and, later, activity of rapid waves in corresponding electrodes to the lesion and superior to the lesion. For cortical stimulation, an Integra type Ojeman Stimulation System was used. Parameters: Frequency 50 Hz, pulse duration 0.5 msec, intensity 0.5 to 10 mA, in trains of 5 to 10 seconds, in progressive increases of 1 mA. When stimulating the anterior electrode of the lesion at 3.62 mA, negative motor phenomena of the left upper limb were triggered. With the latter, the epileptogenic area was defined with exactitude and surgical treatment was planned, avoiding compromising eloquent areas. The lesion, of displasic appearance and firm consistency, peri-primary sensory area, was resected under optical microscopy. Isolated dysmorphic neurons were recognized, with loss of polarity, alteration of the nucleus/ cytoplasm, irregular distribution of the Nissl substance and bulky cells, of irregular large vesicular nucleus and eosinophilic cytoplasm, of the balloon type, spread in the thickness of the cortex and white matter. Diagnosis: Developmental cortical malformation. Focal cortical dysplasia type IIb (presence of balloon cells).\n",
    "summary": "We present the case of a patient with pharmacoresistant focal atonic seizures in the left upper limb. A brain MRI was performed with a diagnosis of parietal cortical dysplasia, and was monitored with video EEG of the scalp and then with deep EEG. The epileptogenic area and its relationship with eloquent areas were defined, and a surgical resection of the lesion was performed, achieving complete control of the seizures.\n"
  },
  {
    "id": "multiclinsum_gs_en_495.txt",
    "fulltext": "A 63-year-old man was diagnosed with poorly differentiated stomach adenocarcinoma 4 years ago. The patient had a comprehensive surgical procedure consisting of radical gastrectomy, esophagojejunostomy, and abdominal lymph node dissection. He began 8 rounds of treatment with docetaxel in June 2022. In May 2023, a total of 8 cycles of chemotherapy were started using the nab-paclitaxel 200 mg/dL, d8 regimen, resulting in a cumulative dosage of 3200 mg. The patient reported a progressive decline in visual acuity in both eyes over a period of 2 weeks, starting in September 2023. The first ophthalmologic examination revealed that the best-corrected visual acuity in the right eye was 0.4, while in the left eye it was 0.5. The evaluation of the anterior portion indicated normal findings. The intraocular pressures in both eyes were within the usual range. Upon Fundus examination, bilateral cystoid macular edema (CME) was seen. Results of fundus fluorescein angiography, indicating little leakage in the right eye and no leakage seen in the left eye. Verified with an ocular coherence tomography scan, the right eye had a central macular thickness of 608 μm, whereas the left eye had a central macular thickness of 612 μm. The degree of prominence of hyporeflective cysts was shown to be higher in the outer nuclear layer, but much lower in the inner nuclear layer. The patient has had excellent binocular vision from infancy, with no prior indications of eye illness or genetic eye disease in his family. He have not used eye medications for an extended period, have not used niacin medicines, and have no history of drug allergies. Subsequently, the diagnosis of taxane-drug-induced CME was established. The use of Nab-paclitaxel was terminated. We administered topical corticosteroids and nonsteroidal anti-inflammatory medications to the patient. Following a period of 4 weeks, his visual acuity had declined to 0.3 in the right eye and 0.2 in the left eye, accompanied with a little reduction in CME. The right eye had a central macular thickness of 552 μm, whereas the left eye had a central macular thickness of 554 μm. Due to the unresolved CME, we started his treatment with topical carbonic anhydrase inhibitors, namely 1% Brinzolamide eye drops administered twice daily. After a duration of eleven days after the use of carbonic anhydrase inhibitors, the patient reported a notable improvement in his visual acuity. Regrettably, the current state of the individual’s overall health has rendered it unfeasible to attend the scheduled ophthalmology follow-up. After a period of 8 weeks after the cessation of nab-paclitaxel, complete resolution of CME was seen in both eyes. The right eye had a central macular thickness of 167 μm, whereas the left eye had a central macular thickness of 173 μm. His visual acuity has enhanced to 0.5 in the right eye and 0.6 in the left eye.\n\nThe cessation of nab-paclitaxel and the administration of topical carbonic anhydrase inhibitors (Brinzolamide) resulted in significant improvement and eventual resolution of CME. Visual acuity improved substantially following the combined treatment regimen, underscoring the effectiveness of this therapeutic approach. This case highlights the importance of early detection and intervention in managing TDICME, emphasizing the potential benefits of brinzolamide in treating this condition. The patient’s case underscores the need for clinicians to monitor for ocular side effects in patients receiving taxane-based chemotherapy and to consider alternative treatments promptly when visual symptoms arise.",
    "summary": "Patient concerns: A male patient, aged sixty-three, who was diagnosed with poorly differentiated gastric adenocarcinoma, experienced a progressive decline in visual acuity in both eyes after a 4-month course of nab-paclitaxel therapy.\n\nDiagnoses: Upon Fundus examination, bilateral cystoid macular edema (CME) was seen.\n\nInterventions: Undergo treatment with carbonic anhydrase inhibitors and discontinue the use of nab-paclitaxel.\n\nOutcomes: After eleven days of treatment with carbonic anhydrase inhibitors, the patient reported significant improvement in visual acuity. Furthermore, CME was completely resolved in both eyes 8 weeks after stopping nab-paclitaxel."
  },
  {
    "id": "multiclinsum_gs_en_130.txt",
    "fulltext": "A 70-year-old man presented with dyspnoea and palpitations on exertion to the emergency department (ED). His medical history was significant for stage IV clear cell RCC, chronic atrial fibrillation on anticoagulation with warfarin, coronary artery disease status post the placement of two stents with an ischaemic cardiomyopathy and a LVEF of 40%–45%. He was recently started on pazopanib for systemic treatment of metastatic RCC. Pazopanib was started at 75% of the recommended dose. At the initiation of therapy, the patient had a creatinine of 1.2 mg/dL and was able to walk 90 min a day without any complaints.\n\nWithin the first week of starting pazopanib, the patient developed dyspnoea on exertion that progressed rapidly to dyspnoea on minimal exertion. He was no longer able to conduct his daily walks. On the 10th day after starting pazopanib, he was unable to shave himself due to dyspnoea, which prompted his ED presentation. In the ED, his blood pressure (BP) was 122/70 mm Hg, heart rate (HR) was 93 beats per minute (bpm), respiratory rate (RR) was 22 breaths/min, and oxygen saturation was 94% on room air. On physical examination, auscultation of the heart was significant for an irregular rhythm with no additional heart sounds or signs of volume overload. His lungs were clear to auscultation, and the remainder of the examination was unremarkable.\n\nInitial labs were significant for a creatinine of 1.4 mg/mL and a supratherapeutic international normalised ratio of 4.0. Blood counts, electrolytes and liver function tests were within normal limits. His B-natriuretic peptide (BNP) was 2685 pg/mL. His troponin results were negative. An ECG showed atrial fibrillation without significant changes compared with previous tracings. A CT angiogram (CTA) of the chest in the ED showed heterogeneous opacification of the left main pulmonary artery with concern for a non-occlusive thrombus.\n\nThe patient was admitted to the hospital and empirically started on anticoagulation with enoxaparin for presumed pulmonary embolism (PE). On the second day, he presented with worsening shortness of breath and compromised mental status. On physical examination, he was dyspnoeic and tachypnoeic with RR of 40 breaths/min and oxygen saturation of 95% on 2 L of oxygen by nasal cannula. His HR ranged between 140 and 150 bpm and his BP was 96/53 mm Hg. He was in respiratory distress, unable to speak in full sentences but alert and following commands.\n\n\nInvestigations\n\nStat labs including blood counts, electrolytes and kidney function did not reveal significant change. Troponin-I was mildly elevated at 0.10 ng/mL (normal range <0.08). A chest X-ray revealed enlargement of the cardiac silhouette and mild vascular congestion. Review of prior CTA with radiology suggested that the findings were more consistent with an old thrombotic event rather than an acute PE. A transthoracic echocardiogram (TTE) revealed a severely dilated left ventricle with severely reduced systolic function and an estimated LVEF of 15%–20%, severe global hypokinesis and some regional variation in the anterior wall. When compared with prior EF of 40%–45%, the LVEF was significantly lower.\n\n\nDifferential diagnosis\n\nThe differential diagnosis of his acutely worsened cardiomyopathy includes new ischaemia, tachycardia induced or pazopanib induced. The mild elevation of patient’s troponin, in the setting of negative ECG changes, was thought to be most likely secondary to Type 2 myocardial ischaemia. His TTE findings showed global hypokinesis compared with prior echo instead of new focal dysfunction, which again supports non-ischaemic cardiomyopathy. His tachycardia began after the worsening of his EF. Given the rapid onset of his symptoms shortly after starting pazopanib, in the setting of no other obvious causes, pazopanib-induced cardiomyopathy remained as the most likely diagnosis.\n\n\nTreatment\n\nThe patient was transferred to ICU and intubated due to continued respiratory distress and shock requiring blood pressure support with norepinephrine. A pulmonary artery (PA) catheter was placed for close monitoring of haemodynamics and vasopressor management and revealed low cardiac output and a cardiac index of 1.7 L/min/m2 concerning for cardiogenic shock. Inotropic support with dobutamine was started and norepinephrine was continued. Beta-blocker therapy was started to control his heart rate. His course was complicated by aspiration pneumonia that required broad-spectrum antibiotics. The patient was weaned off vasopressors and was successfully extubated on ICU day 9. His hospital stay lasted 29 days with management of multiple medical complications including shock, acutely decompensated CHF, aspiration pneumonia, atrial fibrillation with a rapid ventricular response, toxic metabolic encephalopathy and acute kidney injury.\n\n\nOutcome and follow-up\n\nThe patient was discharged to a rehabilitation centre where he was able to participate in physical therapy. He was discharged home after his rehabilitation. His follow-up TTE 3 months after his discharge showed an estimated EF of 20%.",
    "summary": "A 70-year-old man with history of stage IV renal cell carcinoma, chronic atrial fibrillation on warfarin, coronary artery disease status post-percutaneous coronary intervention resulting in an ischaemic cardiomyopathy with left ventricular ejection fraction of 40%–45%, presented with shortness of breath 10 days after starting pazopanib. Within the first week of starting pazopanib, the patient developed fatigue and progressive dyspnoea on exertion. His symptoms quickly worsened and he had compromised mental status. He was transferred to the intensive care unit (ICU) and intubated due to continued respiratory distress. He was found to be in cardiogenic shock and was started on inotropic support with dobutamine and norepinephrine. With maximum support, the patient was slowly weaned off vasopressors and was successfully extubated on ICU day 9. His hospital stay lasted 29 days with management of multiple medical complications, and he was eventually discharged to a rehabilitation facility."
  },
  {
    "id": "multiclinsum_gs_en_198.txt",
    "fulltext": "A 53-year-old African woman presented with heart failure with increasing dyspnea, lower limb edema, and cyanosis of her lips and extremities with refractory hypoxia. We noted that she did not have a history of heart disease or digestive pathology. She was never operated on previously, and had no history of medical pathology or surgery in her family.\n\nA clinical examination revealed blood pressure of 120/70 mmHg, oxygen saturation at 85%, and a 3/6 diastolic murmur of aortic insufficiency with a holosystolic murmur (grade 4/6) suggestive of tricuspid valve regurgitation. Lower limb edema up to her knee joint was also present. We also detected a flushing with hepatalgia and asthenia. A neurological examination was normal; in particular, there was no sensory or motor deficit and no language disorder. The rest of the clinical examination was also normal.\n\nA 12-lead electrocardiogram (ECG) showed sinus rhythm and a heart rate of 66 beats per minute (bpm).\n\nShe underwent transthoracic echocardiography, which showed slightly dilated right heart cavities with right ventricular end diastolic diameter (RVEDD)/left ventricular end diastolic diameter (LVEDD) of 0.8, right atrial (RA) area of 20 cm2, and tricuspid ring of 39 mm with a preserved function in which tricuspid annular plane systolic excursion (TAPSE) was 16 mm and right ventricular (RV) velocity (S’) = 10 cm/second. Tricuspid valves appeared thickened and retracted with restricted mobility and poor coaptation responsible for a severe tricuspid regurgitation. Pulmonary valves were thickened with a moderate pulmonary (IP) insufficiency.\n\nA large patent foramen ovale (PFO) with aneurysm of her interatrial septum was detected with continuous right-to-left shunting.\n\nThe left-sided valves were not normal. Our patient had a moderate aortic regurgitation and minimal mitral insufficiency. The function of the left ventricle was good with ejection fraction (EF) of 55%.\n\nShe was initially treated with furosemide. The evolution of her treatment was marked by regression of the signs of her heart failure.\n\nBecause of her hepatalgia, a computed tomography (CT) of her abdomen was done and showed multiple hepatic and mesenteric nodules. A resection of 30 cm of her small bowel was done with an anterior gastrointestinal anastomosis.\n\nBiopsies of her liver and mesenteric nodules showed a secondary mesenteric and hepatic localization of a well-differentiated endocrine carcinoma. An immunohistochemical study showed positivity for chromogranin and negativity for synaptophysin. Laboratory findings revealed increased serum chromogranin A (574 ng/ml, normal < 102 ng/ml) and urinary 5-hydroxyindoleacetic acid (5-HIAA; 1183 μmol/24hours, normal < 40 μmol/24hours). An octreotide scan showed an intense radiotracer accumulation in her liver as well as normal distribution of the radiotracer in her kidneys and spleen.\n\nBecause of all these elements, we concluded that our patient had carcinoid syndrome complicated by the involvement of both the right side and left side of her heart. Her cyanosis was due to a right-to-left cardiac shunt.\n\nOur patient received somatostatin analogue therapy (one injection every 3 weeks). Her 5-HIAA and chromogranin A levels decreased to 450 μmol/24hours and 109 ng/ml respectively. For the heart disease, cardiac surgery was indicated: foramen ovale closure with tricuspid valve plasty.\n\nThe evolution of her treatment was marked 6 months after the surgical procedure by the regression of hypoxia with good clinical improvement. An echocardiography control showed minimal tricuspid regurgitation, without residual shunt of patent foramen oval.",
    "summary": "We report the case of a 53-year-old African woman with an endocrine tumor of her small intestine complicated by carcinoid heart disease, revealed by right-sided heart failure. The diagnosis was confirmed by transthoracic echocardiography, which showed a severe tricuspid regurgitation with a patent foramen ovale, and by increased serum chromogranin A and urinary 5-hydroxyindoleacetic acid.\n\nInitially she was treated with medical therapy (furosemide and injection of somatostatin). Afterwards she was proposed for surgery. The evolution of her treatment was good."
  },
  {
    "id": "multiclinsum_gs_en_25.txt",
    "fulltext": "A 31-year-old female from the Republic of Zimbabwe presented to the emergency department of our hospital with a 3-day history of fever, chest pain, vomiting, and diarrhea. The patient had no prior medical history of pneumonia, contagious diseases or known sick contacts and denied the use of tobacco or alcohol. Moreover, she had no previous hospitalization history. In Zimbabwe, a subset of the population habitually consumes red clay, and the patient was among this group. Due to the unavailability of red clay, she resorted to consuming garden soil once every two months, with her most recent ingestion occurring six days prior to presentation. She developed a fever with a maximum temperature of 38.8°C accompanied by chills, non-productive cough, and right-sided chest pain exacerbated by respiration 3 days after soil ingestion. She experienced four episodes of vomiting yellow-green fluid and severe diarrhea, with watery yellow stools occurring 3-6 times per hour at its peak. The patient self-administered ibuprofen, but her symptoms persisted, leading to her referral to our hospital due to worsening diarrhea and fatigue.\nOn physical examination, the patient's vital signs were as follows: body temperature 38°C, blood pressure 100/60 mmHg, pulse rate 83 beats/min, respiratory rate 18 breaths/min, and oxygen saturation 99% on room air. Auscultation revealed rough breath sounds bilaterally. Laboratory results indicated a white blood cell count of 28.65 × 109/L, with neutrophils at 25.95 × 109/L and a neutrophil percentage of 90.6%. C-reactive protein was elevated at 198.76 mg/L. Additionally, D-dimer (22.62 mg/L), creatinine (276.0 μmol/L), urea nitrogen (14.27 mmol/L), total bilirubin (61.0 μmol/L), direct bilirubin (18.3 μmol/L), and indirect bilirubin (42.7 μmol/L) were elevated. Chest computed tomography (CT) revealed two suspicious lesions in the left lower lobe, with cavitation observed in the larger lesion.\nEmpirical therapy with piperacillin-tazobactam and moxifloxacin was initiated. To identify the causative pathogen, bronchoscopy was performed, and culture of bronchoalveolar lavage fluid (BALF) identified P. aeruginosa and antimicrobial susceptibility testing demonstrated that the P. aeruginosa isolate was pan-sensitive to cefoperazone-sulbactam, levofloxacin, ceftazidime, ceftazidime-avibactam, meropenem, piperacillin-tazobactam, ciprofloxacin, cefepime, aztreonam and imipenem. Fecal culture concurrently indicated an infection with the P. aeruginosa, while blood and urine microbial culture showed no significant abnormalities. Consequently, the antibacterial regimen was adjusted to piperacillin-tazobactam and ciprofloxacin based on susceptibility results. Symptomatic treatments, including acid suppression, gastric protection, liver protection, antidiarrheal agents, and intestinal flora regulation, were administered, resulting in significant improvement in gastrointestinal symptoms.\n\nAfter 3 days of therapy, the patient's fever, vomiting, and diarrhea resolved, leaving only a mild cough. A repeat CT scan performed after 11 days showed enlargement and fusion of the lesions in the left lower lobe with a small left-sided pleural effusion. Despite these radiological findings, the patient's infection markers had significantly improved, leading to her discharge with instructions to continue moxifloxacin therapy on an outpatient basis. One month later, a follow-up CT scan demonstrated significant reduction in the left lower lobe lesions, and the patient remained asymptomatic.",
    "summary": "We present the case of a previously healthy 31-year-old patient, a middle school teacher, who developed CAP due to P. aeruginosa after ingesting garden soil for three consecutive days. The patient was admitted with symptoms including fever, chest pain, vomiting, and diarrhea. Chest computed tomography (CT) revealed two suspicious lesions in the left lower lobe, with one lesion exhibiting cavitation. Microbiological culture of bronchoalveolar lavage fluid (BALF) and stool confirmed the presence of P. aeruginosa infection. Subsequent antimicrobial susceptibility testing revealed that the P. aeruginosa isolate was pan-sensitive. Following 13 days of targeted antimicrobial therapy, the patient's symptoms and laboratory markers of infection improved significantly. A follow-up CT scan one month later demonstrated substantial resolution of the left lower lobe lesions, and the patient remained asymptomatic."
  },
  {
    "id": "multiclinsum_gs_en_167.txt",
    "fulltext": "We report the case of a boy born at 37 weeks 5/7 of gestational age by the vaginal route, with a birth weight of 2,160 kg (- 2.45 SD according to Niklasson), a size of 44 cm (- 2.56 SD) and a head circumference of 33 cm (- 0.74 SD). This intrauterine growth retardation (IUGR) is in the context of maternal consumption of tobacco and cannabis.\nThe clinical examination at birth is normal. There is no dysmorphia. There is no particular family history or consanguinity.\nGlycemic monitoring was initiated due to RCIU. At one hour of life, the child presented severe symptomatic hypoglycemia (glucose measured at 18 mg/dl) requiring the administration of a bolus of 10% glucose at 2 ml/kg followed by an infusion of 10% glucose at 60 ml/kg/day, which can be gradually decreased. The evolution was initially favorable with intermittent enteral feeding.\nAt eleven days of life, the child presented an episode of tremors. The measured blood glucose was 38 mg/dl with insufficiently inhibited insulinemia at 3.4 mUI/L (N: 3-25 mUI/L).\nThe cortisol and growth hormone responses are satisfactory (22.1 µg/dL and 5.4 µg/L, respectively). The ketonuria is negative. During another episode of hypoglycemia, the blood glucose is measured at 34 mg/dL, with an insulinemia measurable at 5 mUI/L. The glucagon test shows a rise in blood glucose of 40 mg/dL after 40 minutes. The diagnosis of hypoglycemia by hyperinsulinism is made.\nThe treatment consists of increasing daily intake of carbohydrates (infusion of a 10% glucose solution in parallel to continuous feeding by nasogastric tube) to a total of 14 g/kg/d. Given the recurrence of hypoglycaemia when the intake of carbohydrates is reduced (discontinuation of the infusion and switch to discontinuous feeding), treatment with diazoxide per os (10 mg/kg/d) is initiated. Due to the risk of pulmonary arterial hypertension associated with treatment with diazoxide, regular monitoring of cardiac ultrasound is performed and is normal.\nDespite the persistence of hypoglycaemia despite treatment with diazoxide, subcutaneous treatment with octreotide was initiated, first intermittently and then continuously via an insulin pump. The initial dose of 7.5 µg/kg/d was increased to 24 µg/kg/d. In parallel to artificial milk on demand (160 cc/kg/d), the patient received carbohydrates in the form of dextrin maltose associated with water continuously via a nasogastric tube (7 cc/h). Regular abdominal ultrasound monitoring was performed due to the risk of cholestasis associated with treatment with octreotide. Magnetic resonance imaging (MRI) of the brain and the electroencephalogram performed due to repeated hypoglycaemia did not demonstrate anomalies.\nThe genetic analysis of the panel of genes associated with congenital hyperinsulinism highlights a c.2696T>A p. (Ile899Asn) variant in the ABCC8 gene, in the heterozygous state, probably pathogenic (class IV). The genetic analysis of the mother does not highlight a mutation and the father's DNA is not available. The focal or diffuse character of the pancreatic lesion cannot be defined, an 18F-DOPA PET scan is performed and highlights a focal lesion (presence of a hyperfixing nodular focus at the level of the pancreatic body/tail junction). In this context, a partial pancreatectomy with ablation of the pancreatic tail is performed and the patient is cured with the discontinuation of octreotide and diazoxide. The anatomopathological analysis confirms a typical focal lesion, of complete resection, with a normal pancreas around it.\n",
    "summary": "We report a newborn with recurrent hypoglycaemia. The case will highlight a congenital hyperinsulinism (CHI) linked to a non-described variant in the ABCC8 gene. Imaging with fluorine 18-L-3,4 dihydroxyphenylalanine positron emission tomography/computed tomography scanner (18F-DOPA PET/CT scan) has highlighted a focal form of hyperinsulinism justifying surgical treatment leading to a complete healing and the discontinuation of all drug treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_544.txt",
    "fulltext": "An 69-year-old man with a history of kidney failure was admitted to our hospital. Two years prior to admission, an erythematous lesion appeared on his genitals; he was diagnosed with EMPD via skin biopsy. Computed tomography (CT) did not reveal any signs of lymph node or visceral metastases. After the mapping biopsy, total excision and split-thickness skin grafting were performed, and the margins were negative. Six years later, the patient underwent total prostatectomy for prostate cancer. He completed follow-up for 9 years after the total resection. Twelve years after total resection, an erythematous lesion appeared on the resection margin in the lower abdomen, and the serum carcinoembryonic antigen (CEA) was 0.9 ng/mL (cut-off <5.0 ng/mL). Similar lesions were observed in the umbilical fossa, the scar in the umbilical region, and both axillae. Histological examination revealed that all lesions were EMPD and in situ. Immunohistochemically, the tumour cells were positive for CEA, gross cystic disease fluid protein −15, cytokeratin (CK) 7, and periodic acid-Schiff staining and negative for CK20, which was the same result as that of total excision performed 12 years ago. No other lesions were detected on CT.",
    "summary": "We report the case of an 81-year-old man with heterochronous quadruple EMPD. Twelve years after total resection of vulvar EMPD, the patient developed erythematous lesions on the resection margin in the lower abdomen, umbilical region, and both axillae. Histological examination revealed that all lesions were in situ EMPD."
  },
  {
    "id": "multiclinsum_gs_en_455.txt",
    "fulltext": "A 68-year-old female patient was admitted to the hospital due to an incidental finding of a right renal mass during a hospital stay in the orthopedic department 10 days ago. The patient reports no discomfort, fever, pain, or hematuria. She has well-controlled hypertension for 20 years with metoprolol. No history of chronic illnesses or elevated blood glucose treatment.\n\nEnhanced CT showed a right renal mass with associated hydronephrosis, located at the renal hilum, measuring approximately 63.30 × 52.07 mm, with clear margins and heterogeneous enhancement during the contrast phase. Imaging findings were consistent with a malignant renal tumor, staged as T1bN0M0. Multiple small cysts were observed in the left kidney, without any obvious masses. Angiography revealed that the inferior vena cava (IVC) was located to the left of the aorta, and the right renal vein was significantly longer than the left renal vein. The right ovarian vein drained into the right renal vein and then into the IVC. Preoperative renal function was good, with an eGFR-epi of 94.27 ml/min/1.73 m2, right kidney GFR of 16.81 ml/min/1.73 m2, and serum creatinine of 51.01 μmol/L. Cardiopulmonary function was normal, and after evaluation, a right nephrectomy was planned.\n\nDuring operation, the right renal mass was found at the renal hilum, with dense adhesions to the surrounding fat and tissues. The IVC was located to the left, and the right renal vein was notably longer. The right ovarian vein traveled alongside the ureter and drained into the right renal vein before flowing into the IVC. Intraoperative blood loss was estimated at 220 ml, and the surgery lasted approximately 100 minutes. The resected specimen measured 10 x 6 × 5 cm, and the tumor was approximately 5 cm in diameter, located at the renal hilum. On postoperative day 5, the retroperitoneal drain was removed without any incidents.\n\nOn postoperative day 7, routine blood tests were normal, with an eGFR-epi of 83.93 ml/min/1.73 m2 and serum creatinine of 64.98 μmol/L, the patient has been discharged following a successful course of treatment. After the three-months follow-up, both eGFR-epi and serum creatinine were within normal ranges.",
    "summary": "A 68-year-old female with situs inversus presented with a right renal hilum mass incidentally discovered. Imaging revealed a tumor difficult to distinguish from the renal artery and an elongated right renal vein mimicking left-sided anatomy. Radical nephrectomy achieved favorable recovery and preserved renal function."
  },
  {
    "id": "multiclinsum_gs_en_254.txt",
    "fulltext": "40-year-old woman, who came to the emergency department for 3 hours of oppressive chest pain, intensity 8 out of 10 on the visual analogue scale and diaphoresis. As a background of interest, she was found to be overweight and had diabetes mellitus for 7 years, treated with insulin and metformin. She did not report using contraceptives, denied smoking, direct relatives with early coronary artery disease or stimulant use and stated that she exercised regularly daily with 40 minutes of walking.\n\nThe initial electrocardiogram showed a subnormal 0.05 to 0.1 mV in V1 to V6 and aVL. The high-sensitivity troponin I concentration was reported as 1463 ng/dL. Based on the findings, the case was classified as a very high-risk SCAST. The blood parameters of hematology, glucose, urea and creatinine, sodium, potassium, chloride, coagulation profile AST, ALT and DHL were normal.\n\nInitial pharmacological treatment was with a load of 300 mg of acetylsalicylic acid, 600 mg of clopidogrel, 80 mg of atorvastatin and 60 mg of subcutaneous enoxaparin. The patient was taken to the Haemodynamic Laboratory, where an immediate invasive coronary angiography was performed and a long stenosis of approximately 80% of the ostio-proximal segment of the anterior descending artery (DA) was observed, with no evidence of epicardial obstructions or alterations in the flow of the rest of the coronary arteries.\n\nDue to the findings and clinical behavior, it was decided to perform an OCT of the proximal anterior descending artery, in which an image compatible with an intramural hematoma of 8 mm in length was observed, which conditioned a 90% stenosis of the arterial lumen. It was decided to implant a 16 atm. drug-releasing Resolut stent of 3.5 x 15 mm in the ostio-proximal segment of DA to distal left coronary trunk, with post-dilatation of the distal segment of the main trunk with a 4 x 12 mm balloon. The OCT performed after the stent implant allowed to observe an adequate implantation and expansion of the entire device, which was corroborated by a control angiography, so any residual lesion and a final TIMI 3 flow was ruled out.\n\nDuring the 2-day convalescence in the Coronary Intensive Care Unit, the patient evolved without clinical events of relevance. The screening and study intended for other pathologies such as dyslipidemia, autoimmune diseases or thrombophilia only identified mild hypertriglyceridemia of 217, but with negative C-reactive protein, complement, rheumatoid factor and antinuclear antibodies.\n\nThe transthoracic echocardiogram performed prior to discharge showed a non-dilated left ventricle with no regional or global mobility abnormalities and the left ventricular ejection fraction was estimated at 63%.\n\nThe patient was asymptomatic and without complications at discharge and was prescribed outpatient pharmacological treatment with acetylsalicylic acid 150 mg, clopidogrel 75 mg, atorvastatin 80 mg, metoprolol 50 mg and enalapril 5 mg every 12 hours. At the 6-month follow-up, her functional class was I of the Canadian Cardiovascular Society (CCS) category, with no limitations or cardiovascular symptoms in her daily life.\n",
    "summary": "40-year-old woman with type 2 diabetes and no other cardiovascular risk factors presented to the emergency department with chest pain. Her initial evaluation revealed an abnormal electrocardiogram and elevated troponin I. A coronary angiography was performed and showed severe injury to the anterior descending artery. The study was supplemented with an intracoronary optical coherence tomography, which confirmed the presence of HIC without dissection. A stent was implanted in the affected arterial segment with a successful angiographic outcome. The subsequent convalescence was uncomplicated, allowing her to be discharged home with no systolic dysfunction on the echocardiogram and with no complications at 6 months.\n"
  },
  {
    "id": "multiclinsum_gs_en_341.txt",
    "fulltext": "A 42-year-old white male presented to the Lahey emergency department (ED) with 3 weeks of progressive vision loss and temporal visual field loss of the left eye (oculus sinister, OS) and slight discomfort on palpation. His past ocular history was noncontributory, and his past medical history was significant for pulmonary blastoma cT2N2M0, stage IIIA involving the right lung, with extension into the superior vena cava (SVC), 3 years prior to his current presentation. He was treated with chemoradiation and right pneumonectomy with complete response to therapy. He had no first-degree relatives with a history of cancer nor other relevant ocular disease. He had no smoking history and drank alcohol very sparingly, roughly twice per year. In the ED, a computed tomography (CT) scan of the head and computed tomography angiography (CTA) were obtained to rule out a neurologic source of the vision loss. The study showed a lentiform dependent hyperdense material with layering hypodensity within the medial aspect of the left globe, consistent with choroidal detachment. No other acute intracranial process was seen, and there was no evidence of acute infarction, hemorrhage, or mass. The CTA did not show any intracranial aneurysm or other neurovascular abnormality. When the patient was referred to ophthalmology, he was only able to count fingers in the affected eye at distance, but his near visual acuity was intact at 20/30. At that point, a myopic shift was suspected and confirmed with autorefraction. His intraocular pressure (IOP) was normal at 13 mmHg. His ocular motility was orthophoric and full. His pupils were equal, round, and reactive, and there was no afferent pupillary defect. There was a left temporal visual field loss present to confrontational testing. His anterior chamber examination appeared shallow in the affected eye, later found to be due to choroidal effusions pushing the anterior chamber complex forward. The posterior pole examination in the left eye demonstrated a round, elevated, red-hued lesion which was believed to be a serous hemorrhagic choroidal detachment. Visual acuity of the right eye was 20/20, and examination of the anterior and posterior poles was normal.\n\nB-scan ultrasonography of the left eye was obtained, demonstrating medium-to-high internal reflectivity and a fluid level within a large elevated nasal lesion. Subsequently, fluorescein angiography (FA) of both eyes was performed. The right eye was unremarkable, but in the left eye, a large nasal choroidal lesion was identified and found to block dye uptake. On the basis of this presentation, a metastatic choroidal lesion linked to his pulmonary biphasic blastoma was very high in the differential diagnosis, but a de novo tumor could not be excluded. Given the lack of trauma, previous surgery, or any other known ocular history such as glaucoma, a hemorrhagic etiology of choroidal effusions was unlikely. The absence of inflammation and negative B-scan findings made the diagnosis of posterior scleritis less likely.\n\nAs the suspicion for metastasis was high, a positron emission tomography (PET) scan was obtained, which was negative for metastasis. A repeat CT scan did not demonstrate any intracranial metastases. His near vision was still acceptable at 20/30, thus the patient and team opted to monitor the lesion closely. However, at a later visit, the nasal mass increased in size with an increase in subretinal fluid. In this case, there were no financial, language, or cultural barriers present. Therefore, a decision was made to proceed with an intraocular fine needle aspiration biopsy, which confirmed the suspicion of metastasis from lung origin. A multidisciplinary team recommended against the need for further systemic treatment.\n\nA total of 3 weeks after the initial presentation, the subretinal fluid increased significantly, accompanied by submacular fluid, further compromising the patient’s vision. A short course of steroids was initiated to reduce the ocular inflammation and fluid. As the choroidal detachment enlarged, the vision continued to worsen due to forward shifting of the ciliary body and lens complex, ultimately causing angle closure and significant pain.\n\nOn the basis of the worsening clinical presentation and the development of a blind and painful eye, the decision was made to proceed with enucleation. On histopathologic examination, the choroid was infiltrated by a metastatic epithelial tumor, which predominantly showed the typical epithelial component of pulmonary blastoma with glandular formation. The stromal component was not present. The glandular epithelial cells were strongly positive for pan-cytokeratin and thyroid transcription factor 1 (TTF1) immunohistochemical stains. The findings were consistent with the diagnosis of metastatic pulmonary blastoma.",
    "summary": "A 42-year-old white male patient presented to the emergency department with 3 weeks of progressive temporal visual field loss in the left eye (oculus sinister) with slight discomfort to palpation. At the emergency department, he underwent computed tomography and computed tomography angiography of the brain to rule out a central nervous system etiology of his vision loss. The imaging demonstrated lentiform dependent hyperdense material with layering hypodensity within the medial aspect of the left globe, consistent with choroidal detachment. His prior medical history was significant for biphasic pulmonary blastoma cT2N2M0 stage IIIA involving the right lung, with extension into the superior vena cava, diagnosed 3 years prior to the current presentation. He was treated with chemoradiation and excision with complete response to therapy."
  },
  {
    "id": "multiclinsum_gs_en_230.txt",
    "fulltext": "A Black male infant weighing 2,021 g was born at 35 weeks and three days of estimated gestational age by repeat cesarean delivery because of concern for decreased fetal movement in the setting of a low biophysical profile score (based on muscle tone, heart rate, movement, breathing, and amniotic fluid volume). Maternal history was notable for sickle cell trait, advanced maternal age, and obesity. Pregnancy history was notable for oligohydramnios observed via ultrasonography at 31 weeks. Fetal ultrasonography also showed bladder distension, bilateral hydroceles, urethra dilation, and abdominal urinary ascites concerning for lower urinary tract obstruction and possible bladder rupture. Rupture of membranes occurred at delivery.\n\nAt delivery, the infant experienced respiratory distress and was treated with positive pressure ventilation, supplemental oxygen, and intubation. Apgar scores were two and seven at one and 5 min of life, respectively. Examination showed substantial bruising and duskiness of the left upper extremity. The infant was transferred to the neonatal intensive care unit for treatment of respiratory distress and suspected lower urinary tract obstruction. On evaluation within 1 h after birth by orthopaedic and plastic surgery specialists, the distal third of the forearm and hand were cyanotic, and a large blister and surrounding area of desquamation were evident on the dorsum of the hand. No spontaneous movement of the left upper extremity was observed, and no withdrawal or response to stimuli was elicited. Doppler ultrasonography showed arterial flow to the level of the antecubital fossa, but no radial or ulnar pulses were detected. Physical exam findings were consistent with NCS, likely due to compression from uterine wall due to oligohydramnios during pregnancy.\n\nAfter approximately 5 h of serial examinations, as well as extensive discussion with the orthopaedic, plastic surgery, neonatology, and pediatric anesthesia teams, as well as the infant’s parents, the decision was made to perform decompressive fasciotomy of the forearm, hand, and carpal tunnel to enable limb salvage. Fasciotomy was performed at approximately 6 h after birth. The infant was monitored closely throughout the following days. The appearance of the left upper extremity gradually improved. On day three of life, the forearm and hand had improved markedly in color and appeared well vascularized. Doppler signals were present throughout, from the brachial artery to each digit. The fasciotomy wounds were allowed to heal by secondary intention, and a custom splint was applied with the wrist in neutral position and the fingers extended. No signs of infection or ongoing ischemia were present. The wounds were well healed by six weeks of age. At the follow-up visit at four months of age, the wounds were fully healed. The patient had full passive range of motion of the wrist and fingers. He was noted to have slight flexion and extension of the ring and small fingers, but otherwise minimal active motion of the wrist or hand at this point. He had active motion of the shoulder and elbow. The patient will continue receiving occupational therapy, as well as splinting and scar massage to prevent/minimize contractures. Multidisciplinary teams will continue following his progress and recovery closely.",
    "summary": "We present a case of NCS diagnosed and treated based on physical examination findings. Fetal ultrasonography showed bladder distension, bilateral hydroceles, urethra dilation, and abdominal urinary ascites concerning for lower urinary tract obstruction and possible bladder rupture. At 1 h after birth, examination of the infant’s left upper extremity showed no spontaneous movement, the hand and forearm appeared dusky, and the hand had a large blister with desquamation. No pulse distal to the antecubital fossa was detected via Doppler ultrasonography. The infant was diagnosed with NCS and underwent urgent fasciotomy. The clinical appearance and perfusion of the left upper extremity gradually improved. At four months of age, the wounds were healed and the patient had full passive range of motion of the left upper extremity. Recovery of active motion is ongoing."
  },
  {
    "id": "multiclinsum_gs_en_132.txt",
    "fulltext": "69-year-old male patient with a history of cadaveric liver transplantation for cirrhosis secondary to steatohepatitis. The surgical time was 300 minutes (625 minutes cold ischemia time of the graft). Standard technique was used; the arterial anastomosis was performed between the donor celiac trunk and the recipient's hepatic artery using two 8-0 polypropylene hemi-surgents. The patient recovered favorably and was discharged on the 9th day postoperatively. Two months postoperatively, the patient presented abdominal pain in the right hypochondrium accompanied by alterations in the hepatic panel (FAL 1000 IU/l, AST 300 IU/l, ALT 300 IU/l and total bilirubin 1.9 mg/dl). The hepatic Doppler ultrasound revealed a round image in the hepatic hilum of 40 mm in diameter with turbulent flow inside accompanied by focal hypoechoic bilobic lesions. An MRI was performed which revealed the same image of 35 mm in diameter in relation to the hepatic artery, with a void of flow and filling after the administration of intravenous contrast and wedge-shaped subcapsular areas suggestive of ischemic zones. The MRCP revealed severe dilation of the intrahepatic and extrahepatic proximal intrahepatic bile duct with presence of bilomas in both lobes. Subsequently, digital arteriography was performed which confirmed the diagnosis of pseudoaneurysm of the hepatic artery (PAH) of 50 x 60 mm without passage of contrast to the intrahepatic branches, which prevented its treatment by endovascular route.\n\nIn this situation, surgical ligation and resection of the pseudoaneurysm was decided. A primary anastomosis was attempted but a viable proximal end or ostium was not identified. Because of this and the ischemic compromise of the bile duct, re-transplantation was decided and an exceptional route was requested to INCUCAI, thus entering the waiting list and accessing a new graft 30 days later. The patient did not develop other complications during the new waiting period. The evolution after re-transplantation was favorable and the patient was discharged on the thirteenth postoperative day. The anatomopathological analysis reported a pseudoaneurysm of the hepatic artery with haematoma. The patient is asymptomatic and has been monitored for 9 years since the re-transplantation.\n\nThe incidence of PAH has been reported to be 0.27-2% of cases. Despite its rarity, it is considered a serious and life-threatening complication with a mortality rate of 69-75%. It is caused by a partial interruption of the arterial intima, causing blood to leak from the lumen forming a sac that resembles an aneurysm. Although the optimal strategy remains a matter of debate and must be adapted to the specific condition of each patient, most studies agree on the need for intervention due to the high mortality risk associated with rupture of the PAH. Traditional surgical methods for PAH include ligation of the hepatic artery or excision of the affected arterial segment, often accompanied by the use of extra-anatomical autologous grafts or re-transplantation.\n\nThe same image is evident in the coronal section in proximity to the portal vein and large subcapsular biloma. The cholangiopancreatic MRI shows severe dilation of the intrahepatic and proximal extrahepatic bile duct with presence of bilomas in both lobes.\n",
    "summary": "69-year-old man underwent a liver transplant with a cadaveric donor due to cirrhosis secondary to steatohepatitis. The arterial anastomosis was performed between the donor's celiac trunk and the recipient's hepatic artery. Two months postoperatively, he developed abdominal pain and a change in the hepatic panel. The angio-MRI and subsequent digital angiography confirmed a 50 x 60 mm pseudoaneurysm of the hepatic artery (PAH) with dilation of the bile duct and bilomas in both hepatic lobes. Endovascular treatment could not be performed due to the absence of contrast passage to the intrahepatic branches during the angiography. Surgical ligation and resection of the PAH that compromised both hepatic arteries was opted for. The primary anastomosis was not viable due to the failure to identify a viable proximal end or ostium. Given the ischemic compromise of the bile duct, an exceptional pathway was requested for re-transplantation to INCUCAI, thus entering the waiting list and accessing a new graft 30 days later. His subsequent evolution was favorable, and he was asymptomatic under follow-up for 9 years after the re-transplantation.\n"
  },
  {
    "id": "multiclinsum_gs_en_266.txt",
    "fulltext": "This patient was a 73-year-old white male with hypertension who was admitted to the ICU with acute respiratory distress syndrome (ARDS) due to COVID-19. Shortly after admission, he was intubated orotracheally and prone to improve hypoxia due to ARDS. On the third day of admission, he developed oliguria, azotemia and volume overload. The nephrology service was activated to perform a deep venous line for RT. The patient could not be placed in the supine position due to significant hypoxemia. A long-term dialysis catheter was inserted through the left popliteal vein. He was placed on conventional intermittent hemodialysis daily for 8 days. The blood flow during the sessions remained between 300 - 400 ml/min. Due to the severity of the clinical picture, the patient eventually died of respiratory failure on the 11th day. This case report describes a challenging situation in obtaining vascular access when dealing with patients with COVID-19 in the prone position. Technical aspects The left popliteal vein was evaluated by ultrasound. We used transverse and longitudinal cuts to avoid any valves, taking care not to injure the superficially located tibial nerve or popliteal artery, the deepest structure of the popliteal fossa. The popliteal vein was punctured with an 18GA x 7 cm needle, and a 0.035 inch guidewire was inserted without any resistance. A cut was made in the skin over the thread, the vein was dilated and the 50 cm permcath was inserted by the interventional nephrologist, with the help of a 16F splittable introducer. The cuff was sutured in the subcutaneous tissue. Both arterial and venous lines were tested and successfully salinized. Conventional intermittent hemodialysis was initiated without difficulty.\n",
    "summary": "The patient was a 73-year-old man who initially came to our service with acute respiratory failure secondary to COVID-19. Shortly after admission, he was intubated orotracheally and prone to improve the hypoxia due to severe acute respiratory syndrome (SARS). On the third day of admission, he developed acute oliguric renal injury and volume overload. The nephrology service was activated to perform deep venous access for renal replacement therapy (RRT). The patient could not be placed in the supine position due to significant hypoxemia. A 50 cm Permcath (MAHURKARTM, Covidien, Massachusetts, USA) was inserted through the left popliteal vein.\n"
  },
  {
    "id": "multiclinsum_gs_en_220.txt",
    "fulltext": "A 65-year-old Indian man presented to the medical emergency department with complaints of sudden onset weakness of right upper extremity.\n\nThe patient reports progressive exertional dyspnoea of 2 months duration (New York Heart Association II to IV) with associated orthopnoea, paroxysmal nocturnal dyspnoea, palpitations, chest discomfort and cough (productive) with scanty mucoid expectoration. It was associated with pitting oedema of bilateral lower extremities. No associated complaints of chest pain/diaphoresis/presyncope/syncopal attacks and altered mentation. Also there is no history of associated sensory deficit/headache, vomiting, vertigo/diplopia, blurred or loss of vision/dysarthria, dysphagia/facial weakness or deviation/ear pain or discharge/convulsions/loss of consciousness/bladder–bowel disturbances/trauma. No complaint of reduced urine output.\n\nOn examination, blood pressure was 150/90 mm Hg in left arm supine position. The pulse rate of 72 beats/min regular good volume without any radio-radial/radio-femoral delay; with all the peripheral pulses equally palpable. He was afebrile with a respiratory rate of 16/min (thoracoabdominal) with an oxygen saturation of 96% on ambient air. Pitting oedema was present over bilateral lower limbs (slow pitting; grade II) with jugular venous distension (Juglular Venous Pressure (JVP) 13 cm of water). Cardio Vascular System (CVS) examination reveals normal precordium, an apical impulse in left sixth intercostal space lateral to midclavicular line with no palpable thrill over precordium, S1 and S2 were heard normally. On chest auscultation bilateral breath sounds were heard equally with bilateral fine inspiratory basal crepitations. Per abdomen, examination reveals bimanually palpable bilateral kidneys with no other organomegaly/tender hepatomegaly/shifting dullness appreciable. Central Nervous System (CNS) examination reveals normal cranial nerves and sensory system. Glasgow Coma Scale (GCS) was E4V5M6 (15/15). Muscle power was 3/5 in right upper extremity with normal power in other limbs. The motor deficit was more in distal group of muscles. The tone of affected limb was increased, and the deep tendon reflexes were exaggerated suggesting upper motor neuron pattern of weakness. Plantar was bilateral flexor response.\n\nThere was no reported history of similar complaints in the past and any family member. There was no history of diabetes mellitus, systemic hypertension, cerebrovascular accidents. He is a chronic tobacco abuser (hookah smoker). The patient denies alcohol or any other substance abuse. There was no information available pertaining to history of familial renal disease and genetic analysis of family members. Also, there was no history of sudden cardiac death in any family member.\n\n\nInvestigations\n\nComplete haemogram, serum electrolytes, routine urine examination were within normal limits. ECG shows heart rate of 67 beats/min in sinus rhythm with left axis deviation with complete left bundle branch block pattern with no dynamicity on serial tracings and no evidence of atrial fibrillation. Serial Creatine Kinase-MB (Muscle Brain isoenzyme) values were within normal limits with negative serial troponins. Blood urea 67 mg/dL, serial creatinine 1.2 mg/dL with estimated glomerular filtration rate (eGFR) of 65 mL/min/1.73 m2. Fasting serum lipid profile was within normal limits. Prothrombin time was 11.9 s (reference range 9.5–13.5 s) with international normalisation ratio value of 0.99 (reference range <1.1). Serum ACE levels were within normal limits.\n\nChest roentgenogram shows cardiomegaly (cardiothoracic ratio >60%) with no evidence of hilar lymphadenopathy. Abdominal ultrasonography and contrast-enhanced CT revealed multiple cysts in each kidney and hepatic cysts. MR brain imaging reveals acute infarcts in left frontal, parietal, posterior temporal and right high frontoparietal regions with ischaemic gliotic changes in bilateral frontal and parietal regions with senile cerebral atrophy. CT cerebral angiography reveals mildly attenuated calibre of the left middle cerebral artery with no other significant vascular abnormality/aneurysm. Trasn Thoracic Echo(TTE) reveals severely reduced left ventricular function (LV ejection fraction (LVEF) 15%–20%) with global hypokinesia; LV enlargement (51 mm at end diastole and 46 mm at end systole); E>A; e<a with diastolic dysfunction grade II (moderate) with prominent trabeculations and deep recesses in mid LV cavity and LV apex with non-compaction (NC 16.4 mm) to compaction (C 5.2 mm) ratio of 3.1 at (NC:C>2 according to Jenni’s criteria), mild left atrial (LA) enlargement (45 mm) with mild to moderate mitral regurgitation with slight prolapse of anterior leaflet, with trace tricuspid regurgitation with Right Ventricular Systolic Pressure (RVSP) 32 mm Hg. LV end-diastolic volume (LV-EDV) was ~120 mL with LV end-systolic volume (LV-ESV) ~99 mL. Interatrial and interventricular septum and pericardium were normal, with no evidence of patent ductus arteriosus/coarctation of aorta/intracardiac clots/vegetations. CT coronary angiography reveals no significant coronary artery disease. CMR imaging reveals thinned LV myocardium, cavitary portion appears trabeculated and measures 18.9 mm with a compacted portion measuring 5.5 mm. There was markedly depressed LV systolic function with LVEF of 18%–22% with no regional wall motion abnormality; with measured LV-EDV value ~124 mL and LV-ESV ~101 mL. Ratio between N/C layers was 3.43 (NC:C>2.3 according to Peterson’s CMR criteria). No evidence of intracavitary contents/thrombus with outflow tracts appearing normal with findings suggestive of LV non-compaction myopathy and is consistent with echocardiographic findings. There was no evidence of late gadolinium enhancement (LGE) indicative of cardiac inflammation or fibrosis on T2-weighted images on CMR study.\n\n\nDifferential diagnosis\n\nIn our case, NVM cardiomyopathy, among the rare causes of cardiomyopathy with associated LV dysfunction and cardioembolic stroke along with its rare association with ADPKD was found. The key to suspicion of stroke as a primary aetiology to ‘brachial monoparesis’ was acute onset of weakness; which was confirmed on diffusion-weighted MRI of brain. Also for stroke to present as isolated upper limb weakness is very uncommon. There was no history of trauma. Also, there was no evidence of arm/shoulder pain, sensory disturbance, muscle wasting; making ‘brachial plexopathy’ and cervical nerve root compression (peripheral nervous system lesion) as less likely aetiology to explain the motor weakness. There was no history of stressor and no inconsistency in examination findings was reported during his hospital stay; which tends to be the case in functional/psychogenic causes of motor weakness. There was no evidence of coronary artery disease evidenced by normal CT coronary angiography study. Pulse rate was regular with sinus rhythm on ECG and no evidence of LA clot on echocardiography (TTE) study thereby ruling out atrial fibrillation as a likely aetiology of cardioembolic stroke. Transesophageal echocardiography (TEE) could not be performed due to non-availability at our centre, which was a limitation of our case. Also the patient did not agree for referral to higher centre for TEE. Cardiac sarcoidosis was less likely in our case as there was no evidence of hilar lymphadenopathy, normal serum ACE levels and no evidence of cardiac inflammation or fibrosis (LGE mapping) on T2-weighted images on CMR study.\n\n\nTreatment\n\nThere was marked symptomatic improvement after treatment with diuretics (intravenous furosemide). Later, he was started on oral treatment comprising of furosemide, spironolactone, carvedilol1 and sacubitril /valsartan; and oral anticoagulation for secondary stroke prevention and systemic embolism. The patient was advised to stop tobacco abuse. Active physiotherapy exercises for brachial monoparesis were advised. The patient was discharged with outpatient clinic follow-up at Post Graduate Institute of Medical Sciences, Rohtak.\n\n\nOutcome and follow-up\n\nThe patient has been followed up at the outpatient clinic regularly. His brachial monoparesis was improving, and the patient has been doing fine on pharmacotherapy. Clinical family screening of first-degree relatives was advised for both Left Ventricular Non Compaction (LVNC) and ADPKD. After cardiology consult, the patient was counselled regarding the need for implantable cardioverter-defibrillator (ICD) in view of reduced LVEF in case of non-improvement of EF with guideline-directed pharmacotherapy. Considering the role of tolvaptan (oral V2R antagonist) in halting the progressive reduction in eGFR in cases of ADPKD; nephrology consult was planned.",
    "summary": "Here, we report a case of 65-year-old man, chronic smoker, presented with sudden onset right brachial monoparesis, exertional dyspnoea, orthopnoea, bipedal swelling and diagnosed as a case of ADPKD with left ventricular non-compaction cardiomyopathy with acute left ventricular failure and cardiogenic cerebral embolism (no evidence of atrial fibrillation); based on characteristic appearance on two-dimensional echocardiography and cardiac magnetic resonance. The patient was managed with guideline-directed pharmacotherapy for heart failure and anticoagulation as a secondary stroke prevention measure."
  },
  {
    "id": "multiclinsum_gs_en_238.txt",
    "fulltext": "Chief Complaints\nA 38-year-old patient was admitted to the hospital with recurrent abdominal pain and diarrhea for more than 2 years, with fecal residue in the urine for 6 days.\n\nHistory of Present Illness\nThe patient had developed abdominal distension, abdominal pain, diarrhea and mucus in the stool 2 years prior to admission. The symptoms of the patient had worsened 1 year prior, and he went to Zhejiang Provincial People’s Hospital and was diagnosed with Crohn’s disease. The patient was given mesalazine orally. After discharge, the patient stopped taking mesalazine. The patient developed diarrhea that occurred more than 10 times per day, accompanied by dysuria, fecal residue in the urine, and decreased urine volume 6 days prior to admission.\n\nHistory of Past Illness\nThe patient underwent anal fistula surgery 1 year prior to admission.\n\nPhysical Examination\nThe patient was malnourished and was positive for subumbilical tenderness.\n\nLaboratory Examinations\nThe auxiliary examinations after admission showed that the white blood cell count was 9.9 * 10 ^ 9/L, neutrophil proportion was 66.1%, hemoglobin level was 98 g/L, CRP level was 139.9 mg/L, and serum albumin level was 24.5 g/L. Laboratory examinations showed the following: autoantibody (-), immunization (-), tuberculosis antibody (-), and T-SPOT (-). Test for inflammatory bowel disease-associated antibodies showed positivity for ASCA IgG, ASCA IgA, and F12Y IgG and negativity for AYMA IgG, AYCA IgA, and pANCA. The calprotectin level was greater than 1800 ug/g.\n\nImaging Examinations\nColonoscopy revealed the normal mucosa in the terminal ileum, and paving stone-like changes in the colon, ulcers in the local mucosa, and fistulas 25 cm away from the anus on November 30, 2020. The colonoscopic biopsy pathology showed chronic mucosal inflammation with erosion, focal inflammatory exudation, necrosis, infiltration of a large number of plasma cells and neutrophils in the stroma, no granuloma formation, and mild dysplasia of the local glands. The patient underwent enhanced pelvic magnetic resonance imaging, and the results showed multiple abnormal signal shadows in and around the prostate and urethra, an unclear boundary between the lesions and the anorectal canal, and infection with fistula formation. Capsule endoscopy revealed chronic inflammation of the small intestine with villous atrophy.\n\n\nFurther Diagnostic Work-Up\nThe patient was admitted to our hospital again for 5 days due to swelling and pain in the left lower abdomen. There was a palpable mass 10 cm in size in the left lower abdomen of the patient, with obvious swelling and tenderness, increased skin temperature, and local tenderness. The white blood cell count was 17.6 * 10 ^ 9/L, and the CRP level was 139.9 mg/L. B-ultrasound showed a hypoechoic mass and abundant blood supply in the left lower abdomen, with a range of approximately 6.0 * 2.4 * 3.5 cm. Considering the presence of the inflammatory mass and the unclear boundary between the hypoechoic mass and the abdominal cavity, a local sinus was suspected of having formed. Enhanced pelvic magnetic resonance imaging suggested local wall thickening of the sigmoid colon and rectum and inflammatory bowel disease; infection of the left lower abdominal wall with subcutaneous pneumatosis and local communication with the sigmoid colon, suggesting fistula formation; and multiple abnormal signals around the anus and corpus cavernosum, suggesting sinus and fistula formation with infection.\n\nFinal Diagnosis\nThe final diagnosis was severely active CD with enterovesical and enterocutaneous fistulas.\n\nTreatment\nThe patient was administered an intravenous infusion of ustekinumab 260 mg on December 4, 2020. Anti-infective treatment and nutritional support were given. The symptoms of the patient significantly improved. The patient was admitted due to the development of an extraintestinal fistula on January 18, 2021. The patient had multiple internal fistulas and infections, and lacked surgical conditions. Moreover, after undergoing an anal fistula surgery, the patient refused to undergo surgery again, and conservative drug treatment was administered. Conservative drug treatment was administered. Fasting was suggested, and somatostatin was administered to inhibit the secretion of digestive juice. The patient was given an intravenous infusion of ustekinumab 90 mg on February 8, 2021, with anti-infective treatment, nutritional support, and regulation of the intestinal flora. Drainage and debridement of the cutaneous fistula were performed and treated with dressing changes.\n\nOutcome and Follow-Up\nAfter discharge, the patient was given mesalazine orally, supplemented by enteral nutrition support. The cutaneous fistula was treated with a dressing change. The patient’s clinical symptoms significantly improved, CRP had successfully declined from 139.9 mL/L to 25 mL/L, and the cutaneous fistula healed. The patient had been suggested to another dose of ustekinumab after 12 weeks.",
    "summary": "In this case, the patient had recurrent abdominal pain and diarrhea for more than 2 years, with fecal residue in the urine for 6 days. Pelvic magnetic resonance imaging and colonoscopy showed intestinal infection with a rectal fistula, and the initial diagnosis was severely active Crohn's disease with an enterovesical fistula. The patient had multiple internal fistulas and infections, and strongly refused surgical conditions. The patient was given an intravenous infusion of ustekinumab and somatostatin, with anti-infective treatment, nutritional support and regulation of the intestinal flora. Drainage and debridement of the cutaneous fistula were performed. After comprehensive treatment and management, the patient's condition achieved significant clinical remission."
  },
  {
    "id": "multiclinsum_gs_en_316.txt",
    "fulltext": "We present the case of a 51-year-old man who started with paranoid thoughts, auditory hallucinations and addictive behaviour at the age of 20. He was diagnosed with paranoid schizophrenia and was treated with first-generation antipsychotics. In the following years, the patient had several admissions to hospital and psychiatric institutions. Since 2005, his evolution had been partially satisfactory. He maintained a relative independence and did occupational therapy, with great family support.\n\nIn late 2014, the patient developed a rigid acinetic syndrome. His treatment was clozapine (200 mg daily) and aripiprazole (15 mg daily), plus trihexyphenidyl (5 mg three times daily), lorazepam and trazodone. Dopaminergic interference was kept to a minimum. A DaTscan® was performed and was abnormal. Minimal doses of levodopa were tried, but the psychotic symptoms flared up. With only 150 mg levodopa daily, the patient again developed delusions of harm and persecution, and hallucinations, and even required admission to hospital. It was then decided to use a solution of paediatric levodopa (5 mg/mL), although the patient did not tolerate doses of more than 4 mL, which only achieved minimal relief.\n\nThe disease progressed markedly. In 2019, he had marked bilateral rigidity and akinesia, and was unable to stand or walk a few steps unaided. He also had dysphagia and sialorrhea. He lost a lot of weight and developed marked muscle atrophy due to his poor mobility.\n\n\nIn this situation, the patient was evaluated for subthalamic deep brain stimulation (DBS-NST) as the only way to achieve motor improvement in his case. He was not tested for levodopa due to his history, and was also unable to complete the preoperative neuropsychological evaluation. Finally, the patient was operated on in February 2020 under general anesthesia, without complications.\n\nSix months after the ECP-NST, the improvement was already very evident. The patient was able to stand alone without support and the gait improved significantly. He had moderate bilateral akinesia, predominantly in the left extremities. In addition, the severity of dysphagia and sialorrhea decreased appreciably. Levodopa treatment was discontinued, while antipsychotic treatment was not modified at any time. We have not identified a worsening of his psychiatric symptoms. The positive and negative symptom scale is a 30-question questionnaire with a seven-answer range, where higher scores reflect a worse state. One year after the intervention, a slight improvement in the scale score was observed, especially in terms of negative symptoms. These symptoms improved in parallel with the improvement in his quality of life. The family confirmed his greater ability to communicate, his greater spontaneity and his greater speed of reasoning. His global cognitive status, assessed by the Mattis dementia scale, was not modified after the intervention.\n",
    "summary": "We present the case of a patient with idiopathic Parkinson's disease and schizophrenia, with poor tolerance to minimal doses of levodopa, who showed a great improvement after bilateral subthalamic deep brain stimulation (DBS-NST). DBS-NST was considered here, due to the severity of this particular case, as the only possibility of achieving a motor improvement.\n"
  },
  {
    "id": "multiclinsum_gs_en_242.txt",
    "fulltext": "A 77-year-old man diagnosed with cutaneous sarcoidosis was admitted to our hospital resulting from heart failure with AV-block. His cardiovascular history included several previous percutaneous coronary interventions for ST-elevated MI and old MI to the left anterior descending and left circumflex arteries, respectively. Echocardiography showed hypokinesis of the posterolateral and antero-septal walls and no basal thinning of the ventricular septum. No significant coronary artery stenosis was detected during the emergency coronary angiography. CMR showed hypokinesis in antero-septal, antero-apical, and posterolateral walls with subendocardial DE corresponding with the coronary tree of previous MI. Additionally, mid-wall DE was confirmed in the basal-anterior wall with high intensity on a black-blood T2 weighted image. Subsequent FDG-PET imaging demonstrated high uptake in the basal-anterior wall. The patient was successfully diagnosed with CS using combined imaging modalities despite overlapping previous MI. The patient was treated with corticosteroids; the focal high uptake on FDG-PET was improved and had a better clinical course without further cardiac events.",
    "summary": "Patient concerns:\nA 77-year-old man was admitted due to heart failure and advanced atrioventricular block who was previously diagnosed with cutaneous sarcoidosis and old myocardial infarction (MI) with angiographical evidence.\n\nDiagnosis:\nHe was finally diagnosed with CS using CMR and FDG-PET by specifying the myocardial lesion of sarcoidosis.\n\nInterventions:\nHe was treated with corticosteroids based on the diagnosis.\n\nOutcomes:\nThe focal high uptake on FDG-PET was improved and he had a better clinical course without further cardiac events."
  },
  {
    "id": "multiclinsum_gs_en_195.txt",
    "fulltext": "A 28-year-old Somalian male patient presented with hematemesis (vomiting of blood) and melena (black, tarry stool) in October 2023. The patient has no related past medical history. Endoscopic evaluation revealed 4 cords of oesophageal varices. Abdominal sonography and hepatic duplex assessment showed a normal liver size with a coarse parenchymal texture, fine periportal fibrosis, and multiple scattered, well-defined hypoechoic focal lesions, the largest measuring about 17.7 × 16.5mm. The spleen was enlarged, measuring about 16.3cm. Initial management included band ligation for a torn cord observed during endoscopy, terlipressin Injection 1 mg, propranolol tab 40mg and blood transfusion due to pancytopenia.\n\nDuring the investigation of the illness, a stool test was performed to rule out schistosomiasis as a potential cause of portal hypertension. The stool analysis had a negative result. Schistosomiasis is endemic in Somalia, Sudan, Yemen, and Egypt, and more people in those nations require chemotherapy to prevent the disease.\n\nFurther evaluation with high-field MRI showed chronic parenchymal liver changes, with the right hepatic lobe not exceeding 10cm and preferential enlargement of the lobe. The posterior aspect of the right hepatic lobe (segments 7–8) showed faint bright signal on T1 pre-contrast images, with corresponding faint heterogeneous enhancement in the early phases of the dynamic study, but without definite delayed washout or restricted diffusion. The left hepatic lobe segment 2 had two adjacent subcapsular, well-defined lesions, the largest measuring 6.5mm, showing faint bright signal on T2 without significant diffusion restriction. On dynamic post-contrast images, these nodules demonstrated corresponding enhancement throughout the dynamic study with no related washout. Liver biopsy was performed, and microscopic examination of the prepared slides revealed intact architecture. The slides showed 10 enclosed portal areas with mild expansion due to fibrosis, without any inflammatory infiltrate, plasma cells, or interface hepatitis. The parenchyma showed one-cell-thick plates without focal necrosis or parenchymal rosetting. There was no evidence of steatosis, cholestasis, or hemosiderosis, and no PAS-D globules or other storage material was detected. Additionally, no granulomas were found (not seen).\n\nLaboratory examinations revealed normal liver function tests, including AST, ALT, bilirubin, serum albumin, and alkaline phosphatase immunological investigations including alpha-fetoprotein (AFP), HCV antibody, HBS antigen, anti-mitochondrial antibody (AMA), and anti-smooth muscle (ASMA), were mostly negative, except for a weak positive result of ASMA and a weak positive of speckled antinuclear antibody pattern (ANA). The complete blood count showed anaemia, leukopenia, and thrombocytopenia. The coagulation profile, including prothrombin time (PT) and INR, were normal.\n\nThe patient received elective management during his course of illness, and doctors recommended regular follow-up.\n\nAbove the pathological test and excluded all possibility of portal hypertension in the patient diagnosed with PSVD.",
    "summary": "We report a rare case of Porto Sinusoidal Vascular Disorder (PSVD). This patient presented with hematemesis and melena several times, despite having no prior history of chronic disease. An endoscopic evaluation revealed 4 cords of oesophageal varices. The exact cause of portal hypertension was not identified despite the patient undergoing MRI, liver biopsy, abdominal and hepatic sonography, and other required laboratory tests. This patient was performed band ligation and received beta blockers, proton pump inhibitors and whole blood transfusion."
  },
  {
    "id": "multiclinsum_gs_en_432.txt",
    "fulltext": "He was a 31-year-old previously healthy man. On September 12, 2011, he fell while riding a horse, with a mechanism of direct trauma to the right knee. He reported that he started with a stabbing type pain, with intensity 5/10 on the EVA scale (visual analogue scale), constant, without predominance of time, located in the right knee, without irradiation, incapacitating, which increased during mobilization, but decreased with rest and with the intake of analgesics. He was evaluated by a doctor, who performed radiographic studies and later referred the patient to our hospital for definitive management. The patient came to our service with 10 days of evolution, with slight increase in volume at the level of the right knee, without ecchymosis or oedema or skin defects, with signs of increased joint fluid associated with pain, crepitus and limitation of the mobility of the knee. No clinical signs of instability or meniscal injury of the knee were observed. The patient presented with anteroposterior and lateral radiographs of the right knee dated September 12, 2011, in which a solution of continuity of the medial femoral condyle was observed in a coronal direction, with joint involvement and displacement of 3 mm. He also had a magnetic resonance scan dated September 19, 2011, which showed a coronal fracture of the posterior portion of the medial femoral condyle with displacement of 3 mm on the articular surface, with probable injury of both menisci and probable injury of the anterior cruciate ligament. Surgical management was performed on September 27, 2011 by open reduction through an anteromedial subvastus approach of 7 cm and fixation in an anteroposterior direction under the principle of axial compression with two cannulated 7.0 mm screws with washers; the screws were placed under independent, minimal incisions in the anterior face of the knee. The patient was discharged 24 hours after the procedure and active and continuous flexion-extension of the knee was indicated without supporting the extremity. He was referred for postoperative control, observing that he presented no alterations in the healing of the surgical wounds, the sutures were removed, flexion of 120° and extension of 0° were observed, without pain and strength 5/5. He was sent to the rehabilitation service for strengthening of the extremity and he was referred to the tenth week for partial and progressive support of the extremity.\n",
    "summary": "The objective of this report is to present a patient with the diagnosis of a right medial Hoffa fracture, recorded as a unique case in our hospital's files. The patient was referred in November 2011, with a 10-day evolution after a fall from a horse, presenting a forced varus mechanism and a direct contusion of the right knee. He showed anteroposterior and lateral radiographs of the right knee, where a subtle solution of continuity was observed in the coronal plane of the base of the medial condyle, corroborated by magnetic resonance and associated with partial non-surgical injuries of both menisci and the anterior cruciate ligament. He underwent surgery on November 27, 2011, by means of an open reduction with a medial approach and internal fixation with two cannulated 7.0 mm screws. The patient was discharged indicating early and continuous mobilization of the knee, postponing support and rehabilitation until the sixth week. The patient is now able to walk, asymptomatic and with full mobility arcs. The respect of the extensor apparatus by means of a medial approach and the articular surface with cannulated screws is reflected in the adequate evolution of our patient, who was able to return to his daily activities, including riding.\n"
  },
  {
    "id": "multiclinsum_gs_en_559.txt",
    "fulltext": "34-year-old male with a history of bilateral retinal detachment and David surgery (aortic root replacement and aortic valve re-suspension) 12 years prior to this admission; presented to the emergency department with dyspnoea and angina. Physical examination with vital signs within normal parameters; diastolic murmur consistent with aortic insufficiency and 12-lead electrocardiogram with evidence of left ventricular overload. The transthoracic echocardiogram (TTE) showed left ventricular dilation with an ejection fraction (EF) of 60% and severe aortic insufficiency. Angiotomography of the thoracic aorta showed dilation of up to 76 mm, dilation of the right coronary artery, with no evidence of aortic dissection. Based on the above, he was evaluated by the local Heart Team who decided to perform Bentall and de Bono surgery in addition to reconstruction of the right coronary artery.\n\nUpon admission to the Cardiovascular Intensive Care Unit after the planned surgery, elevation of the ST segment was identified in the DII, DIII and AVF leads. The transesophageal echocardiogram (ECOTE) showed akinesia in the inferior, inferoseptal and inferolateral faces in their three thirds, suggestive of myocardial infarction associated with cardiac surgery (type V infarction). For this reason, urgent diagnostic coronary angiography was performed, showing adequate flow in the coronary arteries. However, the evolution was slow with increased use of inotropic and vasopressor agents without improvement in clinical or biochemical parameters of tissue perfusion and the diagnosis of CCBGP was established. Peripheral V-A ECMO was connected with intra-aortic balloon counterpulsation (BIAC) ventricular decompression.\n\nThree days after the start of mechanical circulatory support (MCS), hypoxia was detected in the trunk with normal oxygenation values in the lower extremities. Bacterial pneumonia was suspected and confirmed by a chest X-ray (presence of left basal consolidation), which led to the diagnosis of north-south syndrome. Ventilatory parameters were adjusted without resolution of the hypoxemia, so a new configuration of ECMO V-A to venoarteriovenous ECMO (ECMO V-AV) was performed; that is, extraction of a vein and return to the right heart and aortic arterial cavities. Antimicrobial treatment based on meropenem and vancomycin was also initiated.\n\n48 hours after the start of the new circulatory and venous support configuration, an improvement in the hemodynamic and cardiovascular function was documented, so that 72 hours after the start of assistance it was withdrawn without complications. The patient was discharged alive to his home after 25 days of hospital stay.\n",
    "summary": "We present the case of a 34-year-old male patient with a previous diagnosis of Marfan syndrome who was admitted for acute aortic insufficiency secondary to aneurysmal dilation of the ascending thoracic aorta. In the postoperative period, post-cardio-tomy cardiogenic shock was documented, so circulatory support was initiated with peripheral venoarterial ECMO, which developed hypoxemia due to bacterial pneumonia and data compatible with north-south syndrome.\n"
  },
  {
    "id": "multiclinsum_gs_en_300.txt",
    "fulltext": "A 39-year-old male presented to a tertiary care center following attempted hanging one hour prior. By EMS report, he was found on the ground coughing blood next to a tree with a with suspended wire noose. On presentation, he was alert and oriented. He reported difficulty projecting his voice but denied dyspnea. Physical exam revealed a ligature mark along the anterior neck at the level of the thyroid cartilage. The thyroid notch could be palpated, but other cervical landmarks were obscured by subcutaneous emphysema.\n\nCT angiography revealed intimal injuries with thrombus (AAST Grades III-V) of the bilateral common carotid, left external carotid and bilateral vertebral arteries. A displaced transverse process fracture at C4 was noted. There was extensive subcutaneous emphysema with pneumomediastinum. On closer inspection, the infrahyoid strap muscles were disrupted, with distraction of the hyoid bone and epiglottis superiorly and the thyroid cartilage inferiorly. MRI demonstrated a partial tear of the nuchal ligament, requiring ongoing spine immobilization.\n\nThe OTO-HNS service was consulted to evaluate the patient's airway. Flexible laryngoscopy demonstrated mobile cords bilaterally with mild laryngeal edema. The epiglottis appeared to be detached from the laryngeal cartilage and the mucosa of the aryepiglottic folds/false cords was disrupted.\n\nShortly after initial evaluation by OTO-HNS, the patient was taken to the operating room (OR) for a controlled awake nasotracheal intubation. He was stable from an airway standpoint and due to the extent of his laryngeal mucosal lacerations, we felt the safest option was to transfer him to the OR for definitive airway management under direct visualization the night of his arrival. On hospital day two, the patient underwent tracheostomy, laryngoscopy, esophagoscopy, and repair of the hyolaryngeal injury. After raising flaps, a small defect was noted over the thyroid notch in the investing layer of the deep cervical fascia which, when opened, revealed a large soft tissue defect extending into the supraglottic airway. The sternohyoid, thyrohyoid and omohyoid muscles had ruptured 1–2 cm below their insertion on the hyoid. The thyrohyoid membrane was completely disrupted, as was the mucosa of the false cords and aryepiglottic folds. The epiglottis was detached from the thyroid cartilage and was distracted superiorly with the hyoid by the unopposed forces of the suprahyoid musculature.\n\nDue to co-existing cervical spine injuries, the neck had to remain in a neutral position. An Allis clamp was used to retract the hyoid inferiorly and a single hook to pull the larynx/trachea superiorly. The laryngeal mucosa was repaired first with interrupted 4–0 vicryl suture. To keep tension off the wound, a modified thyrohyoidopexy with epiglottopexy was performed. 20-gauge needle was passed through the anterior thyroid cartilage under visualization with a flexible bronchoscope to ensure adequate distance above the anterior commissure before passing the midline suture. On the airway side, the suture was then passed through the petiole of the epiglottis. The inferior arm of four additional 2–0 vicryl sutures were passed through the superior thyroid ala (2 sutures each side). The superior arm of each suture was then passed around the hyoid. These tension sutures were secured, holding the hyoid and thyroid cartilages in close approximation. The ruptured ends of the strap musculature were reapproximated, penrose drains were placed, and the incision was closed in a layered fashion.\n\nThe patient had a gastrostomy tube placed. He was started on heparin for carotid thrombus and continued one week of intravenous Unasyn. The first tracheostomy change was performed on post-operative day (POD) 7 once resolution of airway edema was confirmed with flexible laryngoscopy. A video swallow study on POD 14 revealed mild-moderate oropharyngeal dysphagia which was minimized with swallow strategies. He was decannulated on POD 17 and discharged the following day.\n\nAt follow up, the patient was no longer in a c-collar. He was tolerating a regular diet. His voice was slightly hoarse, considered a grade one for roughness on the GRBAS scale (grade, rough, breathy, asthenia, strain), but he was able to communicate without limitation. Laryngoscopy demonstrated a well healed larynx with mobile cords, shortening of left aryepiglottic folds and inferior displacement of the epiglottis. Follow up CTA neck to evaluate his carotid injury demonstrated resolution of cervical air with a patent/intact airway.",
    "summary": "We report a case of a 39-year-old male admitted to the Intensive Care Unit following attempted self-strangulation. Alert and clinically stable, his primary symptoms were pain and voice changes. His external exam was remarkable only for a cervical ligature mark and subcutaneous emphysema on palpation. CT imaging demonstrated disruption of the infrahyoid strap muscles and displacement of the hyoid and epiglottis superiorly. Subsequent flexible laryngoscopy by the Otolaryngology-Head & Neck Surgery (OTO-HNS) team revealed avulsion of the epiglottis from the thyroid cartilage and disruption of the aryepiglottic folds/false cord mucosa, resulting in an open wound into the soft tissues of the anterior neck. The airway was secured in the operating room via fiberoptic nasotracheal intubation. A tracheostomy was performed. Neck exploration revealed transection of the anterior strap muscles and thyrohyoid membrane. The wound was repaired in layers via a modified thyrohyoidopexy. At one-month follow-up, the patient was successfully decannulated and tolerating a regular diet."
  },
  {
    "id": "multiclinsum_gs_en_441.txt",
    "fulltext": "A 63-year-old female was admitted to the Emergency Department of our hospital because of a persistent pressure, like chest pain, which developed 3 hours prior to her admission. She had a history of hypertension for approximately 10 years but had no history of diabetes. She was a nonsmoker. The electrocardiogram (ECG) results showed ST-segment elevation at the precordium leads, and ST-segment elevation myocardial infarction (STEMI) was therefore suspected. The patient was transferred to the catheter lab for an emergency coronary artery angiogram (CAG). The CAG failed to show any significant stenosis in the large coronary artery. The thrombolysis in myocardial infarction (TIMI) flow was graded at 3. The patient's chest pain relieved shortly after admission, and she was transferred to the coronary care unit (CCU) for further observation. The patient's troponin levels were monitored every 6 hours, and the pattern was consistent with that of STEMI. The peak value of troponin was 123 ng/mL. Contrast-enhanced computed tomography was performed and revealed decreased contractility of the anterior wall with a reduced ejection fraction (EF). Consistent with these findings, transthoracic echocardiography (TTE) showed that the left atrial diameter was 31 mm, the left ventricular end-diastolic (LVED) diameter was 48 mm, and the EF was 50%. Based on the findings above, a MINOCA diagnosis was made. The patient was discharged 5 days after admission, following an uneventful observation period, with guidelines for the recommended medical therapies including dual antiplatelet therapy, stain, angiotensin converting enzyme inhibitor, and β-blockers.\n\nTen days after discharge, the patient developed shortness of breath, which exacerbated with exertion. Physical examination showed that the point of maximal impulse was laterally displaced. TTE revealed that the left atrial diameter was dilated from 31 to 41 mm, the LVED was dilated from 48 to 60 mm, and the EF had dropped from 50% to 38%. An apex ventricular aneurysm with a thickness of 5.7 mm, a range of approximately 30 mm without contractility, and a hypo-echo appendage attached to the left ventricular apex area without movement with cardiac cycle were observed and the N-terminal pro-B-type natriuretic peptide (NT-ProBNP) level was 7420 pg/mL. Cardiac magnetic resonance imaging revealed a left ventricular thrombus and decreased EF. Based on these clinical findings, the patient was diagnosed as having HF, ventricular aneurysm, and mural thrombosis. The clinical symptoms of this patient were relieved by diuretic treatment and the patient was discharged with the addition of Rivaroxaban to the treatment plan.\n\nOne week later, the patient came to the emergency room again with palpitations and shortness of breath. ECG revealed VT. The patient was admitted to the CCU for further treatment. Treatment with a loading dose of amiodarone, followed by a maintenance dose, failed to terminate the VT. Thereafter, amiodarone was replaced by lidocaine and esmolol. However, the VT persisted with deteriorating HF. The incessant VT lasted for 5 days before it was successfully terminated by 100 J synchronized electrical cardioversion. The VT recurred frequently and every time it was terminated through the use of electrical cardioversion. Epicardium radiofrequency ablation was performed to treat the VT, and the pericardium was punctured with the xiphoid process. Through electrophysiology mapping, the epicardium was ablated, and no VT was observed immediately after the ablation.\n\nFourteen days after the ablation, the VT recurred. About 100 J synchronized cardioversion was used to terminate the VT. Informed consent was obtained from the patient and an ICD was implanted. During the 7-day follow-up period, there were no shock delivered discharges and several episodes of VT were successfully terminated by antitachycardia pacing (ATP). After consultation with a cardiac surgeon, the patient was transferred to the Surgery Department for the removal of the ventricular aneurysm, to restore the heart geometry. One month after the surgery, TTE revealed that the left atrial diameter was reduced to 31 mm, the LVED diameter was reduced to 50 mm, the EF was increased to 50%, and the mitral valve regurgitation was greatly improved. The patient was free of events during the 3-month follow-up period after the surgery.",
    "summary": "Patient concerns:\nA 63-year-old female was admitted to the emergency department with acute onset of chest pain, electrocardiogram showed ST segment elevation in precordium leads.\n\nDiagnosis:\nEmergency coronary artery angiogram no significant coronary artery stenosis being observed. The diagnosis of MINOCA was established. She subsequently developed ventricular thrombus, heart failure, and ventricular arrhythmia.\n\nInterventions:\nThe patient's ventricular tachycardia (VT) was refractory to different treatments. Due to the presence of a ventricular thrombus, epicardial ablation was performed but the VT recurred. The patient was then successfully treated with an implantable cardioverter defibrillator and surgical removal of the ventricular aneurysm.\n\nOutcomes:\nThe patient was free of events during the 3-month follow-up period after the surgery."
  },
  {
    "id": "multiclinsum_gs_en_375.txt",
    "fulltext": "A 60-year-old man who came to the Padjadjaran University Dental Hospital complained of a lump on the tongue two months prior, which was painless and often accompanied by bleeding when consuming acidic foods or drinks. The complaint was followed by abdominal discomfort, difficulty defecating, weight loss, and decreased appetite. The patient had eaten only porridge and lacked water intake for the past two months. The general condition of the patient at the first visit appeared weak and pale with normal vital signs.\n\nExtraoral examination revealed anemic conjunctiva and icteric sclera. Intraoral examination showed multiple and branching fissures on the median dorsum of the tongue; multiple depapillation scattered on the anterior third of the tongue dorsum surface resembling islands with hyperkeratotic edges; and hematoma on the posterior one-third of the tongue dorsum, blackish red in color, irregular shape, negative diascopy test. The diagnoses of tongue lesions were fissured tongue, geographic tongue, suspected syphilitic ulcer, suspected oral squamous cell carcinoma (OSCC), and suspected oral hematoma.\n\nReferrals for routine hematology, Venereal Disease Research Laboratory (VDRL), Treponema Pallidum Hemagglutination Assay (TPHA), and total Immunoglobulin-E (Ig-E) were performed. Serologic examination of VDRL, TPHA, and total Ig-E was conducted to exclude the differential diagnosis of bleeding lesions of the tongue. Based on the laboratory examination results, the diagnosis of bleeding lesions on the tongue was oral hematoma.\n\nCase Management\nPharmacological therapy in the first visit included anti-fibrinolytic agents and hematinic supplements for one week, and non-pharmacological therapy consisted of instructions to maintain oral hygiene, a healthy lifestyle, and avoid trauma factors that trigger bleeding. A referral to the internal medicine department and oral surgery were given to the patient for follow-up on tongue lesions.\n\nInstructions to consult the internal medicine department were given, and the patient was immediately given a blood transfusion and scheduled for an excisional biopsy of the tongue lesion. The excision biopsy was performed by an oral surgeon to be analyzed by the anatomical pathology department. The results of the histopathological-anatomical examination showed sub-epithelial fibro collagenous connective tissue and muscular fibers with mononuclear and polymorphonuclear inflammatory cells so that the lesion was impressed as granulation tissue by nonspecific infection without signs of malignancy.\n\nThe tongue lesion improved during the follow-up appointment at the oral medicine department. The complaint of a lump on the tongue that bleeds easily has disappeared, and the patient is now more comfortable eating. Difficulty in defecation was no longer felt. A healthy lifestyle is implemented by regularly eating vegetables and drinking enough mineral water, but the patient consumes fruit and red meat infrequently. The general condition of the patient seems healthy and has experienced an increased body weight of five kilograms. Anemia condition has shown improvement, as shown by the patient being able to perform blood donation, with a hemoglobin value at that time of 12.8 g/dL.\n\nExtraoral examination revealed non-anemic conjunctiva and icteric sclera. Intraoral examination still showed multiple and branching fissures on the median dorsum of the tongue, as well as a map-like appearance with filiform papillae atrophy. The oral hematoma was healed, and the diagnosis at this visit was a fissured tongue and geographic tongue.\n\nPharmacological therapy such as a folic acid supplement of 400 µg once a day and vitamin B12 twice a day were given at this visit as supportive therapy for geographic tongue lesions. Instructions to continue a balanced lifestyle and maintain oral hygiene were given as non-pharmacologic therapy. The patient was also educated about the condition of the fissured and geographic tongue is a normal variation of the oral cavity that is not dangerous.",
    "summary": "A 59-year-old male complained of a lump on his tongue two months prior, which was painless and frequently bleeding. The complaint was followed by abdominal discomfort, difficulty defecating, weight loss, and decreased appetite. The patient only ate porridge and lacked water intake. Intraoral examination showed a blackish-red, irregularly shaped, painless hematoma on the dorsum of the tongue and a negative diascopy test. Hematology examination showed anemia with hemoglobin 6.7g/dL, hematocrit 21.4%, erythrocytes 3.08 x 106/µL, MCV 69.5fL, MCH 21.8pg, and MCHC 31.3g/dL. The diagnosis of the tongue lesion was an oral hematoma.\n\nCase management: Pharmacologic therapy included antifibrinolytic agents and hematinic supplementation. Non-pharmacologic therapy included dental health education, a balanced lifestyle, and avoiding triggers for tongue bleeding. Management in other fields was also carried out in parallel, including oral surgery and internal medicine. The general condition of the patient general condition improved through multidisciplinary monitoring."
  },
  {
    "id": "multiclinsum_gs_en_479.txt",
    "fulltext": "A 24-year-old man with a history of intravenous drug use (IVDU), low educational level and socioeconomic status, who reported severe headache and paresthesia in the right side of the head. Upon admission to the hospital, the patient had normal vital signs, and no jaundice. Neurological examination did not show any evidence of impaired consciousness or strength, nor any signs of meningeal disease. Paraclinical tests showed the following results: aspartate aminotransferase (AST) 136 U/L, alanine aminotransferase (ALT) 68 U/L, positive IgG antibodies for HCV, 109,910 IU/mL viral load (amount of viral genetic material in a person’s blood) for HCV, normal CD3 count, and normal flow cytometry results. HIV infection was ruled out, and abdominal ultrasound and computed tomography (CT) scan showed no abnormalities.\n\nOne week later, he presented with generalized tonic-clonic seizures and somnolence. Lumbar puncture (LP) revealed high opening pressure (OP), and cerebrospinal fluid (CSF) revealed lymphocytic pleocytosis and high proteinorrachia (≥ 45 mg/dL). China ink test in the CSF showed encapsulated blastoconidia suggesting Cryptococcus, with positive Cryptococcal latex in 1/512 dilutions, so induction phase was initiated with amphotericin B and fluconazole. Cryptococcus gattii was observed in the last CSF culture report. Magnetic resonance imaging (MRI) of the brain revealed altered signal intensity in the head of the caudate nucleus and contrast-enhanced lesions in the splenium of the corpus callosum, lenticular nucleus, and anterior limb of the left internal capsule, consistent with CM.\n\nSince he was a non-HIV patient, treatment was started with amphotericin B deoxycholate at 1 mg/kg/day + endovenous fluconazole 800 mg/day for 4 weeks. Subsequently, consolidation therapy was initiated with oral fluconazole 800 mg/day, followed by indefinite fluconazole 200 mg/day. The patient exhibited clinical progression without neurological deficits and decreased OP (less than 20 cm H2O).\n\nOne month after discharge and 10 days after changing to 200 mg/day fluconazole, the patient reported severe headache and a generalized tonic-clonic seizure with dysarthria during the postictal phase. At that time, he had not yet started antiviral treatment against HCV. During hospitalization, he was disoriented and somnolent. LP showed OP of 43 cm H2O, and simple cranial CT revealed hypodensity in the left frontal cortical and subcortical areas, with CSF reporting proteinorrachy (158 mg/dL). Considering that this was a CM relapse, a combination of liposomal amphotericin B (5 mg/kg/day) and fluconazole (600 mg every 12 h) for 4 weeks was initiated, followed by consolidation and maintenance therapy with fluconazole 400 mg per day for 8 weeks (minimum) and at 200 mg per day for 6–12 months, respectively.\n\nIn the following days, new seizure episodes with disorientation, somnolence, fever, and emesis occurred. A new cranial CT scan showed ventriculomegaly, and MRI showed multiple nodular lesions in the brain parenchyma and near the basal nuclei. A biopsy was performed for these lesions, which showed negative PAS, Gomori, and Ziehl-Neelsen staining. However, fibrillar and neuroglial structures, fibrotic tissue and inflammation with lymphoplasmacytic infiltrate, well-defined granulomas, and perivascular inflammation were identified. Negative results were obtained in smears and cultures for Mycobacterium tuberculosis, cultures for bacteria and fungi, PCR for M. tuberculosis, and KOH. The patient continued treatment without neurological involvement, fever, headache, or seizures. LP showed an OP of 5 cm H2O and cranial CT scan during follow-up did not show ventriculomegaly, so the patient was discharged 3 months after readmission. Upon discharge, the patient was prescribed fluconazole 800 mg per day, and was followed by the infectious disease unit, and was prescribed with sofosbuvir/velpatasvir 400/100 mg per day for 12 weeks, as well as antiseizure management with levetiracetam. HCV load remained under 12 U/mL at one month of treatment, at the end of treatment, and 3 months after termination, so the antiviral treatment was considered successful. Brain MRI with contrast was performed during follow-up, which showed resolution of the Cryptococcal lesions.",
    "summary": "We report the case of a 24-year-old man who presented with meningitis secondary to Cryptococcus gattii infection. He had a history of IVDU and HCV infection, was HIV-negative and without antiviral treatment. The patient received adequate antifungal treatment during induction, consolidation, and maintenance phases. His condition relapsed, requiring dose adjustment, with an excellent response during clinical follow-up for both meningitis and HCV infection. A brain biopsy was requested during relapse to rule out other co-infection."
  },
  {
    "id": "multiclinsum_gs_en_545.txt",
    "fulltext": "A 42 year-old patient was referred to our tertiary cancer center with a history of recurring seroma of the left breast. The patient had undergone bilateral breast implant removal with partial capsulectomy 11 months prior to her first visit at our institution. The patient presented with no notable comorbidities, and had a history of bilateral breast augmentation in the submuscular plane with cosmetic indication at age 21 in the year 2003. No information could be found regarding the type of implants she had originally received. The patient returned to the same surgeon in 2008 complaining of bilateral seroma, to undergo a first bilateral breast implant replacement with textured anatomical implants of 425 cc (Sebbin LSA TF 425). In 2013, she underwent a second implant replacement procedure to increase the size with 480 cc implants from the same manufacturer (Sebbin LSA TF 480). In 2017, the patient returned for a check-up where she complained of pain and breast volume increase bilaterally. At the time, she had received an ultrasound scan which identified periprosthetic effusions bilaterally, with no lymphadenopathy or palpable masses in the breast regions. The effusions were drained without analysis, but recurred over the years, when the patient sought help from the same surgeon and underwent a third revisional procedure in 2022, with a bilateral breast implant removal and sampling of the anterior periprosthetic capsule. The surgeon sent two specimens from the right side (9 × 1 cm and 3 × 3 cm) and one from the left (2 × 1 cm). Histopathological report of the specimen found ‘Acellular amorphic proteinaceous material’ on the right side, and ‘Sclero-hyaline fibrous tissue with lymphocyte-monocyte inflammation, requiring correlation with the clinical presentation’ on the left side. Despite the explantation, seroma still recurred on the left side, and was sent for cytopathological testing which identified ‘a population of atypical pleomorphic cells with irregular contours suggestive of a lymphoproliferative process with CD30+ elements’ for which further diagnostic testing was advised. For this reason, the patient sought treatment at our institution where the case was managed by a multidisciplinary team (MDT) featuring a plastic surgeon, an hematopathologist, a hematologist, an oncologist, a radiotherapist, a surgical oncologist, and a breast imaging radiologist. The original histological specimen from the capsule sampling was reviewed by a hematopathologist from our referral center, who identified occasional sparse large atypical CD30+ cells that were deemed compatible with BIA-ALCL diagnosis. Anaplastic cells presented the following phenotype: CD30+, CD3-, CD7-, CD5-, CD4-, CD8-, Granzyme B+/-, TIA1-, ALK1-, PAX5-, CD79a-, CD68-, CD15-/+. The patient received an ultrasound scan with fine-needle aspiration cytology of the recurring effusion which confirmed an atypical CD30+ lymphoproliferative process. Total body scanning with positron emission tomography/computerized tomography (PET/CT) was performed in a different facility in closer proximity to the patient’s domicile, revealing a 67 × 20 mm area of seroma in the left breast region with focal 18F-FDG (Fluorodeoxyglucose) uptake (SUV max 1.8). No other areas of uptake could be located in all other explored body segments. The patient also received magnetic resonance imaging (MRI) of both breasts with contrast medium to complete preoperative staging, confirming the seroma of the left side. Slides of the specimen from the previous surgery were reviewed by the hematopathologist who deemed the findings sufficient for identifying BIA-ALCL with early infiltration of the periprosthetic capsule (pT2 according to the proposed MD Anderson-TNM staging system). Three weeks after the initial visit, the patient underwent radicalization surgery with en-bloc capsulectomy containing only 150 cc of serous effusion without implant. The liquid contents were sent for culture and cytopathological testing while the solid specimen was sent for histopathological examination. Additionally, the patient underwent sentinel lymph node biopsy of 2 axillary nodes identified preoperatively through segmental lymphoscintigraphy. Lymph nodes presented chronic reactive silicone-associated lymphadenopathy with no signs of lymph node metastasis. Histology report of the capsule revealed cell aggregates infiltrating the periprosthetic capsule, but clear resection margins and no signs of infiltration beyond the capsule. As such, the patient received a stage IC (pT3pN0M0). Post-operative course was uneventful, and no further adjuvant treatments were deemed necessary by the MDT. She continued her stringent monitoring protocol, with post-op PET/CT at 6, 12 and 18 months from surgery showing no signs of local or distant disease recurrence. As it stands, the patient is still continuing her follow-up visits and scans, with a disease free survival beyond 18 months.",
    "summary": "We describe the case of a 42 year-old woman with a history of bilateral breast augmentation for cosmetic purposes 21 years prior, who developed recurring seroma of the left side. She sought help from her first surgeon who performed 2 breast implant exchange procedures placing textured devices and finally a bilateral breast implant removal over the course of two decades. The patient did not receive capsulectomies in the previous implant exchanges, and received sampling from the anterior capsule in the last procedure, where BIA-ALCL was diagnosed on the left side. She was referred to a tertiary cancer center where preoperative workup confirmed presence of local residual disease. Following multidisciplinary team management, she underwent revision of en-bloc capsulectomy of the left side without need for additional treatments. Post-operative course was uneventful with no signs of local recurrences at 18 months follow-up."
  },
  {
    "id": "multiclinsum_gs_en_46.txt",
    "fulltext": "21-year-old primigravida mother with no medical history. Early pregnancy check-up complicated with threatened preterm labour at 31 weeks, so she received full antenatal corticosteroid treatment. She presented hypertensive pregnancy with preeclampsia-eclampsia syndrome and pregnant women's cholestasis in the third trimester, which was treated with ursodeoxycholic acid. Infectious pregnancy routines with no significant elements, no history of HSV infection, either before or during pregnancy. Spontaneous onset of labour, termination of pregnancy by caesarean section due to unstable foetal condition. Newborn male, 3,000 g birth weight, good adaptation to extrauterine life, discharge to home at 4 days of life with exclusive breast feeding. At 8 days of life, he was seen in the paediatric emergency department for oedema of the eyelids and bilateral ocular discharge of 48 hours' evolution. Physical examination highlighted significant bilateral oedema of the eyelids that prevented visualisation of the conjunctiva; redness, local heat and bilateral ocular discharge of pus, with no skin lesions. Temperature on admission was 36.7°C, physical examination with no significant elements. Diagnosis of neonatal ophthalmia was made and hospital admission was requested with culture of ocular discharge, PCR for Chlamydia, Gonococcus and HSV types 1 and 2. Treatment was initiated with a dose of 100 mg/kg intravenous Cefotaxime, 20 mg/kg/day Azithromycin and 2 mg/kg/day Tobramycin ophthalmic, every 6 hours. At 24 hours, a positive result for HSV-1 was received, so treatment was initiated with 20 mg/kg/day Aciclovir intravenous, every 8 hours, discontinuing antibiotic treatment. During the course of the disease, he remained asymptomatic from a neurological point of view and without skin lesions, with a clear improvement in ocular discharge and oedema of the eyelids after the treatment was initiated. The haemogram, liver profile, azotaemia and creatinine were normal. The cerebrospinal fluid analysis showed a normal cytochemical study, negative PCR for HSV, negative multiplex and negative culture. The cerebrospinal fluid analysis was not repeated. The PCR in blood, nasopharynx and rectum was negative for herpes virus. At 72 hours, an eye fundus examination was performed, showing bilateral epithelial corneal ulcer, adding to the treatment of Aciclovir topical and artificial tears. He completed 14 days of intravenous Aciclovir, with a normal eye fundus examination, without corneal ulcer. At 22 days of life, he was discharged with suppressive treatment with 60 mg/kg/day oral Aciclovir, control with paediatric and ophthalmologist outpatients.\n",
    "summary": "8-day-old newborn with no significant history, who presented with edema and erythema of the eyelids, accompanied by bilateral ocular discharge. A herpes virus type I infection was diagnosed by PCR technique, without elements of disseminated disease or central nervous system involvement. He received a full course of intravenous acyclovir with complete clinical improvement.\n"
  },
  {
    "id": "multiclinsum_gs_en_260.txt",
    "fulltext": "A term boy baby with birth weight of 3 kg was delivered by caesarean section in view of fetal distress. He cried immediately after birth. Routine care was given and at 10 min of life, he was noticed to have a low SpO2 (oxygen saturation) reading of 75–80%. So, he was started on oxygen by head box at 5 L/min. He had good respiratory efforts with mild tachypnea. As he continued to have low SpO2 even after a trial of both 5 L/min of head box oxygen and T piece resuscitator PEEP (positive end expiratory pressure) with 6 cm of water with FiO2 (inspired oxygen fraction) 100%, he was intubated and started on positive pressure ventilation. Baby was shifted to the Neonatal Intensive Care Unit for further management.\n\nEven after mechanical ventilation in synchronized intermittent mandatory ventilation (SIMV) mode with maximum stabilizing pressures of PEEP 6 cm and peak pressure 20 cm of water and adequate sedation, the maximum SpO2 attained was 80%. He had cyanosis and features of poor perfusion (tachycardia and prolonged capillary refill time). So, the baby was started on inotrope support after a bolus of Normal Saline. Initial differentials considered were septic shock, pneumothorax, lung malformations, and cyanotic heart disease. Blood culture was done and baby was started on first line antibiotics. Chest X-ray showed normal cardiac shadow and normal lung fields. Echocardiogram was done which ruled out persistent pulmonary hypertension and structural heart disease.\n\nArterial blood gas done after 1 h of ventilation (at 2 h of life) showed pH of 7.5, paCO2 19.1 mmHg, paO2 of 199 mmHg, lactate 4 mmol/L, bicarbonate 18.1 mmol/L and base excess of −3.6. As there was unexplained hyperoxemia despite low SpO2 and persistent cyanosis, methemoglobinemia was suspected which was confirmed by high metHb (methemoglobin) level (7.6%). Serial blood gas values showed hyperoxemia and high metHb levels. He was given 3 mg intravenous single dose methylene blue and started on oral ascorbic acid 300 mg once daily. His ventilator settings were slowly weaned and he was extubated after 16 h to room air. Inotropes were also tapered and stopped within 24 h. As his blood culture had no growth, antibiotics were stopped after 2 days. From day 2 of life, he was maintaining a saturation of 75–85% in room air.\n\nThere was no relevant perinatal and family history. Glucose-6-phosphate dehydrogenase level and hemoglobin electrophoresis were also normal. Since day 3, he was on orogastric feeds and was otherwise stable except for persistent cyanosis. After sending genetic test (clinical exome), he was discharged on day 9 while on direct breast feeds as he continued to be stable except for cyanosis and low SpO2 reading (80–85%) in room air with normal paO2.\n\nAfter discharge, the baby was under regular follow up and by 2 months of life, his saturation in room air was 88–90% and by 4 months SpO2 >92% on room air with no cyanosis. The clinical exome showed mutation in gamma chain of fetal hemoglobin – amino acid substitution of Tyrosine for histidine at codon 63 (p.His63Tyr) due to missense mutation in HBG2 gene (chr11:g.5275647G>A). Once we received the genetic test result, oral ascorbic acid was stopped and the parents were counselled about the excellent prognosis of this rare disease condition. At 5 months of life, he was well, acyanotic and his metHb level was normal.",
    "summary": "We report a newborn baby presented with cyanosis and desaturation right from birth, later found to have methemoglobinemia and started medication. Genetic evaluation revealed a mutation in the gamma chain of fetal haemoglobin (HbF) causing abnormal hemoglobin. Physiologically significant mutations in gamma-globin genes cause symptoms in the fetus and neonate that gradually abate in the first few months of life."
  },
  {
    "id": "multiclinsum_gs_en_118.txt",
    "fulltext": "69-year-old male patient with a history of arterial hypertension, type II diabetes mellitus and arthrosis, presented to the emergency department of the Franco Ravero Zunino Hospital (HFRZ) on March 27, 2024 with a 3-day history of a condition characterized by right molar pain with subsequent increase in right facial volume and periorbital cellulitis, caused by a fall of 4 days before admission. The patient's medical records revealed a history of poor metabolic control associated with diabetic ketoacidosis in 2022 and diabetic foot.\n\nPhysical examination revealed exacerbated pain, oedema and erythema in the right periorbital region, associated with necrotic lesions in the right infraorbital region linked to chemosis, purulent exudate in the right eye, limited opening of the eye and decreased visual acuity.\n\nIntraoral examination revealed the absence of teeth, the presence of multiple root remains and poor hygiene control. During his stay in the emergency department, the patient was reevaluated and a rapid progression of the necrotic lesions was observed, which increased in size and compromised the right geniana and palpebral region.\n\nLaboratory tests revealed leukocytosis with neutrophilia (23,400 mm3), procalcitonin (PCT: 10.14), elevated inflammatory parameters (CRP: 44.4), hyperglycemia (412 mg/dl) and ketonemia (+++). The gas results were consistent with metabolic ketoacidosis associated with sepsis of cutaneous focus. The emergency images, performed by computed axial tomography (TAC) with contrast at the admission of the patient, confirm the presence of oedema and periorbital inflammatory changes preseptal in relation to the right zygomatic region, without postseptal orbital compromise. Given the clinical presentation of the patient and his general medical condition, admission to the ICU was decided for intrahospital monitoring and management.\n\nIntrahospital management was initiated with empirical antibiotic therapy with ampicillin/sulbactam, supplemented with cloxacillin and surgical cleansing in the central ward. Under general anaesthesia with orotracheal intubation, an approach was performed that involved the hospital's maxillofacial surgery team. Extensive surgical debridement was performed, comprising skin and subcutaneous cell tissue, which implied the extirpation of all necrotic and devitalised tissue. The extirpated tissue was sent for biopsy and culture. During the postoperative period, the patient remained in the ICU and evolved adequately, afebrile, with a decrease in facial oedema and resolution of acute renal failure.\n\nMicrobiological analysis of the patient's samples revealed a polymicrobial infection with the identification of Staphylococcus aureus, Staphylococcus lugdunensis and Staphylococcus epidermidis. Based on the microbiological results, the infectious disease team recommended continuing empirical treatment with ampicillin/sulbactam and cloxacillin. After four days, a new evaluation was performed by the infectious disease team, which suggested discontinuing empirical treatment with ampicillin/sulbactam and initiating empirical therapy with cotrimoxazole and cloxacillin.\n",
    "summary": "We present the case of a 69-year-old patient with uncontrolled diabetes mellitus, who came to the emergency department with a 3-day history of right molar pain with subsequent right facial swelling and periorbital cellulitis. The case showed a cyclical evolution influenced by the existing comorbidities, so the patient was subjected to both surgical and medical treatment by a multidisciplinary team. In addition, we performed a literature review on FN.\n"
  },
  {
    "id": "multiclinsum_gs_en_2.txt",
    "fulltext": "35-year-old man, occupation: sandblaster for eight years. He joined the guard in a bad general condition, thinner, saturating 88% to the ambient air with dyspnea functional class III/IV. As background he reported pulmonary tuberculosis diagnosed a month ago by bronchoalveolar lavage, in treatment with four anti-fungal drugs (HZRE), former smoker of 5 packs/year, former cocaine consumer and recent diagnosis of ES, in treatment with meprednisone 20 mg/day.  In the chest radiograph, a left pneumothorax grade I was observed, for which a pleural drainage tube was placed. In the thoracic tomography he presented confluent hyperdense masses, thickening of the pulmonary interstitium with a pattern of non-specific interstitial pneumonia (NSIP), associated with bilateral volume loss and mediastinal adenomegaly. Based on the work background and the tomographic findings, the diagnosis of pulmonary silicosis complicated by secondary interstitial pulmonary disease was made. Due to the advanced clinical stage, it was not possible to carry out complementary studies to confirm the diagnosis or pulmonary function studies. As therapeutic measures, antifungal treatment was continued, chronic home oxygen therapy was indicated and he was referred to a specialist office of interstitial diseases and rheumatology to continue the interdisciplinary management of the patient. Immune suppressive treatment could not be carried out due to the active infection that the patient was suffering. After 10 months the patient was re-admitted for respiratory insufficiency and deterioration of the general state. He died under palliative care. The case was discussed in an ethics committee, and with the approval of the patient and family.\n",
    "summary": "We present the case of a 35-year-old man, a sandblaster for eight years, recently diagnosed with pulmonary tuberculosis and systemic sclerosis, who was admitted with a picture of dyspnea and poor general condition. A chest radiograph was performed, which showed a pneumothorax grade I. A thoracic tomography also showed confluent hyperdense masses associated with a pattern of non-specific interstitial pneumonia (NSIP), findings consistent with complicated pulmonary silicosis. Due to the advanced clinical stage, invasive diagnostic studies and pulmonary function studies could not be performed. As an initial treatment, a pleural drainage tube was placed, antiphimic treatment was performed and chronic home oxygen therapy was indicated. The patient was referred to interstitial diseases and rheumatology consultations for multidisciplinary management, although the infectious picture contraindicated the possibility of an immunosuppressive treatment. Finally, the patient died under palliative care.\n"
  },
  {
    "id": "multiclinsum_gs_en_258.txt",
    "fulltext": "A 27-year-old female patient presented with right eye redness, itching, and burning four hours after receiving her COVID-19 mRNA booster vaccine, third total dose. She used artificial tears, but her symptoms were unchanged on the following day which prompted her to seek an ophthalmological exam. She denied photophobia, blurry vision, double vision, foreign body sensation, epiphora, visual flashes, or visual floaters. There were no prior similar episodes with the same vaccine prior two doses. The left eye was asymptomatic and unaffected. The patient’s past medical history was significant for myopic astigmatism of both eyes, bilateral allergic conjunctivitis, allergic rhinitis, Crohn’s disease, and mild intermittent asthma.\n\nOn ophthalmic examination best corrected visual acuity remained 20/20 bilaterally. Intraocular pressures measured at 15 mmHg in the right eye and 16 mmHg in the left eye. The right conjunctiva had 2+ injection that blanched with phenylephrine drops. There was no scleral injection, no scleral tenderness, and no physical irritation adjacent to the episcleritis area (eg, no trichiasis). The anterior chamber of the right eye appeared deep and quiet. The associated episcleritis described. The remainder of the anterior and posterior segments clinical exam was unremarkable. The patient continued artificial tears and started ibuprofen 200 mg three times daily for one week. The patient adhered to and tolerated the described regimen and one week later, all ocular symptoms and signs resolved.\n\nThe patient was satisfied by the care she received. She was relieved that her symptoms resolved, and her final vision was not affected. She plans to double check with her rheumatologist before future COVID-19 booster vaccine doses. Written informed consent was obtained from the patient for publication and for use of data and images.",
    "summary": "A 27-year-old female presented with a 1-day history of right eye redness, itching, and burning. Patient reported developing these symptoms within 3-4 hours after vaccination. Her past medical history was relevant for Crohn's disease. Ophthalmic examination revealed right 2+ conjunctival injection that blanched with phenylephrine drops. Otherwise, her ophthalmic exam was unremarkable. The patient was started on artificial tears and ibuprofen 200 mg three times daily for one week. After one week all symptoms resolved, and ophthalmic examination was back to baseline."
  },
  {
    "id": "multiclinsum_gs_en_551.txt",
    "fulltext": "23-year-old female patient, ASA I, comes to the Health Center of the Peruvian University of Applied Sciences (CUS-UPC) to place an implant in the edentulous area of the 1.6. During the evaluation, the patient reports that a few months ago the first upper right molar was fractured and, as a result, the atraumatic extraction of said tooth was performed.\n\nFollowing clinical inspection, the absence of tooth 1.6, thin gingival phenotype and decreased height of edentulous ridge Seibert type II 13 were observed. Tomographically, the height of the residual bone ridge was measured in relation to the floor of the maxillary sinus (6 mm) and the width of the bone crest at the cervical (11.20 mm), middle (11.80 mm) and apical (12.40 mm) levels, indicating the presence of an ovoid maxillary sinus, according to Nie et al. Surgical planning was performed for a maxillary sinus elevation with transcrestal approach and the placement of a 4.8 x 8 mm dental implant.\n\nThe surgical procedure was initiated as follows:\n\n• Asepsis and antisepsis\n\n• Infiltrative anesthesia technique for vestibular and palatine edentulous area 1.6 using 2 cartridges of 2% lidocaine with epinephrine 1:80,000.\n\n• Supracrestal incision in the edentulous area 1.6 and sulcular incisions in mesial of the tooth 1.7 and distal of the tooth 1.5.\n\n• Partial thickness flap was lifted and the surgical guide was tested to perform the milling sequence to a length of 6 mm, leaving 1 mm distance to the floor of the maxillary sinus, which was checked with the depth gauges, according to the diameter of the milling cutter used during the osteotomy. The milling sequence was performed to the 3.5 mm diameter milling cutter and then the 2 mm lift of the maxillary sinus was performed with the transcrestal approach technique using an osteotome, until a length of 8 mm was reached.\n\n• Implant placement φ 4.8 x 8 mm (Bone Level tapered, Straumann®) and locking screw, both with an insertion torque of 20 N.\n\n• Suture with interrupted points with polyglycolic acid 5/0 and wash the surgical area with 0.09% saline.\n\n• Post-operative radiograph of the implant in the edentulous area 1.6.\n\n• Indication to take amoxicillin 500 mg + clavulanic acid 125 mg every 8 hours for 7 days, ketorolac 10 mg every 8 hours for 3 days, cetirizine 10 mg every 24 hours for 3 days and chlorhexidine 0.12%, 2 times a day, for 10 days. Among the post-surgical indications, the patient was instructed to rest completely, without physical effort, eat soft food, not blow her nose, not suck liquids for two weeks, not immerse her head in water, not sneeze or cough with her mouth open, keep her head elevated and apply ice packs for the first 4 hours.\n\nA post-surgical check was performed 7 days later, which showed soft tissue in the process of healing, so stitches were removed and washed with 0.9% saline, and a control tomography was performed that showed the elevation of the maxillary sinus, approximately 2.83 mm. Likewise, post-surgical checks were performed 35 and 56 days later, in which soft tissue was found in the process of healing.\n",
    "summary": "A sinus lift without bone grafting was performed in a 23-year-old female patient who required a dental implant in the edentulous area of the 16th tooth. The clinical and tomographic evaluation allowed planning and performing the sinus lift through the transcrestal approach and without the need for bone grafting. The residual ridge of 6 mm allowed the simultaneous placement of a dental implant. After 6 months of tomographic follow-up, before the prosthetic load, a vertical bone height of 8.83 mm was achieved, resulting in a vertical bone gain of 2.83 mm. In addition, adequate integration of the dental implant without postoperative complications was observed.\n"
  },
  {
    "id": "multiclinsum_gs_en_224.txt",
    "fulltext": "A 29-year-old female patient presented to the urology department with intermittent right flank pain for one year and occasional urinary burning sensation without hematuria; her overall condition was stable. The patient showed no signs of cough, fatigue, weight loss, had no previous surgeries, but had frequent sheep exposure. Despite normal laboratory tests, the echinococcus antibody test yielded a positive result. Subsequent abdominal ultrasound revealed a large mid-anterior cystic lesion in the right kidney, measuring approximately 63 mm with thick walls and no significant doppler flow. Contrast-enhanced CT imaging in both transverse and coronal views revealed a cystic mass with septations on the lateral side of the right kidney, featuring a thick, regular wall that enhances with contrast. This lesion is classified as Bosniak category 4, with coronal imaging showing involvement of the collecting system and contact with the liver. HC was suspected based on the clinical and radiological evaluations. The chest X-ray findings were unremarkable, with no evidence of pulmonary cysts. Following a three-month regimen of albendazole 400 mg administered twice daily, the patient underwent surgical intervention. An open procedure was performed through a right subcostal Kocher incision, resulting in right nephrectomy and partial liver resection due to adhesions. The specimen, weighing 372 g and measuring 13 × 8 × 6 cm, showed a large white cyst with thin walls containing a detached membrane, affecting the renal calyces and pelvis. The final diagnosis was HC of the kidney accompanied by chronic pyelonephritis. Post-operative laboratory tests showed normal results, with stable urinary output and vital signs. The urinary catheter was removed after 24 hours due to adequate urinary output (2 L). The kidney drain was taken out after 3 days, with drainage volumes of 200 ml, 100 ml, and none on consecutive days. The patient returned to normal activities without complications.",
    "summary": "A 29-year-old female with intermittent right flank pain and urinary burning was diagnosed with a Bosniak category 4 hydatid cyst (HC) after positive echinococcus antibodies. Imaging confirmed the diagnosis, leading to a three-month albendazole treatment followed by right nephrectomy and partial liver resection. Histopathological analysis confirmed HC and chronic pyelonephritis. The patient had an uneventful recovery and returned to normal activities."
  },
  {
    "id": "multiclinsum_gs_en_428.txt",
    "fulltext": "This is a case of a 12-year-old male adolescent who was referred to HUCSH from the Oromia region’s Guji zone with complaints of bloody diarrhea lasting for one week and occurring 8–10 times per day, which had intensified in the days leading up to his presentation to our hospital. He also had a 2-week history of vomiting of ingested matter 3–5 times per day, which became bilious and more frequent over the last two days prior to his admission to our hospital. He also had a history of high-grade intermittent fever, chills, rigors, arthralgia, and a significant but unquantified weight loss during the two-week period.\n\nFurther questioning revealed that he had previously swum in a pond and had a self-limited itchy skin condition. The family said that similar cases had occurred in their town that resolved with medications provided at a local health center; however, their child’s situation was unusual and more serious despite the fact that he was treated likewise.\n\nHe was started on metronidazole, ceftriaxone, cimetidine, Vit B complex, and Vit K with the impression of fulminant viral hepatitis, schistosomiasis and acute kidney injury (AKI), and was referred to Hawassa University Comprehensive Specialized Hospital (HUCSH) for inpatient care and further workup for the above complaints.\n\nPhysical examination: General appearance: acute sick looking; Vital signs: all were within normal limits with the exception of the temperature, which was 37.8 degree Celsius.\n\nAbdominal examination revealed tenderness in the epigastrium area and hepatomegaly, with a total liver span of 11 cm. The rectal examination was normal. There was no evidence of lymphadenopathy. The rest of the exam was also unremarkable.\n\nThe investigation results for malaria (Rapid Diagnostic Test/blood film), antinuclear antibody (ANA), serology for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV were all negative.\n\nThe total and direct serum bilirubin were 2.33 mg/dL and 1.69 mg/d, respectively (elevated), and subsequently dropped to 1.84 mg/dL and 1.53mg/dL after 3 days, respectively. The serum albumin was in the normal range,3.9 g/dl.\n\nStool Examination revealed ova of S. mansoni and Trophozoite stages of E. histolytica.But the stool antigen examination for H. pylori infection was negative.\n\nAbdominal ultrasound revealed hepatomegaly with hypodense hepatic nodules likely due to acute hepatitis, and also significant wall thickening and edema of the colon and the small bowel loops likely due to enterocolitis.\n\nThe results of complete blood count (CBC) were as follows: WBC = 12 *103(elevated), Neutrophil = 67.8%, Lymphocyte = 22.5%, Eosinophil = 9.7%, Platelet = 92 *103(Low), other parameters were all normal.\n\nAspartate transaminase (AST) was 137 U/L on the day of admission (elevated 2.5 times) and 35U/L on the 3rd days, whereas the alanine transaminase (ALT) was 110 U/L on the day of admission (elevated 2.5 times) 41U/L on the 3rd days.\n\nCoagulation profile (all were elevated): PTT=68.2.4 seconds, PT = 21.1seconds, INR = 2.41, after 1 week PT = 16.4 seconds =1.17 (normal).\n\nThe renal function test revealed creatinine of 1.5 mg/dL and urea of 85 mg/dL, with BUN/Cr ratio of 26.5, suggestive of prerenal azotemia (from the vomiting and poor intake he had).\n\nUrine analysis: Leucocyte = +1, WBC = 7-10/HPF, Protein = +2, Ketone = +1, and the rest of the urinalysis results were unremarkable. It suggests urinary tract infection, and perhaps kidney insults from Schistosoma mansoni.\n\nThe serum electrolytes and random blood sugar were all in the normal ranges.\n\nFecal Calprotectin (CLIA)=7.68 microgram/g [less than 50 is normal (negative)]. It helps to differentiate irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), monitor the effectiveness of IBD therapy, and detect IBD relapse.\n\nColonoscopy: After informed consent, video pan colonoscopy was done smoothly up to the cecum and revealed diffuse colon mucosal inflammation with intense rectal inflammation with extensive ulceration and exudates and loss of vascular patterns. Rectal biopsy was taken with the impression of ulcerative colitis r/o IBD with the recommendation of fluid and electrolyte and antibiotics with follow histology and laboratory tests for differential diagnosis and treatment.\n\nThe macroscopic examination (gross description): multiple gray white to gray brown soft tissue fragments,0.5 cm, in aggregate. Note: Due to the loss of elastic tension and to formalin shrinkage, the measurements in the gross description may be less than those taken at the time of surgical removal.\n\nMicroscopic description of biopsy: Section show colonic type mucosal fragments with diffuse lymphoplasmacytic and eosinophilic infiltrates in the lamina propria associated with mild crypt distortion, fibrosis, areas of hemorrhage and foci of neutrophilic infiltrates. There are few Schistosoma eggs and focus of giant cell reaction.\n\nThe final biopsy diagnosis was colon and rectum schistosomiasis.\n\nHe was admitted to our hospital for two weeks and was given prednisolone 2 mg/kg (ie, 30 mg po bid) and Praziquantel (40 mg/kg/day, ie, 2 tablets of 600 mg po/day). Serial determinations of liver and renal function tests and coagulation profiles were done. He also had repeated abdominal ultrasound exams, which all showed improvements over the previous results. He was then referred to a gastroenterologist for evaluation, where a colonoscopy and biopsy were performed, and schistosomiasis induced ulcerative colitis was confirmed, and he continued prednisolone 2 mg/kg (30 mg po bid) for another one month, and stopped being tapered over 2 months and the second dose of praziquantel (1200 mg) was also given within 1 month interval. Now, his clinical condition is apparently okay, and he is attending his school without any symptoms.",
    "summary": "This is the story of a 12-year-old male adolescent from the Guji zone of the Oromia regional state of Ethiopia who presented to Hawassa University Comprehensive Specialized Hospital (HUCSH) complaining of bloody diarrhea of 1 week associated with vomiting of ingested matter of 2 weeks. He also had history of fever, chills, rigors, arthralgia, and weight loss during a 2 weeks period. Further questioning revealed that he had previously swum in a pond and had a self-limited itchy skin condition. The family said that similar cases had occurred in their town that resolved with medications provided at a local health center."
  },
  {
    "id": "multiclinsum_gs_en_207.txt",
    "fulltext": "51-year-old male patient with a single relevant antecedent of gouty arthritis diagnosed 20 years ago, without treatment to date of the study. Consultation for clinical picture of four years of evolution characterized by burning type pain, insidious onset, located in the right hip, intensity 8/10 on the analogous scale of pain, not irradiated and accompanied by reduction in mobility arcs and functional limitation of the ipsilateral extremity. The physical examination is accompanied by a palpable mass at that level.\n\nHe brings a computed tomography (CT) scan of the abdomen showing a large lesion at the neck of the femur with a diagnostic impression of chondrosarcoma. Based on the findings of the history, physical examination and diagnostic imaging, a diagnosis of chondrosarcoma in the right proximal femur is made and additional imaging studies, such as magnetic resonance imaging (MRI) and a pelvic CT scan, are requested.\n\nHowever, the patient returned to the consultation with a worsening of the clinical picture, which was accompanied by a limitation of standing and walking with a cane, and also brought with him complementary imaging studies.\n\nA biopsy of the right femoral neck lesion was performed and the sample was sent for histopathological study. The result was obtained 15 days after the sample was taken and the lesion was described as follows: \"No elements of malignancy in the observed samples. Presence of gouty tophi in the observed samples\".\n\nAllopurinol and colchicine were initiated as pharmacological therapy and the patient was closely monitored by the oncological orthopaedics team. The clinical picture improved with a reduction in pain in the right hip joint and a marked decrease in the volume of the mass and progressive recovery of the mobility arcs.\n\nFinally, a new control MRI was requested, which showed severe right coxofemoral synovitis with gouty tophi. The control radiograph also showed evidence of gouty tophi in the right hip without joint space involvement. After six months, this patient continued to be monitored closely, with residual limitations in mobility arcs, which had improved with outpatient physiotherapy.\n",
    "summary": "51-year-old male patient with a history of gouty arthritis; who has a clinical picture of approximately four years of evolution, characterized by pain in the right hip of intensity 8/10 on a pain analogue scale, without irradiation, associated with functional limitation characterized by reduction of mobility arcs and impossibility of standing. Imaging studies are performed which are suggestive of a tumour lesion at the level of the proximal femur with characteristics of malignancy, for which a biopsy and subsequent histopathological diagnosis of gouty tophi are performed.\n"
  },
  {
    "id": "multiclinsum_gs_en_48.txt",
    "fulltext": "29-year-old female patient with a history of fever, vomiting and abdominal pain in the previous week, diagnosed with influenza B with normal abdominal-pelvic CT. She began having several repeated epileptic seizures, so a cranial CT and MRI were performed with no relevant findings. The patient's condition worsened and she went into status epilepticus. A cranial CT was performed 72 hours after the previous imaging tests, showing multiple confluent cortical and subcortical white matter lesions in the parieto-occipital and frontoparietal bilateral areas. The study was completed with a cranial MRI, which, in addition to the described white matter involvement, showed multiple bilateral millimetric foci of leptomeningeal and cortical enhancement. There was no evidence of involvement of the basal ganglia or the brainstem, nor were there any foci of diffusion restriction.\n\nA lumbar puncture was performed with normal results. During admission, orange-coloured urine was observed and a study of porphyria was performed due to the suspicion of acute porphyria, which was positive (porphobilinogen, ALA and porphyrin urine tests). Treatment with haematin was initiated, the colour of the urine was normalised and progressive reconnection with the environment was observed, allowing sedation to be suspended after 20 days of admission. The patient was discharged without neurological sequelae.\n",
    "summary": "29-year-old male presented to the emergency department with abdominal pain, vomiting, and seizures. A computed tomography (CT) and magnetic resonance imaging (MRI) of the brain were performed to determine the underlying cause, which confirmed the presence of a parieto-occipital lesion. Laboratory and urine tests were positive for porphyria, with improvement and resolution of the condition following treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_563.txt",
    "fulltext": "A 65-year-old man was diagnosed with pulmonary adenocarcinoma, then treated with chemotherapy. The cancer metastasized, and the patient was diagnosed with end-stage lung cancer. Cancer pain was treated with oral opioid therapy. Metastasis of the cancer caused obstructive jaundice and cholangitis, and the patient experienced septic shock. The attending physician performed emergent endoscopic biliary stent placement, in order to treat obstructive jaundice. The patient was medicated with continuous infusion of noradrenaline (0.2 μg/kg/min) through a peripheral vein, in order to maintain blood pressure. He underwent repeated placement of peripheral venous catheters, such that it became difficult to identify adequate peripheral veins for placement and maintenance of indwelling catheters. In the context of this treatment, the patient's congestive heart failure continued, which caused ascites and edema of the lower extremities.\n\nThe patient experienced orthopnea and could not sleep at night. The attending physician requested that the anesthesiologists secure a reliable venous line. The anesthesiologists checked the patient's groin and thighs; they excluded the femoral vein as a candidate for central venous access due to massive edema of the thighs. The anesthesiologists attempted to allow the patient to assume the supine or reverse Trendelenburg position; however, these positions caused worsening of the patient's dyspnea. The patient could solely tolerate the sitting position. The anesthesiologists then discontinued attempts to catheterize via the internal jugular and subclavian veins, because of the risk of air embolism during central venous catheterization of the patient in the sitting position.\n\nThe right subclavian vein was suspected to exhibit narrowing, based on computed tomography scan images. Thus, the anesthesiologists chose the left arm for insertion of a PICC, and found that the medial brachial vein exhibited sufficient size (diameter 4 mm) to place a PICC with ultrasound examination. The anesthesiologists allowed the patient to assume the sitting position, and placed the patient's arm on an over-bed table. PICC placement (4.5 Fr, double lumen, Argyle PICC Kit, Nippon Covidien, Inc., Tokyo, Japan) was performed using ultrasound guidance (6-15 MHz, SonoSite Edge, SonoSite Japan Co., Tokyo, Japan) with maximal sterile barrier precaution. Cannulation was performed without complications. The technique is summarized as follows.\n\n(1) The patient was allowed to sit on chair with a backrest.\n(2) The patient's stability was ensured (e.g., with aid from an assistant or nurse).\n(3) The patient's arm was raised and cleaned with disinfectants (1% chlorhexidine alcohol).\n(4) The adjustable over-bed table was covered with a disinfected drape.\n(5) The patient's arm was placed on the table.\n(6) The arm was allowed to abduct approximately 90° via adjustment of the height of the table.\n(7) The operator wore a cap, mask, and surgical gown (maximal sterile barrier precaution).\n(8) The assistant placed a towel between the drape and table to ensure that the medial side of the patient's arm faced upwards.\n(9) The ultrasound probe was covered with a sterile plastic cover.\n(10) Local anesthetic (1% lidocaine 3 mL) was injected with a 25-G needle.\n(11) A 20-G over-the-needle catheter (48 mm in length) was inserted into the skin.\n(12) The vein was accessed using a short-axis out-of-plane approach; the anterior wall of the vein was penetrated using a long-axis in-plane approach.\n(13) The PICC was placed using the modified Seldinger technique.\n\nThe anesthesiologists attempted to locate the catheter tip in the inferior vena cava or upper right atrium; however, the catheter tip could not proceed to the vena cava. Therefore, the catheter tip was placed in the left brachiocephalic vein. The left brachial vein and left subclavian vein appeared to maintain blood flow after PICC placement.\n\n\nContinuous infusion of noradrenaline and opioid therapy was initiated through the PICC. The patient's orthopnea was slightly ameliorated, and he could sleep at night; however, he remained in the sitting position. The patient died 11 days after insertion of the PICC due to respiratory failure. The PICC was used without difficulty until his death.",
    "summary": "Patient concerns:\nA 65-year-old man was diagnosed with end-stage lung cancer. He had experienced septic shock and was medicated with continuous infusion of noradrenaline through a peripheral vein, in order to maintain sufficient blood pressure. However, indwelling peripheral venous catheters were difficult to place and maintain.\n\nDiagnosis:\nThe patient experienced orthopnea due to congestive heart failure and could not assume any other position.\n\nInterventions:\nAn anesthesiologist performed PICC placement while the patient was in the sitting position, using ultrasound guidance.\n\nOutcomes:\nThe patient's orthopnea was slightly ameliorated, and he was able to sleep at night.30732193"
  },
  {
    "id": "multiclinsum_gs_en_573.txt",
    "fulltext": "A 28-year-old woman with a university education and a stable job is described, in treatment for major depression with a history of five attempts at suicide, treated with quetiapine, risperidone, sertraline and clonazepam. She was first seen in a low-complexity center for abdominal pain associated with vomiting, related to intentional ingestion of large amounts of paracetamol tablets. According to a rough estimate, the dose was 20 grams the day before and 10 grams the same day. Her laboratory showed elevated liver enzymes (TGO 3475 IU/L and TGP 2798 IU/L), a decrease in prothrombin time (PT 1%), and hyperlactatemic metabolic acidosis. Treatment with activated charcoal and N-acetylcysteine was initiated. At 24 hours of the event, the patient was referred to the intensive care unit of our center for a grade III encephalopathy, tachycardia, hypotension, and oliguria. A tracheal intubation was performed, infusion of vasoactive drugs (noradrenaline 0.08 gamma/k/h), haemodialysis (balance -1500), cultures and empirical antibiotic treatment with piperacillin/tazobactam. The admission laboratory showed a TP 10% (RIN 6.2), Factor V 5%, TGO 9711 IU/L, TGP 8030 IU/L, BT 6.5 mg/dL and hyperlactatemic metabolic acidosis (pH 7.25; pCO2 21 mm/Hg; PO2 74 mm/Hg; HCO3 9.1 mmol/L and lactate 12.7 mmol/L). FHF was diagnosed, Clichy4 score positive, King's College5 3 points, MELD6 34 points. In the computed tomography of the brain there were no signs of effect of mass or oedema. At the pulmonary level, consolidation in the right lung with predominance of the upper lobe. In the bronchoalveolar lavage, Staphylococcus aureus was isolated sensitive to methicillin, so the antibiotic treatment was adjusted. After 48 hours of admission and without progression of failure, enrollment in the emergency transplant list was decided.  At 24 hours of admission, the patient accessed an ideal cadaveric donor. The duration of the surgical procedure was 5 hours, with piggy-back explant technique with a cold ischaemia time of 6 hours and 30 minutes. She required 5 units of red blood cells, 10 units of fresh frozen plasma, 12 units of platelets and 16 of cryoprecipitate during the surgery. The patient evolved in the first 24 hours postoperative, with clinical and biochemical improvement (TP 82%, TGO 621 IU/L, TGP 1519 IU/L, total bilirubin 6.1 mg/dL, normalisation of the internal environment and lactate). At 48 hours she was able to disengage from mechanical respiratory support. On the fifth postoperative day she presented an isolated convulsive episode that subsided spontaneously, without the need for anti-convulsive drugs. She evolved favourably and remained under multidisciplinary follow-up with the mental health service where it was decided to grant hospital discharge while continuing psychiatric treatment in a rehabilitation center with ambulatory controls with the specialists involved. She is currently in her sixth year post transplant with adequate controls, good graft function and adherence to immunosuppressive treatment (tacrolimus XL and mycophenolate mofetil). She maintains strict follow-up by the psychiatric team and is on lithium, levomepromazine, quetiapine and sertraline. Informed consent was obtained in writing from the patient for the publication of this case and the accompanying images. A copy of the informed consent is available for review on request.\n",
    "summary": "A 28-year-old woman with a history of major depression and five prior suicide attempts deliberately ingested a significant amount of acetaminophen tablets. She developed fulminant liver failure and metabolic acidosis and underwent emergency liver transplantation due to the severity of her condition.\n"
  },
  {
    "id": "multiclinsum_gs_en_13.txt",
    "fulltext": "Patient information\nA 27-year-old man smoker was involved in a road accident; he felt from his motorbike without a helmet. The man drove the motorbike to the hospital and reported a headache and haemorrhagic wounds in the forehead.\n\nThe patient has no pathology history and works in a rural area.\n\nClinical findings\nAfter his admission to emergency room, he lost consciousness and suffered two convulsive seizures. On physical examination, the Glasgow Coma Scale was 6/15 (no eye opening, withdrawal in the face of pain, no verbal response) with bilateral mydriasis, haemodynamic distress and good saturation. A penetrating head injury was identified with a profuse intracranial haemorrhage.\n\nTimeline\nAfter a fall on a motorbike, the patient got back on his motorbike and immediately went to hospital, complaining of headaches and a bleeding forehead wound. He received emergency treatment to stabilize his hemodynamic and respiratory functions. He was then transferred unconscious the same day to a better-equipped center, where he underwent a CT scan and underwent successful surgery.\n\nDiagnostic assessment\nHis haemoglobin level was 6 g/dL and his blood group was O rhesus positive. The hospital had neither an intensive care unit nor a scanner. Penetrating head trauma complicated by intracranial haemorrhage leading to shock and seizures was the only diagnosis suggested. Vital prognosis based on clinical presentation was bad.\n\nTherapeutic intervention\nAn initial intervention consists of an intracranial packing through the cranial breach followed by a cephalic bandage which help stop bleeding. The treatment involved stabilisation of the cervical spine, orotracheal intubation with oxygen at 6 L per minute and an insertion of a Foley catheter. Two peripheral venous ports were used to administer NaCl 0.9 % 1000 CC, Geloplasma* 500 CC, Mannitol 20 % 250 CC; Phenobarbital inj 40 mg/2 ml: 100 mg, then Thiopental 250 mg: bolus of 100 mg × 2 due to other convulsive seizures; Amoxicillin + Clavulanic Acid injection 2 g; Gentamycin 160 mg intramuscularly. A tetanus serum of 1500 IU and a transfusion of 450 CC of blood were performed.\n\nThe patient was transferred unconscious to a team at a first-category hospital, free of intubation in a stable haemodynamic state.\n\nOn the first day following the transfer, the patient progressed well; he was conscious and able to walk, with no neurological, haemodynamic or respiratory distress. The CT scan revealed an acute bifrontal edematous, an haemorrhagic parenchymal contusion predominantly on the right, a layer of acute subdural haematoma (3 mm) on the left fronto-parieto-temporo-occipital region, a 5 mm left subfalcoral hernia, a discrete compression of the right lateral ventricle, an acute bifrontal superior subarachnoid haemorrhage, a depressed frontal fracture with osteomeningeal breach and a fracture of the third cervical vertebra with spinal cord compression. The patient underwent a successful operation at the first category hospital.\n\nFollow-up and outcomes\nThe post-operative period was marked by convulsive seizures, for which the patient was put on anticonvulsants with a good outcome.",
    "summary": "A 27-year-old man, smoker with no pathology history was involved in a road accident, falling from a motorbike without a helmet. In admission to our rural district hospital, the Glasgow Coma Scale during physical examination was 6/15 with bilateral mydriasis, haemodynamic distress and good saturation. A penetrating head injury was identified with profuse intracranial haemorrhage. Intracranial packing known in damage control neurosurgery to tamponade severe intracranial haemorrhage and which is a lifesaving neurosurgical manoeuvre was used. The patient was transferred unconscious to a first-category hospital, free of intubation and in a stable haemodynamic state. The post-operative period was marked by convulsive seizures, for which the patient was put on anticonvulsants with a good outcome."
  },
  {
    "id": "multiclinsum_gs_en_233.txt",
    "fulltext": "A 20-year-old female patient presented with progressive abdominal distension associated with abdominal cramp, failure to pass flatus and feces as well as frequent vomiting of ingested and bilious matter of one-day duration. The day before, she gave birth through C/S for an indication of severe fetal bradycardia. She also had preeclampsia without severity signs and an adult onset malnutrition with a body mass index (BMI) of 16.5Kg/M2. She had no history of previous abdominal surgery. She denied any similar complaint in the past or previous history of bowel habit change or constipation with passage of a blood mixed stool. She did not have any known chronic medical illness.\n\nOn physical examination she was acutely sick looking and in pain. Her blood pressure was 90/70mmHg, pulse rate was in the range of 116–120 beats per minute, respiratory rate was in the range of 22–24 breaths per minute. She did not have an objective fever record. Her abdomen was grossly distended and symmetric with visible peristaltic bowel movements. There was diffuse direct tenderness all over her abdomen, more at the right lower quadrant. There was a positive sign of intraperitoneal fluid collection with shifting dullness. There was a well approximated suprapubic surgical wound with clean dressing. Her digital rectal examination finding was unremarkable. She had a 3cm long, linear, vertically oriented, superficial wound on her left labia-majora which was initially thought to be an iodine burn to the skin, by the obstetrics team.\n\nShe was catheterized and resuscitated with two bags of normal saline and produced 200mL of urine over an hour. A nasogastric tube (NGT) was inserted but with no significant output. She was investigated with Complete blood count (CBC) and plain abdominal radiograph. Her white blood cell count was 1780 cells/µL with neutrophil predominance of 88%, hemoglobin of 12.7mg/dl and platelet count of 78 x 103/ µL. Her renal function test was normal and her liver enzymes were slightly elevated above the normal range but was not significant. Her plain abdominal radiograph shows centrally located multiple-air fluid levels with dilated peripherally located large bowel loop and whitening of the pelvic space indicating a fluid collection. Abdominal computed tomography (CT) scan was not requested because we work in a resource limited setting and for patients with bowel obstruction, we request CT scan when there is possibility of alternative diagnosis or when tumor obstruction is suspected.\n\nAfter obtaining informed written consent, she was explored under general anesthesia with a diagnosis of acute abdomen secondary to mixed bowel obstruction secondary to small bowel volvulus. The intra-operative finding was a distal ileum encircling the cecum and proximal ascending colon, both of which were mobile and not attached to the right posterolateral abdominal wall. Both the ileum and cecum as well as ascending colon were viable. The tip of the appendix was entangled with the ileal knot, and it was gangrenous. The proximal small bowel and distal large bowel were grossly distended otherwise in their normal location. There was about four-liter of serous intraperitoneal fluid.\n\nIntra-operatively, the patient was persistently hypotensive (80/50 mmHg) since after the induction of anesthesia and was started on vasopressor support. Considering the patient’s instability and viability of the bowels involved in the knot, right hemicolectomy was differed. Proximal and distal decompression of the distended small and large bowels was performed respectively. Cecum and ascending colon were fixed to the right posterolateral abdominal wall using interrupted sero-muscular stitches with non-absorbable suture (Silk 2–0).\n\nPost-procedure, she was extubated and kept nothing by mouth (NPO) for 24 hours and put on maintenance fluid with replacement of her loss. She was persistently hypotensive despite fluid resuscitation and vasopressor support and hence she was put on double antibiotics with Ceftriaxone 1gm, IV, BID and Metronidazole 500mg, IV, TID with consideration of septic shock of genitourinary focus. She gradually deteriorated and up on re-evaluation on her first post-operative day, the superficial wound on her vulva has expanded upwards to the suprapubic area with clinical signs of Fournier’s gangrene. Therefore, we revised her antibiotics to Meropenem 1gm, IV, BID, Vancomycin 1gm, IV, BID and Metronidazole 500mg, IV, TID. After informed written consent was obtained, she was taken back to the operation theatre for radical debridement of the Fournier’s gangrene and subsequently transferred surgical intensive care unit (ICU) intubated due to persistent septic shock and delayed awakening from anesthesia. Unfortunately, she passed away with multi-organ failure due to refractory septic shock on her second post-operative day after the initial exploration.",
    "summary": "We present a case of ileocecal knotting in a postpartum patient with abdominal distention, vomiting and failure to pass feces and flatus. Plain abdominal radiograph revealed dilated small bowel loops with multiple air fluid levels. Exploratory laparotomy was performed with intra-operative finding of ileocecal knotting with viable bowel, mobile cecum and ascending colon and gangrenous tip of appendix. We untied the knot and performed an appendectomy. Due to intra-operative instability of the patient's vital signs, right hemicolectomy was differed and cecum as well as ascending colon were fixed to right posterolateral abdominal wall."
  },
  {
    "id": "multiclinsum_gs_en_68.txt",
    "fulltext": "A 62-year-old female underwent a diagnostic left heart catheterization in 2012. The procedure was complicated by a left main coronary artery dissection requiring an emergent coronary artery bypass graft (CABG) of the left anterior descending coronary artery and the obtuse marginal artery. Unfortunately, the dissection of her left main coronary artery resulted in the worsening of the patient’s heart failure symptoms despite the emergent CABG. Since the patients’ ejection fraction after CABG never improved, she transferred to our advanced heart failure clinic. Over two years, multiple right heart catheterizations (RHCs) were completed; Fick method calculations consistently demonstrated a normal cardiac index. However, the patient experienced worsening symptoms. Once she was profoundly symptomatic, her case was presented at the medical review board, and she was approved for an OHT. Her transplant was uneventful; however, during surgery an abnormal amount of blood was noted draining from the pulmonary veins. Her initial 24-h post-operative course was remarkable for a high cardiac index and right ventricular (RV) cardiac output, a low systemic vascular resistance, and an elevated pulmonary pressure.\n\nWhile a shunt was suspected, an iatrogenic shunt was ruled out via bubble echocardiography. However, computed tomography (CT) scans revealed an abnormal left superior pulmonary vein draining into the innominate vein. The CTA demonstrated the presence of an extracardiac shunt in the form of PAPVR.\n\nAfter a multidisciplinary decision to pursue operative repair, the chest was re-opened. The left superior pulmonary vein (LSPV) was identified and visualized. A careful dissection was initiated from the pulmonary hilum toward the innominate vein outside the pericardium. The venous connection was completely mobilized, a tributary branch was ligated, and the vein was transected at the innominate level. After mobilizing the vein, an end-to-side anastomosis was made between the LSPV and the donor heart left atrial appendage while under cardiopulmonary bypass with beating heart. The heart and lung machine was used to avoid hemodynamic instability during the exposure of the left atrial appendage for the anastomosis. After the anastomosis and hemostasis, the patient was weaned from cardiopulmonary bypass and no inotropic support was required. The cannulas were removed after protamine was administered. The chest was closed in standard fashion, and the patient recovered in the intensive care unit. The patient was discharged home on Day 15.",
    "summary": "A 62-year-old patient with ischemic cardiomyopathy and systolic heart failure underwent orthotopic heart transplantation. The immediate post-operative course was remarkable for an elevated cardiac index and pulmonary artery pressures as well as decreased systemic vascular resistance. The post-operative echocardiogram did not reveal an intra-cardiac shunt. However, computed tomographic angiography (CTA) showed a left superior pulmonary vein draining into the innominate vein. Operative repair of the left superior pulmonary venous connection to the left atrial appendage was completed under cardiopulmonary bypass with beating heart. Her hemodynamics improved immediately, and she had an unremarkable postoperative course."
  },
  {
    "id": "multiclinsum_gs_en_34.txt",
    "fulltext": "68-year-old man with hypertension, chronic obstructive pulmonary disease and active smoking, consulted in the emergency department on 01/02/23 for progressive loss of visual acuity (3 months of evolution) associated with left brachio-crural hemiparesis, exacerbated in the days prior to the consultation.\n\nA NIHSS of 5 points was observed with dysarthria and minimal paresis of the left half-body, blood pressure 160/80 mm Hg, heart rate 75 lpm and pulse oximetry of 94% (FiO2 environmental). An angiography-CT scan showed a severe stenosis of the right ACI and a magnetic resonance imaging showed acute infarctions in the right cerebral hemisphere.\n\nThe echo Doppler confirmed a severe stenosis (VPS 356 cm/s) of the right ACI. After being evaluated thoroughly, confirming a severe symptomatic right carotid stenosis associated with a morpho-logically high lesion (which makes CEA technically difficult) and high surgical risk, we decided to carry out endovascular treatment by TCAR.\n\nOn 2/8/23, under general anesthesia and systemic heparinization (100 IU/kg of unfractionated heparin, for an Activated Coagulation Time [ACT] >250 s), the dissection of the ACC and VYI was performed. Once the carotid-jugular fistula was created, the ACC was clamped, establishing the dynamic reversal of flow.\n\nThe lesion was crossed (with the microguide in place) and the distal ICA was cannulated. An 8x30 mm carotid stent (Casper® Mirovention, Terumo) was deployed. Because the lesion was severe and distal, a phenomenon of proximal migration (towards the ACC) occurred during deployment, requiring the installation of a second stent (7x30 mm) to successfully treat the lesion.\n\nAngiographic control showed immediate improvement of the ACI lumen and adequate expansion of the stents. The ACC was unclamped (reestablishing anterograde cerebral flow), the endovascular devices were removed, and the incision was closed as previously described.\n\nThe patient recovered satisfactorily, without complications, and was discharged on the second postoperative day with dual platelet antiaggregant treatment.\n\nHe has not presented neurological events during follow-up and the control echo-Doppler (3, 6, and 12 months) shows the stent is permeable and without signs of re-stenosis.\n",
    "summary": "68-year-old man with hypertension and chronic obstructive pulmonary disease who developed a stroke secondary to a severe stenosis in the right internal carotid artery. A CT scan was performed due to its location and surgical risk. During the procedure, a temporary fistula was created between the carotid artery and the ipsilateral jugular vein to reverse the flow and protect the brain, allowing the stent to be safely deployed. The patient recovered without complications and remains asymptomatic at one year follow-up.\n"
  },
  {
    "id": "multiclinsum_gs_en_571.txt",
    "fulltext": "We wish to report a case of a 94-year-old woman, operated for Fuchs’ endothelial corneal dystrophy (FECD) with DMEK in the right eye 20 months previously and in the left eye 24 months previously, who showed acute signs of bilateral graft rejection following routine vaccination with a single dose of BNT162b2 mRNA COVID-19 Vaccine (Pfizer-BioNTech).\n\nThe patient’s past medical history was unremarkable, and her only regular medications were for arterial hypertension. Past ocular history included a cataract operation in the left eye 20 years earlier and in the right eye three years earlier. The cornea became edematous after the phacoemulsification procedure in the right eye. Best corrected visual acuity (BCVA) expressed as a decimal and corneal thickness (CT) expressed in micrometers (µm) were 0.3 and 679µm in the right eye and 0.2 and 668µm in the left eye. Three months after cataract surgery, DMEK was performed in the right eye and the patient underwent a re-bubbling procedure due to partial graft detachment one week later. Six months later DMEK was performed in the left eye; however, full detachment of the graft was noted postoperatively, for which the patient underwent successful re-operation after one week. In accordance with hospital guidelines, the patient received the standard post-transplantation treatment regimen: combined dexamethasone/tobramycin and ketorolac, four times daily. After one month, the treatment was changed to one drop dexamethasone 0.1% four times daily and tapered to one drop daily after three months.\n\nResults\nPost-operative BCVA and CT were 0.7 and 559µm in the right eye and 0.4 and 590µm in the left eye after nine and three months, respectively. At two-year DMEK follow-up of the right eye, both corneas were clear, the grafts were described as well-functioning in both eyes and BCVA was 0.4 in the right eye and 0.6 in the left eye. The reduced visual acuity was thought to be due to posterior capsule opacification and the patient underwent posterior capsulotomy with neodymium-doped yttrium aluminum garnet laser (Nd:YAG) in the right eye.\n\nSix months after the posterior capsulotomy, the patient attended two-year follow-up of the left eye complaining of a sudden painless worsening of vision in both eyes. BCVA had reduced to 0.2 in the right eye and to 0.3 in the left eye. Intraocular pressures were normal. Both corneas were increased in thickness, with a CT of 710µm in both eyes, and swept-source optical coherence tomography (SS-OCT) showed bilateral Descemet's membrane folds with moderate intraocular reaction, categorized as Standardization of Uveitis Nomenclature (SUN) grade 3. The patient was diagnosed with bilateral graft rejection. Further enquiry revealed that the visual deterioration started after she had been given her first dose of COVID-19 vaccine two weeks earlier.\n\nThe patient was treated with dexamethasone/tobramycin six times a day and with hypertonic saline four times a day in both eyes. In the meantime, she received her second dose of COVID-19 vaccine as planned. The dexamethasone/tobramycin was tapered to four times daily after one week, but when the corneal edema failed to resolve after one month, the hypertonic saline was discontinued and hourly dexamethasone 0.1% was added, tapering to eight drops daily after five days.\n\nHaving failed to respond to medical treatment, the patient was given re-DMEK transplantation first in the left eye and then in the right eye four months later. The right eye required a re-bubbling procedure due to partial graft detachment after one week. The patient received the standard postoperative treatment regimen: dexamethasone/tobramycin and ketorolac four times daily. After one month, both preparations were discontinued, and the patient received dexamethasone 0.1% four times daily. After three months, this was tapered down to one drop daily.\n\nDuring the recovery period following re-DMEK transplantation, an improvement in overall corneal clarity was noted and the BCVA and CT were 0.5 and 538µm and 0.63 and 504µm in the right eye and the left eye, respectively.",
    "summary": "A 94-year-old woman with Fuchs' endothelial dystrophy who underwent DMEK 24 months earlier (right eye) and 20 months earlier (left eye) demonstrated bilateral graft rejection two weeks after the first dose of COVID-19 vaccine. Standard treatment regimen was followed, and clinical status documented with slit-lamp examination and swept-source optical coherence tomography throughout.\n\nResults: Preoperative best corrected visual acuity (BCVA) and corneal thickness (CT) were 0.3 and 679µm right eye and 0.2 and 668µm left eye. Postoperative BCVA and CT were 0.7 and 559µm right eye and 0.4 and 590µm left eye. Standard treatment regimen consisted of dexamethasone/tobramycin and ketorolac, four times daily. At one month, both preparations were discontinued, replaced by dexamethasone 0.1% four times daily. At three months, this was tapered to once daily. Post-rejection, BCVA and CT were 0.2 and 710µm right eye and 0.3 and 710µm left eye. Treatment was with dexamethasone/tobramycin six times daily. Poor response resulted in re-DMEK transplantation, starting in the left eye. At one-month follow-up, BCVA and CT were 0.5 and 538µm right eye and 0.63 and 504µm left eye."
  },
  {
    "id": "multiclinsum_gs_en_120.txt",
    "fulltext": "A male newborn (35w + 5) presented to the emergency department on his sixth day of life for progressive failure to thrive associated with a 100-g weight loss. The mother reported having a fever, cough, and sore throat the day prior to delivery. At birth, the Apgar Scores were 9, 9, and 10 at 1, 5, and 10 min, respectively. Other than a late preterm delivery, there were no other abnormalities detected. The mother and newborn were discharged with a plan to return for follow-up in three days. At follow-up, the newborn was in good condition but subsequently developed a failure to thrive in the following days.\n\nOn admission, the baby was mildly febrile to 37.5 °C and he exhibited generalized hypotonia with hypo-reactivity to external stimuli. The patient had multiple apneic episodes resulting in oxygen desaturations; an arterial blood gas drawn revealed a pH of 7.21, consistent with metabolic acidosis. As neither viral nor active bacterial infections could be excluded, broad-spectrum antibiotics were initiated, and blood cultures were obtained. A markedly saturation to 75% persisted, requiring transfer to the pediatric intensive care unit where the patient was placed into a neonatal incubator with escalation of oxygen therapy. Laboratory studies revealed disseminated intravascular coagulation (DIC), and fresh frozen plasma and platelets were transfused. The patient also received vitamin K and continued with broad-spectrum antibiotics. The following day, the patient developed diffuse generalized jaundice and became oliguric with labs revealing hepatocellular injury (elevation in aspartate aminotransferase [AST] and alanine aminotransferase [ALT]), and thrombocytopenia to <15,000. Despite aggressive treatment, the metabolic acidosis persisted. Polymerase chain reaction returned positive for enterovirus, specifically CVB3 VP1 gene, on the third day.\n\nThere was a progressive deterioration of hepatic and renal function in the following days despite antibiotics, immunoglobulin therapy, and intensive care level support. Pleconaril, an antiviral drug from a capsid inhibitor class, was also added to the therapeutic regimen. The baby developed tonic-clonic contractions at the upper and lower extremities and massive pulmonary, hepatic, and gastric bleeding. Four days into the hospital course, the patient experienced a cardiac arrest from which there was no return of spontaneous circulation despite resuscitative measures. Ultimately, the cause of death was sepsis due to Coxsackievirus B3 infection associated with multiorgan failure.\n\nAn autopsy was requested. The external examination did not show any abnormalities. The autopsy revealed multiple hemorrhagic areas in the lungs and liver, subepicardial and kidney petechiae, and gastric hemorrhage. Histology confirmed diffuse lung interalveolar hemorrhage, intraparenchymal liver hemorrhage, heart interstitial hemorrhage, and gastric mucosal focal hemorrhage.",
    "summary": "A male newborn was admitted to the emergency department with fever, generalized hypotonia, hypo-reactivity to external stimuli, multiple episodes of apnea and desaturation, and metabolic acidosis. Laboratory studies revealed disseminated intravascular coagulation, and evidence of progressive multiorgan failure. Polymerase chain reaction performed on specimens collected at the time of admission returned positive for Enterovirus, specifically Coxsackievirus B3 VP1 gene. The patient eventually succumbed after several days due to severe sepsis, despite aggressive treatment with immunoglobulins and Pleconaril. An autopsy revealed hemorrhage in the lung, liver, heart, and gastric mucosa."
  },
  {
    "id": "multiclinsum_gs_en_21.txt",
    "fulltext": "The patient, a 61-year-old male, was diagnosed with acute pancreatitis 9 months before admission and received conservative treatment. After discharge, he intermittently experienced upper abdominal distension and pain, and an abdominal computed tomography (CT) scan showed the formation of a pancreatic pseudocyst. Four days before admission, the patient developed severe dyspnea with chest pain and cough, severe enough to prevent lying flat. Physical examination indicated shortness of breath, bilateral diminished breath sounds, tachycardia, and with no abdominal abnormalities. The patient had a long history of alcohol and tobacco use and multiple previous surgeries, including lumbar fixation surgery and abdominal wall lipoma removal.\n\nLaboratory tests showed slightly elevated serum tumor marker cancer antigen 125 at 98.25 U/mL (normal range 0–35 U/mL) and urine amylase at 333 U/L (normal range 32–641 U/L). Imaging (CT) revealed massive bilateral pleural effusion and the formation of a pancreatic pseudocyst.\n\nDiagnosis and interventions\nUpon admission, thoracic puncture drainage was performed, bacterial culture of the pleural fluid was negative, no tumor cells were found, but the cancer antigen 125 level in the pleural fluid was significantly elevated at 1859 U/mL (normal range 0–35 U/mL). Amylase levels in the pleural fluid were 53,844 U/L on the left and 1365 U/L on the right. On the sixth day, a diagnosis of PPF was confirmed, and an ERCP was performed with the placement of a 7Fr nasopancreatic duct to drain the pancreatic pseudocyst.\n\nImmediately after admission, thoracic puncture drainage was performed, draining a large amount of pale blood-tinged pleural fluid, along with parenteral nutrition support and somatostatin treatment, gradually assisting the patient in pulmonary function exercises. On the seventh day, an ERCP examination revealed communication between the pancreatic pseudocyst and the pleural cavity. During pancreatic duct cannulation, the guidewire could enter the pseudocyst, so a 7Fr nasopancreatic duct was placed for drainage. The culture of pancreatic fluid from the nasopancreatic duct grew Enterococcus faecium and Klebsiella pneumoniae, but the patient did not develop fever, and white blood cell count and C-reactive protein were normal, yet antibiotics were administered. On the ninth day, no fluid was drained from the bilateral thoracic drains, and another ERCP was performed. The nasopancreatic duct was cut at the duodenal papilla, leaving the internal part as a pancreatic duct stent.\n\nOutcomes\nThe patient received a total of 13 days of hospital treatment, during which 4180 mL of pleural fluid was drained from the left side, 2470 mL from the right, and 495 mL from the nasopancreatic duct. Six months after discharge, the remaining nasopancreatic duct was removed. There was no recurrence during a 5-year follow-up, and the patient’s general condition was good",
    "summary": "Patient concerns: A 61-year-old male with a history of alcohol and tobacco use presented with severe dyspnea, chest pain, and cough. He had been diagnosed with acute pancreatitis 9 months prior and intermittently experienced upper abdominal pain and distension post-treatment.\n\nDiagnoses: PPF.\n\nInterventions: The patient underwent thoracic drainage, nasopancreatic duct drainage, and pancreatic duct stent placement, along with parenteral nutrition and somatostatin therapy.\n\nOutcomes: Treatment resulted in resolution of pleural effusion and pseudocyst. The patient had no recurrence during a 5-year follow-up period."
  },
  {
    "id": "multiclinsum_gs_en_557.txt",
    "fulltext": "36-year-old bisexual man on pre-exposure prophylaxis of HIV, with no travel history, who reported attending an event where he had contact with casual partners whose identities and backgrounds were unknown. Ten days later he developed a fever, odynophagia and neck pain, and consulted several times, until seven days after the onset of symptoms he was admitted for persistence of symptoms despite the indicated antibiotic treatment. On admission he presented pharyngeal exudate, bilateral painful cervical adenopathies and umbilical papules on the scrotum and penis and pustules on the face of five days evolution. A computed tomography of the neck with intravenous contrast was performed, which ruled out collection, abdominal ultrasound with mild hepatosplenomegaly, and initiated empirical treatment with ceftriaxone and azithromycin. Samples were taken for culture, serologies, and scarification of two lesions of the face that were sent to the National Reference Laboratory, INEI-ANLIS Dr. Carlos G. Malbrán, for PCR of endpoint for Orthopoxvirus, with result DETECTABLE, confirming the diagnosis of monkeypox. The sequencing showed a high percentage of homology with sequences of the West African clade (MPV-ARG003-2022, Genbank_ID ON800897). Other differential diagnoses were discarded. The patient evolved with the appearance of a tongue ulcer and new asynchronous lesions in the buttocks, perianal region, right inguinal, umbilical, frontal, neck, right hand and dorsum of the foot in a total of no more than 25. In the laboratory an increase in transaminases was observed 2.2 times the normal value, with no other significant data.  Due to persistence of neck pain, a new computed tomography was requested 14 days after the onset of symptoms that evidenced adenomegalies with hypodens central aspect of necrotic appearance, that did not require surgical drainage. On day 17 PCR was performed on samples of pharyngeal exudate and semen that also resulted positive for monkeypox virus. The patient was discharged with frank clinical improvement two days later. The patient gave his written informed consent for the publication of this case report and the accompanying images.\n",
    "summary": "It is a young bisexual man, in pre-exposure antiretroviral prophylaxis for HIV, whose presentation was exudative pharyngitis without other documented etiology and adenopathies that evolved to necrosis, presence of characteristic asynchronous lesions in face, neck, abdomen, extremities and genitals. The diagnosis was by detection of viral DNA by polymerase chain reaction in skin lesions, pharyngeal exudate and semen. Pharyngeal involvement with presence of exudate after discarding other infections could be a rarity for the epidemic form of the disease. The finding of the virus in semen already reported in other publications is not yet sufficient to confirm the sexual route as a form of transmission.\n"
  },
  {
    "id": "multiclinsum_gs_en_378.txt",
    "fulltext": "A 54-year-old Lebanese woman on maintenance hemodialysis (HD) three times weekly for focal segmental glomerulosclerosis (FSGS) was admitted to the emergency department after undergoing her scheduled HD the day before due to sudden onset of severe lower back pain on the left side, nausea and vomiting. The pain had started suddenly about 12 hours before her presentation and worsened rapidly. In a side note, a severe secondary hyperparathyroidism with cutaneous calcification was treated with cinacalcet for 3 years without response requiring parathyroidectomy (hypertrophy of four glands) 8 months prior to her current admission. Five days prior to her presentation, she was admitted to the hospital for severe anemia and retrograde haemorrage. Her ultrasound evaluation of the renal showed bilateral small kidneys with thinned parenchyma containing cysts up to 3 cm and vascular calcification without hydronephrosis. Four days prior to her presentation, a colonoscopy through the terminal ileum revealed a 7 mm polyp in the left descending colon, which was removed by mucosectomy. The microscopy returned as a sessile tubular adenoma with low grade dysplasia. The patient denied fever or a history of trauma. There was no prior history of antiplatelet use. In the emergency, her blood pressure and pulse rate were 112/65 mmHg and 96 bpm, her temperature was 36.8°C and she presented a mildly distended abdomen with significant pain in the left costovertebral angle. The laboratory findings showed hemoglobin of 9.0 g/dL while the hematocrit was 29.7%, total white blood cell count 12.2 × 1000/microliter, creatinine of 6.06 mg/dL, and C-reactive protein level of 6 mg/L. In addition, the PT was 83% and the INR was 1.13. On the day of presentation (i.e., 4 days after the colonoscopy), a multiphasic computed tomography (CT) of the thorax, abdomen and pelvis was performed with and without intravenous contrast. The examination revealed a large left perirenal intraparenchymal hematoma with a perirenal subcapsular collection up to 1.8 cm thick with a haematic collection in the entire renal compartment reaching a diameter of more than 9×4 cm, left hydronephrosis and oedema around the perirenal fat and calcifications in the hilum. For decompression of the renal pelvic system and drainage, we opted to treat her with retrograde insertion of a double J ureteral stent on the left, which identified a clot in the middle part of the left ureter. Culture of urine and cytology were negative. A simple abdominal radiograph showed the double J in place. The patient remained hemodynamically stable, but presented a new drop in hemoglobin (6.1 g/dL) the same night, which required a transfusion of one unit of packed red blood cells to stabilize. A decision was made for surgical exploration with presumptive diagnosis of subacute left perirenal hematoma and to exclude underlying malignancy. She underwent a session of HD without heparin. On the third day, she underwent a radical open nephrectomy on the left with preservation of the adrenal gland. She received another 2 units of packed red blood cells during the intervention. The renal parenchyma was almost entirely replaced by a hematoma measuring 9×9×7 cm and extending into the perirenal fat. A small papillary mass was sent separately for analysis. A detailed histopathological evaluation revealed a renal parenchyma with lesions of chronic nephritis mutilated by large hemorrhagic areas extending into the perirenal fat. In addition, there was a neoplastic proliferation of 2 mm, with papillary architecture covered by small cubic atypical cells and foamy macrophages in the shaft, compatible with papillary adenoma. On the day following the operation, the patient underwent HD and received a packed red blood cells. The postoperative period was uneventful. The hemoglobin level remained around 10 g/dL. She was discharged on the seventh day without any signs or symptoms of bleeding. The patient remains well and asymptomatic and is currently on regular HD.\n",
    "summary": "Here is an unusual case of a 54-year-old female HD patient who presented with HPE within a few days of a colonoscopy. The cause of the HPE was a rupture of a DRCA cyst. We consider the colonoscopy to be a provoking factor and hypothesize its etiopathogenesis. The patient underwent a successful left nephrectomy.\n"
  },
  {
    "id": "multiclinsum_gs_en_555.txt",
    "fulltext": "A 12‐year‐old female child with end‐stage heart failure due to restrictive cardiomyopathy underwent orthotopic heart transplantation. Severe primary graft dysfunction was present during operation, requiring the use of venous arterial extra‐corporeal membrane oxygenation. Heart function has completely recovered after 4 days, and her post‐operative period was complicated by transient acute renal failure and complete atrioventricular block that lasted >3 weeks after the operation. In order to avoid left ventricle dyssynchrony and possible right ventricle lead damage due to multiple‐rejection surveillance endomyocardial biopsies, a transvenous dual‐chamber pacing using isolated left ventricle pacing through the coronary vein was indicated.\n\nUnder local anaesthesia and mild sedation, the left cephalic vein was cut down, and a guiding catheter was introduced into the subclavian vein and placed into the coronary sinus initially to perform a cardiac venogram. A unipolar steroid‐eluting endocardial pacing lead with active fixation mechanism (Attain StarFix® 4195, Medtronic, Minneapolis, MN) was implanted into the anterior inter‐ventricular vein branch. Measurements at implantation were as follows: threshold 2 V at 0.4 ms, R wave 6 mV, and impedance 300 Ω at 4.8 mA. A second bipolar steroid‐eluting endocardial pacing lead with active fixation (2088T®, St. Jude Medical, Minneapolis, MN) was implanted at the right atrium.\n\nBoth leads were secured and connected to a rate‐adaptive pacemaker (Accent DR®, St. Jude Medical, Minneapolis, MN) that was placed in a left infra‐clavicle muscular pocket and programmed to VDD. The electrophysiological lead measurements were stable after the implant: ventricular threshold 1.5 V at 0.7 ms, R wave 4.5 mV, P wave 4.3 mV (bipolar), ventricular impedance 260 Ω, and estimated battery longevity 5 years.\n\nThe post‐implant electrocardiogram showed right bundle branch block morphology‐paced complexes, and the echocardiographic evaluation showed absence of atrioventricular, inter‐ventricular, and intra‐ventricular dyssynchronies. At 5‐year follow‐up, the patient remained in Functional Class I with the same pacing system and preserved ventricular function.",
    "summary": "A 12‐year‐old child with end‐stage heart failure due to restrictive cardiomyopathy was submitted to orthotopic heart transplantation. Primary graft dysfunction required venous arterial extra‐corporeal membrane oxygenation. Heart function normalized, but complete atrioventricular block remained after 3 weeks. A dual‐chamber pacing with transvenous left ventricle pacing through the coronary sinus was performed. At 5‐year follow‐up, the patient is stable with the same pacing system and with preserved ventricular function."
  },
  {
    "id": "multiclinsum_gs_en_543.txt",
    "fulltext": "20-year-old male, HIV negative, with pulmonary TB and irregular treatment in 2020-2021. He was admitted for bacillary impregnation syndrome, pain and functional impotence of the right shoulder. He presented a poor general state, thinned, severe muscular hypotrophy, cold tumour lesions with fistulae in the back, skull and anterior thoracic area with caseous secretion, without presenting motor or sensory deficits. The rapid molecular examination (GeneXpert Mtb/Rif) of the thoracic secretion was positive for Mycobacterium tuberculosis, sensitive to rifampicin (the phenotypical antibiogram showed a pan-sensitive strain). The CT demonstrated pulmonary consolidations and a tree in bud, along with cervical, dorsal and lumbar bone involvement with lytic images and pre- and para-spinal collections. The MRI showed infiltrative images from C4 to C6, D4 to D6, D9 to D12; pathological fracture of D6 and D10 and infiltration in L1, L2 and L3. He initiated anti-TB treatment with a standard first-line scheme (isoniazid, rifampicin, pyrazinamide, ethambutol). Given the extensive destruction and the danger of quadriplegia/paraplegia due to cervical and/or dorsal involvement, a permanent dorsal decubitus position, a Philadelphia collar, kinesiological treatment and a scheduled neuro-surgical procedure at the cervical levels, D6 and D10, were indicated. Prior to the scheduled surgery, he presented an acute case of paraplegia with a D8 sensory level, with a bladder compromise. It was interpreted as a level of acute compression at D6. Emergency neuro-surgical treatment with posterior spinal decompression via a dorsal laminectomy 6 and partially 5 and 7 and evacuation of a epidural collection was indicated. He was progressively recovering motor and sensory function. Subsequently, the scheduled cervical surgery via anterior approach with a corpectomy of C4, C5, C6 and C7 plus arthrodesis of C3 to D1 with vertebral body replacement plus autologous graft, plaque and screws was performed. In the control CT, a posterior luxation of D6 with spinal canal compression and neurological compromise due to spinal canal compression was evident. The surgical tactics were reconsidered due to mechanical and neurological instability. Decompression and alignment of the luxated level was performed with posterior arthrodesis of the three non-adjacent spinal levels, cervical, dorsal 6 and dorsal 10 in a single surgical procedure. It was fixed from C3 to D12 with polyaxial screws and cervicodorsal transition rod. In each surgical procedure, spontaneous evacuation of caseous material, BAAR positive, and profuse washing was evident. He presented clinical, bacteriological and pulmonary improvement. He recovered mobility with kinesiological rehabilitation in addition to the specific treatment (3 months of first phase and indication of continuation with isoniazid and rifampicin to complete 12 months). He walked on his own after a prolonged 5-month hospitalisation.\n",
    "summary": "A 20-year-old male with non-contiguous multinivelled spondylitis tuberculosis (cervical, dorsal 6, dorsal 10 and lumbar) is presented. He is a HIV negative patient with disseminated tuberculosis with severe general condition and multiple disease sites. Some of them had fistulas secreting caseum. The patient presented acute paraplegia that required, taking into account the sensory level at dorsal 6, an urgent decompression surgery via posterior route. Then the scheduled surgery was performed. In the first instance, the cervical region via anterior route, with corporectomy, placement of vertebral body replacement plus autologous graft and plate with screws. Subsequently, a luxation of dorsal 6 level backwards was evidenced, compressing the spinal cord and, given the mechanical instability, a third surgical time was indicated via posterior route that comprised reduction, decompression and fixation, resolving the three levels via posterior route with bars and screws. The surgical, medical and kinesiological treatment of this rare form of Pott's disease was successful, with recovery of its mechanical stability and progressive recovery of its neurological state.\n"
  },
  {
    "id": "multiclinsum_gs_en_512.txt",
    "fulltext": "A 25-year-old patient presented for a neurosurgical consultation concerned about his health. His history included a headlong dive into a swimming pool during the holidays two weeks previously. The dive resulted in a fracture of the cervical spine. The patient underwent surgery where he was staying for his holidays. Posterior stabilization of the cervical spine was performed. The patient was wearing a cervical collar, and the surgical wound still had not healed, with the sutures not yet removed. The patient demonstrated no pareses and was able to move about on his own. He did not have detailed medical documentation or diagnostic examination reports for preoperative and postoperative periods. At discharge, he was given an incomplete postoperative CT of the cervical spine in the form of a few old-style films showing some of the views but without digital images. The discharge summary did not contain the necessary detailed description of the treatment provided, including no details about the instrumentation used. The hospital staff or the operators could not be contacted because they would not answer the phone or reply to e-mails and text messages. We decided that a new CT of the cervical spine should be obtained. It revealed status post atypical hangman’s fracture of the cervical spine: a fracture of the C2 pars interarticularis on the left, dislocation of C2 against C3, fracture of the C2 vertebral body with detachment and anterior displacement of a part of the C2 vertebral body. The patient was operated on from a posterior approach. Posterior stabilization of C2-C3 was performed. The screws were correctly positioned in the lateral masses of C3. Within the C2 vertebra however, both screws were initially placed transpedicularly, but their ends did not reach the C2 vertebral body or lateral masses of C1 and extended into the left and right C1-C2 joint spaces. CT images of the status post initial surgery performed at another centre. Leaving this spinal stabilization in place made the patient unable to perform rotational movements of the head as the screws were placed within the C1-C2 joints. Anterior stabilization to prevent C2 dislocation against C3 was also not performed, and appropriate spinal stability was not ensured. After analysing the spinal CT images, we decided to re-operate. Our intention was to restore rotational head movements while ensuring stability of the cervical spine. We decided to use both an anterior and posterior approach. The first stage of the procedure from a posterior approach consisted of the removal of the screws from C2 bilaterally, with the ends of the screws being within the C1-C2 joint spaces, followed by the placement, from the same approach, of shorter screws that ended within C2, thus not reaching the joint spaces and not blocking head rotation. Before the procedure, we did not know what type of screws (manufacturer) had been used originally. It was revealed intraoperatively that the screws were of a type that was also available at our hospital. We did not change the location of the screws within the C3 lateral masses as they were properly implanted. The C2-C3 screws were then joined with longitudinal rods bilaterally. In the second stage of the procedure, from an anterior approach, we performed a C2/C3 discectomy and placed a cage in the C2/C3 space, followed by the placement of a pressure screw throughout the length of the body of C2 and the odontoid process. Finally, we used a cervical plate fixated with 4 screws for C2-C3 stabilization. The postoperative period proceeded without any complications. Apart from minor pain associated with the surgical wound, no concerning symptoms such as dysphagia or voice hoarseness were observed. A follow-up CT scan revealed normal postoperative appearances matching the preoperative assumptions. The patient was discharged home in a good overall and neurological condition. A follow-up functional X-ray of the cervical spine at 8 weeks after the procedure also revealed normal postoperative appearances. At present, the patient has functional flexion/extension and rotational head movements and cervical spine stability is also preserved.",
    "summary": "We present a case of an atypical hangman's fracture caused by a headlong dive into a swimming pool and striking the pool's bottom. The patient had undergone surgery at another centre, where posterior C2-C3 stabilisation was performed. Due to the presence of screws in the C1-C2 joint spaces, the patient could not perform rotational movements of the head. Anterior stabilization to prevent C2 dislocation against C3 was also not performed, and appropriate spinal stability was not ensured. Our decision to reoperate was motivated, among other factors, by our intention to restore rotational head movements. The revision surgery was performed from both an anterior and posterior approach. After the surgery, the patient was able to rotate his head while maintaining cervical spine stability. The case presented here represents not only a unique example of an atypical C2 fracture but also highlights a fixation technique that provided the necessary stability for successful fusion. The utilized method restored functional rotational movement of the head, thus preserving the patient's quality of life, which is of paramount importance considering the patient's age."
  },
  {
    "id": "multiclinsum_gs_en_240.txt",
    "fulltext": "A 25-year-old Syrian male presented on 8 February 2024, with a chief complaint of severe, gradually worsening abdominal pain for 6 days. The pain was localized to the periumbilical region, characterized as stabbing pain, exacerbated by fatty meals, and graded as 9/10 on the severity scale. He reported four episodes of vomiting but denied fever, changes in weight, appetite, or bowel habits. He also noted occasional nocturia without urgency, frequency, or dysuria. On further questioning, he denied passing frothy urine. His review of systems was otherwise unremarkable. Past surgical history included nasal polypectomy and hemorrhoidectomy, while past medical history was unremarkable. He had no known allergies and was not taking any medications. Family history was significant for maternal ischemic heart disease managed with percutaneous coronary intervention (PCI), hypertension, and hyperthyroidism. He was a heavy smoker (seven pack years) and denied alcohol consumption.\n\nThe patient was alert and oriented and had an average build on admission. His heart rate was 84 beats per minute (bpm), blood pressure was 144/81 mmHg, respiratory rate was 18 breaths per minute, and oxygen saturation was 99% on room air. Physical examination revealed periorbital edema and bilateral lower limb edema. There was no jaundice, pallor, cyanosis, or palpable lymphadenopathy. Abdominal examination demonstrated mild tenderness in the periumbilical region, moderate ascites, and no guarding or rebound tenderness.\n\nLaboratory investigations revealed a significantly low anion gap, accompanied by substantial proteinuria and hematuria on urine dipstick analysis. The 24 hour urine protein excretion was markedly elevated, indicating significant protein loss. The complete blood count (CBC) results were within normal limits. However, the erythrocyte sedimentation rate (ESR) was elevated, and liver function tests demonstrated low total protein, severely decreased albumin, and increased alkaline phosphatase levels. Renal function tests indicated a considerable elevation in creatinine, consistent with impaired kidney function. Coagulation studies showed a prolonged prothrombin time (PT), elevated international normalized ratio (INR), and increased d-dimer, suggesting a hypercoagulable state. Thrombophilia screening was mainly unremarkable, except for mildly reduced protein S levels, likely due to urinary loss. Serological analysis showed a mild reduction in complement component C3, while results for ANA, ANCA, dsDNA, and PLA2R antibodies were negative.\n\nAn abdominal computed tomography (CT) scan with contrast enhancement was ordered, which revealed superior mesenteric vein thrombosis, leading to veno-occlusive mesenteric ischemia. This ischemia resulted in hypoperfusion of the jejunum, ileum, cecum, ascending colon, proximal transverse colon, diffuse mesenteric fat stranding, and moderate ascites. Renal ultrasound showed bilateral increased cortical echogenicity, mild free fluid in the abdomen, and bilateral pleural effusion, indicative of nephrotic syndrome. There was no hydronephrosis.\n\nA provisional diagnosis of nephrotic syndrome with secondary venous thrombosis was made, and inpatient management began with enoxaparin (70 mg, subcutaneous injection every 12 hours) and prednisolone (70 mg, oral, daily). An ultrasound-guided renal biopsy was performed to confirm the diagnosis. The patient was referred to a nephrologist, who initiated an empirical treatment regimen consisting of cyclosporine (100 mg, oral twice daily) and furosemide (40 mg, oral daily), on which he was discharged, along with apixaban (10 mg, oral, twice daily for 7 days, then reduced to 5 mg, twice daily for 3 months), prednisolone (70 mg, oral, tapered over 6 weeks), atorvastatin (40 mg, oral, daily), alfacalcidol (1 mcg, oral, daily), calcium carbonate (500 mg, oral, daily), and pantoprazole (40 mg, oral, daily).\n\nOn 19 February 2024, the patient returned with worsening facial and periorbital edema, along with swelling in the lower limbs and newly developed scrotal edema. He reported poor compliance with the treatment regimen. These symptoms and the decline in his serum albumin levels were managed as a flare-up of his nephrotic syndrome, and he was started on steroid therapy. He was discharged on 20 February with perindopril (5 mg, oral, daily) being added to his treatment regimen and instructed to follow-up in 1 week to review renal biopsy results. On 24 February 2024, he revisited the emergency department due to a flare-up of his symptoms. However, he chose to leave against medical advice (LAMA) before he got further assessment and treatment.\n\nThe patient presented again on 29 February 2024, with severe right-sided abdominal pain and shortness of breath. He was not adherent to medications. Laboratory tests showed an elevated C-reactive protein (CRP) level of 110 mg/L (normal range: 0–5 mg/L) and a white blood cell count of 18 × 10⁹/L (normal range: 4.0–11.0 × 10⁹/L), suggesting inflammation. Chest X-ray confirmed a mild right-sided pleural effusion. Compared to the previous scan, a CT angiography of the abdomen revealed no evidence of recurrent superior mesenteric vein thrombosis; the portal vein, splenic vein, and superior mesenteric artery remained patent. However, there was submucosal edema, suboptimal mucosal enhancement in the cecum, and similar findings in the ascending and transverse colon. The jejunal and ileal loops demonstrated optimal enhancement. Mild free fluid in the abdomen and stranding in the mesenteric fat persisted. Additionally, a small perinephric collection was noted near the lower pole of the left kidney. There was no intraperitoneal air.\n\nInitially, the patient had piperacillin/tazobactam based on clinical suspicion of infection, but cultures returned negative. On 1 March 2024, biopsy and electron microscopy findings showed subcapsular cortical tissue containing two glomeruli without crescent formation. The glomerular basement membranes were regularly thick and structurally normal, with no evidence of splicing or lamellation. Significant podocyte foot process effacement was noted, but no specific osmiophilic deposits or fibrils were observed. These findings were consistent with a diagnosis of primary podocytopathy of the minimal change type without indications of immune complex or complement-mediated glomerulonephritis. Following these results, the patient’s condition gradually improved. He was discharged on his previous treatment regimen and chose to follow-up in his home country.",
    "summary": "The patient is a 25-year-old Syrian male, previously in good health, presenting with severe abdominal pain and vomiting that had persisted for 6 days. Investigations revealed hypoalbuminemia with nephrotic range proteinuria. Computed tomography scan of the abdomen and pelvis with contrast showed superior mesenteric vein thrombosis. Renal biopsy revealed minimal change disease. The patient was mainly treated with a therapeutic dose of enoxaparin, followed by apixaban. He also received oral prednisolone, a short course of cyclosporine, and furosemide. With the appropriate treatment, the patient's symptoms gradually improved and he was discharged. This successful management of a rare complication in a nephrotic syndrome patient demonstrates the potential for positive outcomes in such cases."
  },
  {
    "id": "multiclinsum_gs_en_146.txt",
    "fulltext": "A 24-year-old man with MFS-related cardiovascular complications was admitted to our Internal Medicine Department because of 3 consecutive episodes of acute decompensated HF with reduced ejection fraction (ADHFrEF) from 2014 through 2017. His remaining medical history includes arterial hypertension, dyslipidemia, hyperthyroidism, anaphylactic shock due to flecainide, and previous tabagic habit.\n\nMFS diagnosis was made in 2010 when ascending aorta and aortic valve substitution with mechanical prosthesis were performed due to type A acute aortic dissection in presence of family history—mother, father, and 3 sons with MFS. During intraoperative period, inferior acute coronary syndrome occurred and was treated with coronary artery bypass graft surgery.\n\nOn May 2014, mechanical descending aorta and aortic arch prosthesis implantation were performed due to chronic dissecting aneurysm. Peri-aortic hematoma and medullary ischemia complicated surgery and caused lower limb paraplegia, dolorific and thermal hypoesthesia, and rectal incontinence. After 2 months, during his first admission for ADHFrEF, laboratory tests were notable for N-terminal pro-BNP (NT-proBNP) of 12,000 pg/mL and transthoracic echocardiogram showed normal prosthesis function, dilatation of all cardiac chambers (mainly the left ones) with moderate mitral and tricuspid insufficiency, left ventricular hypertrophy, inferior wall akinesis, septal dyskinesis, and hypokinesis of the remaining walls with severe left ventricular ejection fraction (LVEF) reduction −20%. He was treated with intravenous diuretics and internal cardiac defibrillator (St. Jude Ellipse DR, DDD mode) without cardiac resynchronization therapy (electrocardiogram criteria not met) and discharged on maximal medical therapy (furosemide, carvedilol, ramipril, spironolactone, digoxin, and amlodipine).\n\nNew episode of ADHFrEF occurred on august 2017. Notable admission laboratoristic values included NT-proBNP of 2719 pg/mL and midregional-proadrenomedullin (MR-proADM) of 1.61 nmol/L, whereas transthoracic and transesophageal echocardiogram showed an LVEF of 35%, normal prosthesis function, severe tricuspid regurgitation, and rupture of the anterior leaflet of the chordae tendineae with severe mitral regurgitation. Patients were treated yet with intravenous diuretics and digoxin and discharged on optimal medical therapy (furosemide, carvedilol, ramipril, spironolactone, digoxin, and amlodipine).\n\nLastly, he was readmitted to our Internal Medicine Department on November 2017 due to third episode of ADHFrEF and infected mediastinal fluid collection secondary to 1 month before severe valvular insufficiency surgical correction with mitral mechanical prosthesis implantation (31-mm ST Jude) and De Vega tricuspid annuloplasty.\n\nPhysical examination was notable for blood pressure 120/80 mm Hg, pulse 82 bpm, respiratory rate 26 apm, O2 saturation 87% on room air with orthopneic obligatory position, and Marfanoid habitus (weight 147 kg, height 2.2 m). Cardiopulmonary evaluation revealed metallic second heart sound, stony dull percussion with reduced tactile vocal fremitus and crackles at the basis of the lungs, widely diminished vesicular breath sounds, presence of abundant ascites, and leg swelling.\n\nNotable laboratoristic values included NT-proBNP of 10,132 pg/mL and MR-proADM of 2.36 nmoL/mL.\n\nArterial blood gas analysis revealed severe hypoxemia with respiratory and metabolic alkalosis (pH 7.56, pO2 46 mm Hg, pCO2 24.8 mm Hg, HCO3− 21.9 mmol/L, alveolar-arterial gradient 31 mm Hg). Although electrocardiogram highlighted atrial fibrillation with ventricular rate of 80 bpm, left ventricular hypertrophy, and inferolateral subepicardial ischemia, transthoracic echocardiogram showed the same features as the previous except for LVEF of 30%, presence of mitral mechanical prosthesis, with paravalvular leak and mean gradient of 9 mm Hg, and mild tricuspid insufficiency.\n\n\nHilar congestion with cardiomegaly, right upper lobe pulmonary consolidation, and infected mediastinal fluid collection have been shown on chest x-ray and high-resolution computed tomography, respectively.\n\nPatient was treated with intravenous furosemide 250 mg q.d., canrenone 100 mg q.d., piperacillin/tazobactam 4.5 g q6h, and teicoplanin 12 mg/kg b.i.d., then 12 mg/kg q.d. On day 9, once reaching hemodynamic stabilization, sacubitril/valsartan midrange dose of 49/51 mg b.i.d. has been added to carvedilol 3.125 mg b.i.d., spironolactone 100 mg q.d., furosemide 250 mg q.d., and digoxin 0.25 mg q.d.\n\nOn 1-month follow-up sacubitril/valsartan has been increased to 97/103 mg b.i.d. for patient's good clinical condition, allowing persistent and progressive clinical, laboratory (NT-proBNP reduction and MR-proADM increase), echocardiographic-LVEF increase (42% vs 30%), left ventricle end-systolic diameter, left ventricle end-diastolic diameter, left ventricular mass, and left ventricular mass index reduction, and quality of life improvement without new episodes of ADHFrEF until 9-month follow-up (Fig. ​(Fig.1B1B and D; Table ​Table1).1). Because of the lack of a specific dosage regimen for sacubitril/valsartan in MS-related cardiomyopathy, we used the recommended therapeutic scheme.",
    "summary": "Patient concerns:\nA 24-year-old man was admitted to our Internal Medicine Department due to dyspnea, ascites, and leg swelling. Arterial blood gas analysis revealed severe hypoxemia with respiratory and metabolic alkalosis. Hilar congestion was highlighted on chest x-ray.\n\nDiagnoses:\nRecurrent acute decompensated heart failure with reduced ejection fraction despite optimal medical therapy in Marfan-related cardiomyopathy.\n\nInterventions and outcomes:\nSacubitril/valsartan was added to optimal medical therapy after hemodynamic stabilization allowing progressive clinical, laboratoristic, and echocardiographic improvement. Patient maintained a free survival from heart failure and a good quality of life until 9-month follow-up."
  },
  {
    "id": "multiclinsum_gs_en_42.txt",
    "fulltext": "A 25-year-old male came into the emergency department with a laceration at the right upper arm associated with significant prolonged bleeding as he arrived 5 h after injury. He had a Glasgow Coma Scale of 15 with no airway compromise, however, was hypotensive (80/50 mmHg), tachycardic (140 bpm), with a respiratory rate of 26 and clinically pale. Pulsatile bleeding was noted on the involved extremity with pain, muscle weakness and faint pulses. The patient was then immediately brought to the operating room for wound exploration after resuscitation. Past medical history was unremarkable with no known comorbidities. Intraoperatively, there was a transected brachial artery for which a reverse saphenous vein interposition graft was placed as vascular reconstruction. Twelve hours after the procedure, he complained of sudden and profound loss of vision bilaterally. Ocular examination confirmed bilateral vision loss with preservation of corneal and pupillary reflexes while extraocular muscle movements, intraocular pressure, and funduscopic examination were all normal. There were no neurological deficits, and his cerebellar and cognitive functions were intact. Electrocardiogram and echocardiography did not reveal any underlying cardiac pathology or source of emboli. Computed Tomography (CT) of the brain revealed bilateral occipital lobe hypodensities confirming the diagnosis of acute posterior circulation ischemia. Further neuro-ophthalmologic examination with Automated Visual Field (AVF) testing showed right homonymous hemianopsia for which close observation was done. The patient thereafter noted a gradual resolution of the visual field defect and was discharged after 6 days with a Visual Acuity Score of 20/30. He currently continues to have no other visual or neurologic symptoms at 1 year of follow-up with the same visual acuity score although a repeat imaging with a cranial MRI (Magnetic Resonance Imaging) is planned.",
    "summary": "We present a case of a 25-year-old male who underwent brachial artery repair with reverse saphenous vein graft interposition after sustaining a right upper arm laceration associated with massive hemorrhage and shock due to delayed consult. He presented with profound bilateral loss of vision 12 h after surgery characterized as right homonymous hemianopsia. Computed tomography of the brain demonstrated ischemic infarcts in the occipital lobes. Close observation was instituted, and his symptom resolved spontaneously within a week."
  },
  {
    "id": "multiclinsum_gs_en_332.txt",
    "fulltext": "A 28-year-old female patient was on follow-up at our clinic after she presented with anterior neck swelling of 4 years. She claimed that the swelling was small at the beginning but progressed in size gradually, at which time she started filling some pressure locally. Lately, she had also been feeling easily fatigued, she has had palpitation and shortness of breath on exertion, and some degree of heat intolerance. However, her appetite had been as usual and she did not experience any weight loss. Upon examining her, her blood pressure was 118/80 mmHg, pulse rate was 114 beats per minute, and the temperature was 36.6°C. Neck examination showed 5cm × 6cm measuring enlarged thyroid gland in the anterior neck, which had firm consistency, nodular surface with mobility and no tenderness. There were no clinically detectable cervical lymphadenopathies (LAP). There were no signs of ophthalmopathy, and neurologic exam was normal. During her initial diagnosis, she was investigated with baseline complete blood count (CBC), serum TSH, T3 and T4, liver function tests (LFT), neck ultrasound and fine needle aspiration cytology (FNAC).\n\nDespite having normal free T3 and T4 levels, the patient was started on PTU 100 mg orally three times daily (TID) and propranolol 40 mg PO TID based on clinical symptoms of hyperthyroidism and low TSH levels. Neck ultrasound revealed that both thyroid lobes were enlarged in size due to multiple heterogeneous echo benign nodules with internal coarse shadowing calcifications, largest in the right lobe measuring 3.5 × 2.5 cm in the widest dimension. There were no significant LAP. Thyroid scintigraphy is warranted in this case, however due to its unavailability in our setting, we could not perform it. On FNAC, smear showed low cellular yield composed of sheets and clusters of atypical cyst lining cells, lymphocytes and abundant thin and thick colloid in fluidy background. The conclusion was atypia of undetermined significance (AUS); therefore, repeat FNAC after 3 months was planned. The repeat FNAC showed moderate cellular yield composed of clusters and dispersed bland follicular epithelial cells, along with foamy histiocytes, cyst lining cells and abundant thin and thick colloid in fluidy background. The index was nodular colloid goiter with hyperplastic focus.\n\nAfter taking the ATDs for 7 months, she came to the clinic for her regular follow-up, at which point she was experiencing none of the clinical features of hyperthyroidism. Her pulse rate was maintained within the normal limits (80–84 beats per minute) and the TSH, T3 and T4 had normalized.\n\nAt this point, the patient was advised to have a definitive thyroidectomy to treat the toxic MNG and was admitted to the elective surgical department. Upon admission routine pre-operative lab investigations were sent. The LFT was within normal limits and the CBC test done twice 24 hours apart showed leucopenia with agranulocytosis. The patient had no fever, sore throat or any other signs and symptoms of infection, and the agranulocytosis was an incidental finding.\n\nThe diagnosis of asymptomatic PTU-induced agranulocytosis was made, with absolute neutrophil count of less than 500/µL, while she was on PTU for the control of hyperthyroidism which was not evident on her initial CBC profiles. Since she was asymptomatic and work-up for infection (urine analysis and chest X-ray) were unremarkable, she was not started on broad-spectrum antibiotics. However, the offending ATD was immediately discontinued. The patient was kept inpatient for monitoring on lugol’s iodine and propranolol 20 mg po QID. She was advised on danger signs like sore throat, fever, cough and so on. Eight days after discontinuing the ATD, the CBC profile was determined once again, showing normalized total leukocyte, as well as, absolute neutrophil count.\n\nAfter informed consent was obtained from the patient, she was taken to the operation theater. She was put under general anesthesia, and subtotal thyroidectomy was performed. The intra-operative finding was 8 × 6 cm measuring thyroid gland with multiple calcified nodules.\n\nDunhill’s thyroidectomy procedure was performed after identifying and preserving both RLNs and the parathyroid glands. Drainage was left in the thyroid bed and incision closed in layers. The patient had smooth post-operative course, and she got discharged on the 2nd post-op day (POD). Histopathological analysis revealed nodular colloid goiter with cystic degeneration. The patient was followed for 6 months at the outpatient clinic. She has no complaints, and her clinical examination and laboratory test results are normal. She is clinically, as well as biochemically, euthyroid.",
    "summary": "A 28-year-old female patient was on follow-up at our clinic after she presented with anterior neck swelling of 4 years. The patient was started on propylthiouracil (PTU) and propranolol based on clinical symptoms of hyperthyroidism and low thyroid stimulating hormone (TSH) levels. After taking the ATDs for 7 months, she came to the clinic for her regular follow-up. At this point, she was declared euthyroid and booked for surgery. Investigations were sent and the complete blood count (CBC) result showed leucopenia with agranulocytosis, even though she was completely asymptomatic. The offending ATD was immediately discontinued. The patient was kept inpatient for monitoring, and lugol's iodine and propranolol were initiated. Eight days after discontinuing the ATD, the CBC profile was determined once again, showing normalized total leukocyte, as well as, absolute neutrophil count. Eventually, the multinodular goiter (MNG) was managed with subtotal thyroidectomy."
  },
  {
    "id": "multiclinsum_gs_en_137.txt",
    "fulltext": "A 61-year-old man visited our hospital with an accidental cut in his left thumb while using a power saw. The patient was diagnosed with an open fracture of the distal phalanx that was separated into two main fragments in the coronal plane. The extent of the soft tissue laceration closely coincided with the proximal extent of the fracture. The wound was irrigated and primarily sutured on the same day. However, the volar bone fragment was pulled by the flexor pollicis longus (FPL) tendon and displaced to the volar side.\n\nThe next day, surgery was performed using a digital block. The suture was opened and the tissue intervening between the bone fragments was removed. After adjusting the alignment of the joint surface of the distal phalanx, a 1.0-mm Kirschner wire was inserted as a transfixion pin from the volar bone fragment towards the dorsal bone fragment. However, the compression between the bone fragments was insufficient. Therefore, with the interphalangeal (IP) joint temporarily hyperextended so that the distal phalanx would not obstruct the passage, a 1.2-mm Kirschner wire was inserted along the volar side of the distal phalanx into the proximal phalanx head to create a flexion block pin. A Kirschner wire was obliquely inserted from the side of the FPL tendon to avoid penetration. When the wound was sutured again and the IP joint was passively flexed, volar and dorsal bone fragments were compressed against each other. A dorsal splint was used to maintain this position.\n\nResult\nBecause the patient wanted an early return to work, manual activity was permitted with continued immobilization for 6 weeks, after which the pins were removed and a volar splint was placed for continued immobilization. Eight weeks after surgery, bone union was confirmed, and active range of motion exercises were started. Seven months after surgery, the active flexion range of motion of the IP joint was up to 45° and the active extension range of motion was up to 0°, resulting in a mildly limited range of motion. However, the patient was satisfied with his daily life and was able to work without any inconvenience.",
    "summary": "A 61-year-old man sustained an open fracture of the distal phalanx of his left thumb while using a power saw. The fracture occurred in the coronal plane and the volar bone fragment was dislocated under traction by the flexor pollicis longus tendon. The patient underwent surgery the day after the injury. A flexion block pin was inserted to reduce the volar bone fragment, and an external flexion force was applied using a dorsal splint to compress the dorsal bone fragment into the volar bone fragment. The pin was removed 6 weeks postoperatively, and active range of motion exercises were started 8 weeks postoperatively. Bone union was achieved with good alignment, and although the interphalangeal joint remained slightly restricted in range of motion, the patient returned to his previous job and was satisfied with the function of the left thumb."
  },
  {
    "id": "multiclinsum_gs_en_10.txt",
    "fulltext": "A 61-year-old patient with steroid therapy for rheumatoid arthritis and bilateral groin pain was diagnosed bilateral osteoarthritis of his hip joints [9]. He received bilateral intraarticular injection of hyaluronic acid and presented twelve weeks later to our emergency department with fever, reduced general condition and increasing immobilizing pain. Radiographs of the pelvis showed rapid progressive destruction of both hip joints with extensive osteolysis, concomitant subluxation and an acetabular bony defect of the left side. Joint aspiration showed pus in both hip joints and the diagnosis of rapid progressive bilateral septic arthritis was made. Bilateral resection of both femoral heads with debridement of the hip joint and implantation of antibiotic-loaded PMMA spacers was done via a minimally invasive antero-lateral approach.\n\nEmpirical systemic antibiotic therapy was started with vancomycin and ampicillin i.v. E. coli was detected in tissue samples of both hip joints and systemic antibiotic therapy was adapted to meropenem i.v. Two follow-up surgical procedures with exchange of the antibiotic-loaded PMMA spacers were undertaken for infection control due to persistent drainage.\n\nTwelve weeks after resection of the femoral head and successful infection control, the patient received total hip arthroplasty with the additional use of a silver multilayer coating (HyProtect®, Bio-Gate, Nürnberg, Germany). This coating consists of an ultrathin siloxane layer directly on the implant surface (10 to 30 nm), from which silver ions are released.\n\n12 weeks after resection of the femoral head, total hip arthroplasty on the right side with a cementless standard cup (Allofit®, ZimmerBiomet, Warsaw, USA) and a cementless femoral stem (Avenir®, ZimmerBiomet, Warsaw, USA) via the previously used minimally invasive antero-lateral approach with this ultrathin silver multilayer coating was performed. Both the back surface of cup and the entire femoral shaft were silver coated.\n\nThe left hip was treated 18 weeks after femoral head resection with a silver-coated reinforcement cage (Burch-Schneider®, ZimmerBiomet, Warsaw, USA) for a Paprosky type IIB acetabular defect and a cemented polyethylene cup (Durasul®, ZimmerBiomet, Warsaw, USA). The cementless femoral stem (Avenir®, ZimmerBiomet, Warsaw, USA) was also silver coated at its entire intramedullary part. This intervention was also performed via the previously used minimally invasive antero-lateral approach. The patient was put under systemic antibiotic therapy for an overall treatment period of 18 weeks after implantation of the right side. Ertapenem 1 g was applied intravenously for this time frame once a day, after dismissal in an outpatient setting. This allowed for antibiotic coverage of the right side of 18 and of the left side of 12 weeks of antibiotic treatment.\n\nPartial weight bearing with 20 kg on the operated side and the use of crutches was advised for 6 weeks after the interventions.\n\nThe wounds on both sides healed uneventfully. The patient was seen regularly for clinical and radiological follow-up. Full weight-bearing without the use of crutches was achieved 7 weeks post-operatively on both sides. There were no signs of PJIs and no further revision surgery was necessary.\n\nAt a final follow-up three years after the implantation of silver-coated prostheses, the patient showed normal skin appearance with minimal scars after minimally-invasive antero-lateral approaches on both sides without any signs of argyria. There was excellent functional outcome of both hips with normal gait and a WOMAC Score of 6 on both sides (pain: 0, stiffness: 0, physical function: 6). Blood leukocyte count was 7.29/nl (reference: 4.23–9.1) and the C-reactive protein (CRP) level was at 12.4 mg/l (reference: <5 mg/l). The slightly elevated CRP level is attributable to the underlying rheumatoid arthritis of the patient. Radiographs revealed well-integrated and non-loosened hip prosthetic components on both sides three years after implantation with correct articulation.",
    "summary": "This case report is about a 61-year-old patient with rapid destruction of both hip joints due to septic arthritis that was successfully treated with a staged implantation of silver-coated hip prostheses with an ultrathin silver multilayer coating. At a three-year follow-up, there were no signs of infection, a good state of all prosthetic components was noted and the functional outcome was excellent."
  },
  {
    "id": "multiclinsum_gs_en_407.txt",
    "fulltext": "A 41-year-old man with a known history of dilated cardiomyopathy with reduced ejection fraction and paroxysmal atrial fibrillation was referred to our outpatient pulmonary clinic in February 2024 after 2 episodes of hemoptysis. He had previously undergone a radiofrequency ablation for atrial fibrillation in March 2023. Despite his cardiac history, the patient was asymptomatic on presentation, with no evidence of cardiopulmonary symptoms.\n\nIn the months leading up to his referral, the patient had experienced 2 separate episodes of hemoptysis in October and November 2023. During these episodes, chest computed tomography scans revealed ground-glass opacities (GGOs) in the left upper lobe, suggestive of alveolar hemorrhage. Anticoagulation therapy, initiated after his ablation procedure, was paused, and the hemoptysis subsequently resolved. Imaging at the time showed the presence of GGOs, but without a clear diagnosis. The patient had been managed conservatively, and anticoagulation was eventually discontinued in November 2023.\n\nFurther work-up, including a coronary and thoracic angiography performed in December 2023, revealed a soft-tissue mass near the left hilum, which was initially concerning for malignancy. A subsequent fluorodeoxyglucose positron emission tomography scan, along with comprehensive pulmonologic and rheumatologic evaluations, ruled out neoplastic and infectious causes, and vasculitic processes such as granulomatosis with polyangiitis (GPA) and anti-glomerular basement membrane (GBM) disease. Both anti-neutrophil cytoplasmic antibodies and anti-GBM antibody tests were negative, and the patient showed no systemic signs of vasculitis, such as renal involvement, ear-nose-throat (ENT) symptoms, or cutaneous manifestations.\n\nIn February 2024, a repeat computed tomography scan using a pulmonary vein protocol identified a high-grade stenosis of the left upper pulmonary vein. The stenosis had not been present on preablation imaging, confirming it as a postablation complication. After a multidisciplinary discussion involving pulmonology, cardiology, and radiology teams, the decision was made to pursue conservative management given the absence of recurrent symptoms and the patient’s preference for a noninvasive approach.",
    "summary": "We present a 41-year-old man with a history of paroxysmal atrial fibrillation and dilated cardiomyopathy who developed new-onset hemoptysis and ground-glass opacities on imaging, months after his ablation procedure. Differential diagnoses included vasculitis, infection, and interstitial lung disease, all of which were ruled out. A dedicated pulmonary vein protocol computed tomography scan confirmed the diagnosis of high-grade stenosis of the left upper pulmonary vein. Due to the patient's asymptomatic status posthemoptysis, conservative management was pursued."
  },
  {
    "id": "multiclinsum_gs_en_288.txt",
    "fulltext": "The authors present the case of a 49-year-old male patient. He was asymptomatic and had no personal history of chronic medication use. He was currently a smoker, but denied alcohol or toxic use. The patient was admitted to the emergency department due to chest pain and dyspnea that began half an hour earlier. Five days before admission to the hospital, the patient reported a similar episode of chest pain that began while walking and persisted for about 30 minutes after rest.\n\nUpon arrival at the emergency department, the patient was prostrate and cyanotic with increased respiratory rate and hypoxia despite a high-flow oxygen mask. The patient progressed rapidly to cardiopulmonary arrest and advanced life support was initiated and he was intubated and ventilated. Blood gas analysis revealed severe metabolic acidosis with hyperlactatemia (pH = 6.87, carbon dioxide partial pressure - PaCO2 - of 105 mmHg, oxygen partial pressure - PaO2 - of 120 mmHg, bicarbonate - HCO3 - of 13.9 and lactate of 13.5 mmol/L). The electrocardiogram showed wide complex tachycardia with regular R-R intervals (170/minute) with a rightward shift in the axis, suggesting monomorphic ventricular tachycardia. As there was no response to advanced life support maneuvers, with persistence of ventricular tachycardia without pulse, and taking into account the complaint of chest pain, the hypothesis of acute myocardial infarction was considered and alteplase was administered for thrombolysis, given that the hospital did not have a hemodynamic laboratory. After recovery of spontaneous circulation, an electrocardiogram revealed sinus rhythm (90/minute) and bifasic T between V3 and V5.\n\nThe patient was transferred to the intensive care unit. A transthoracic echocardiography revealed discrete hypokinesia of the apical segment of the inferior left wall. Blood analysis showed mild anemia (hemoglobin 11.5 g/dL), acute renal injury (creatinine 2.26 mg/dL and urea 76 mg/dL) and mild hypokalaemia (3.2 mmol/L). Markers of myocardial necrosis were slightly increased: hs-troponin 84 pg/mL (cut: 34.2 pg/mL), creatine kinase 510 IU/L (cut: 200 IU/L), creatine kinase MB 6.8 ng/mL (cut: 7.2 ng/mL) and myoglobin 2914 ng/mL (cut: 116 ng/mL). The level of D-dimer was also elevated (1,678 ng/mL; cut: 500 ng/mL). Hs-troponin increased to 358.50 pg/mL after 3 hours, and its maximum value was 832 pg/mL, 24 hours after admission.\n\nThrombolysis was complicated by bleeding at the insertion site of the central venous catheter and profuse haematemesis. Upper gastrointestinal endoscopy was performed, which showed mucosal bleeding, digested blood and clots in the stomach. Because of the active bleeding, the case was discussed with the haemodynamic laboratory, and angiography was delayed until clinical stabilisation and cessation of the haemorrhage.\n\nThree days after admission, the patient improved gradually, allowing orotracheal extubation. A computed tomography of the skull showed no changes. A ventilation-perfusion scan was performed, excluding pulmonary embolism. A coronary angiography revealed coronary arteries without relevant lesions and a right coronary artery with abnormal origin from the left coronary sinus. Then, an ACTC confirmed the abnormal origin of the right coronary artery from the left coronary sinus, with a path between the trunk of the pulmonary artery and the aorta posteriorly - an interarterial path with a length of 18 mm; there was no evidence of an intramural path or coronary atherosclerosis, with a zero calcium score. A cardiac magnetic resonance did not bring important information and no late contrast was detected.\n",
    "summary": "The authors report a rare case of use of Advanced Life Support in the context of cardiac arrest due to an anomalous aortic origin of the right coronary artery in a 49-year-old patient. The patient was admitted with chest pain and dyspnoea, which rapidly progressed to pulseless ventricular tachycardia and cardiac arrest. Acute myocardial infarction was suspected and, in the absence of a haemodynamic laboratory in the hospital, thrombolysis was performed. Subsequently, a coronary angiography revealed the absence of angiographic lesions in the coronary arteries and anomalous origin of the right coronary artery from the opposite Valsalva sinus. A coronary computed tomography angiography confirmed the finding and determined a pathway between the pulmonary artery and the aorta. The patient underwent cardiac surgery with a mammary bypass to the right coronary artery, without any new episode of arrhythmia.\n"
  },
  {
    "id": "multiclinsum_gs_en_209.txt",
    "fulltext": "A 55-year-old female patient with no significant medical history presented to the emergency room with sudden onset of dyspnea. She had no history of hypertension, palpitations, headaches or diaphoresis. She was noted to be tachycardic (180 beats/min) and hypertensive (170/120 mm Hg) and was started on diltiazem drip. She also developed frothing and became hypotensive. Emergent intubation was done for impending respiratory failure. ECG showed ST-segment elevations in I, aVL, V2 and V3. Bedside echocardiogram showed a left ventricular ejection fraction (EF) of 10% with dyskinesis of the apex and hypokinesis of the other segments. She was started on diuretics and norepinephrine drip for the management of pulmonary oedema and hypotension. Cardiac catheterisation did not reveal any significant coronary artery disease. Cardiogenic shock secondary to fulminant myocarditis was suspected and an intraaortic ballon pump was placed. She was transferred to our hospital for advanced heart failure therapies as the patient continued to be hypotensive.\n\nInvestigations\n\nLaboratory assessment on admission showed metabolic acidosis with high lactate levels, elevated aspartate aminotransferase, alanine aminotransferase and acute kidney injury. The toxicology drug screen was negative. CT scan of the abdomen showed a 4 cm heterogenous enhancing right adrenal mass with areas of central hypoenhancement consistent with the appearance of a PHEO. Biochemical assessment showed high levels of plasma metanephrines; however, it is to be noted that the patient had recently been on pressor agents.\n\n\nDifferential diagnosis\n\nCICMP can mimic several cardiovascular disorders. It can present as hypertrophic cardiomyopathy which is similar to hypertrophic obstructive cardiomyopathy (HOCM) and are characterised by hypertrophy of the posterior wall and interventricular septum, as well as anterior motion of the mitral valve replacement; however, in CICMP, all these changes regress after surgical excision of the PHEO or PGL. CIMCP can present takotsubo or reverse takotsubo syndrome which are indistinguishable from primary takotsubo’s. CIMCP-induced myocarditis can be confused with viral myocarditis due to the similarity in presentations; however, in CIMCP, these changes are reversible with treatment of PHEO or PGL. Several radiological characteristics are useful to differentiate different radiological lesions.\n\n\nTreatment\n\nDopamine drip was initiated in addition to the norepinephrine drip; however, the patient continued to remain hypotensive. Venous arterial extracorporeal membrane oxygenation (VAECMO) was started for resistant cardiogenic shock, and there was a marked improvement in the acidosis, liver enzymes and kidney function. Doxazosin therapy was initiated 1 day after the VAECMO was started and titrated to control blood pressure. The VAECMO flow rate was slowly weaned and stopped over 5 days. Subsequently, propranolol was added to control the heart rate with excellent response to both the agents.\n\nFollow-up echocardiogram, a week after admission, showed significant improvement in cardiac function with an EF of >50%. Right adrenalectomy was done 3 weeks after the original admission. Pathology revealed a PHEO with no lymphovascular invasion.\n\n\nOutcome and follow-up\n\nOn follow-up in the clinic 3 weeks after surgery, the patient’s blood pressure had normalised and was off antihypertensives. Genetic evaluation revealed no pathogenic mutations in RET, VHL, NF-1, SDH, MAX and TMEM127 genes.",
    "summary": "A 55-year-old female patient was presented with severe dyspnea due to sudden onset of heart failure (ejection fraction (EF) <10%). Echocardiogram showed a takotsubo pattern with an akinetic apical segment. Coronary angiography did not reveal any obstructive disease. She became hypotensive which was refractory to conventional pressor agents. Catecholamine-induced cardiomyopathy was suspected after the CT scan of the abdomen showed a 4 cm necrotic right adrenal mass consistent with pheochromocytoma (PHEO). Venous arterial extracorporeal membrane oxygenation and α blockers were initiated. There was a rapid improvement in cardiac function with EF normalising in 1 week. Subsequently, β-blockers were added and right adrenalectomy was done 3 weeks after the admission. She did extremely well after surgery with her blood pressure normalising without the need for antihypertensive therapy. Genetic evaluation revealed no pathogenic mutations implicated in the development of PHEO."
  },
  {
    "id": "multiclinsum_gs_en_82.txt",
    "fulltext": "A 38-year-old, O negative, pregnant woman in her fourth gestation was referred to our hospital for pregnancy surveillance. A first trimester spontaneous abortion resulted from the first gestation; no specific exams were conducted. The second pregnancy fetal demise was diagnosed at 16 weeks of pregnancy. Only a placental intervillositis was found on laboratory workup study.\n\nOn the third pregnancy, serological studies and sonographic evaluation were normal until 34 weeks of gestation. In the third trimester ultrasound, a left ventriculomegaly (VMG) (10 mm) was detected. A live newborn was born by vaginal delivery at term, with an Apgar score 9/10/10 at first, second and third minutes respectively and neonatal weight of 2,830 g. After delivery, physical exam revealed petechiae spread across the chest, left flank, and abdomen. A severe thrombocytopenia (32 × 109/L) was diagnosed requiring platelet transfusion. The neurological examination was normal, however transfontanellar ultrasound confirmed the VMG previously diagnosed, measuring 10 mm, without any sign of ICH. No further imagological studies were conducted. The placenta anatomopathological report identified mild chronic intervillositis.\n\nNeonatal thrombocytopenia etiology assessment was performed. Although maternal platelet count was normal, the maternal and paternal platelet antigen serological typing revealed that the father was homozygotic for HPA-1a and the mother was homozygotic for HPA-1b. Moreover, maternal serum was positive for HPA antibodies. In respect to HLA genotypes father was homozygotic HPA-1a and mother was homozygotic to HPA-1b and maternal serum was positive for HPA-1a antibodies. Thus, the diagnosis of FNAIT was established. At four years old by the time of the mothers fourth pregnancy, the only known clinical impairment was VI nerve palsy.\n\nOn the fourth pregnancy, high dose IGIV (1 g/kg/week) was started at 14 weeks of gestation and prednisolone (0.5 mg/kg/day) at 20 weeks. The dose administered remained stable throughout the pregnancy. In the second trimester routine serologic evaluation, a positive anti-treponemal test and a toxoplasmosis seroconversion were identified. Previous syphilis screening was assessed with a VDRL test, with a negative result. In the second trimester, after positive treponemal test, reflex non treponemal testing (VDRL) was negative. The patient was previously not immune to toxoplasmosis but by second trimester a positive IgG with negative IgM were offered in the routine evaluation. Time lapse between first and second trimester analysis was 15 weeks. After debating all possibilities, and taking into account the patient wishes, treatment of a possible late latent syphilis and prevention of fetal toxoplasmosis was initiated. Remaining pregnancy was uneventful with no recorded signs of fetal affection in ultrasound examinations.\n\nA cesarean delivery for breech presentation was decided at 37 weeks of pregnancy. The neonate was born with 2,660 g and an Apgar score of 9/10/10 at first, second and third minutes respectively. Newborn platelet count from umbilical cord was 262 × 109/L and physical examination was unremarkable. Currently with 12 months, the child has normal neurodevelopment. Reassessment of maternal serologies confirmed toxoplasmosis IgG and anti-treponemal negativity, six months after delivery.",
    "summary": "We report a case of a 38-year-old pregnant woman, with a previous affected child with fetal neonatal alloimmune thrombocytopenia. To prevent recurrence, intravenous immunoglobulin treatment was administered in early second trimester. In the second trimester routine analysis, a positive anti-treponemal test and a toxoplasmosis seroconversion occurred. Infection suspicion based on test positivity of some infectious agents, after passive acquired antibodies, can lead to anxiety and subsequent unnecessary treatment."
  },
  {
    "id": "multiclinsum_gs_en_73.txt",
    "fulltext": "A 26-year-old primigravid lady presents to our hospital with the complaint of progressively worsening abdominal pain of 3 days duration. After arrival to our hospital, she fainted but maintained consciousness. She reported a recent urine pregnancy test positive result in another clinic but did not have a pelvic ultrasound. The pregnancy was wanted, planned, and supported. On physical examination, she was acutely sick looking in severe pain, hypotensive (60/40 mmHg), and tachycardic (120 beats/minute). She had tender abdomen with guarding and rigidity on palpation. Blood exams showed a hemoglobin of 12.5 g/dL. Transabdominal ultrasound scanning was pertinent for significant hemoperitoneum to the level of Morrison’s pouch, left adnexal cystic mass, and IUP with crown-to-rump length based gestational age of 7 weeks + 5 days. Visualization of the ectopic pregnancy was limited by the presence of the adnexal cyst. However, due to cultural sensitivity, our patient declined transvaginal sonography.\n\nWith the impression of a ruptured ovarian cyst to rule out HP, she was rushed to an emergency laparotomy. The intra-operative findings were pertinent for approximately 1000 mL of hemoperitoneum, ruptured left tubal ectopic pregnancy, and intact left ovarian cystic lesion. As the ovarian tissue was thinly spread over the cyst sparing the ipsilateral ovary was technically difficult. With this impression, a left total salpingio-oophorectomy was done. To preserve the IUP, care was taken to avoid excessive uterine manipulation.\n\nThe entire surgical specimen was subjected for histopathology. She had a smooth postoperative course and was discharged on post-operative day-1. Obstetric ultrasound scan on the 30th laparotomy day showed a viable IUP heralding the continuation of the pregnancy. The detailed description of the histopathology is presented below. On her postoperative period, she was put on 250 mg intramuscular 17α-hydroxyprogesterone weekly for 3 doses.\n\nGross Pathology\nMacroscopically the received specimen consisted of a 7x6x6 cm cystic mass with 6 cm long opened up fimbriated fallopian tube. Cut surface through the cystic tissue showed an uninoculated cyst filled with serous fluid.\n\nHistopathology\nSections from the cystic mass showed thick cyst wall made up of luteinized granulosa cells theca lutein cells with abundant eosinophilic cytoplasm and central vesicular nuclei.\n\nSections from the fallopian tube show edematous wall infiltrated by variable sized chorionic villi with hydropic changes, extra-villus intermediate trophoblasts, fibrin clots, congestion and hemorrhage.\n\nWith these macroscopic and histopathologic findings, the diagnosis was finalized as ectopic pregnancy plus theca lutein cyst.",
    "summary": "We present a 26-year-old primigravid, ethnic Tigrayan lady from the Tigray region of Ethiopia. She presented to our hospital with the complaint of progressively worsening abdominal pain of three days duration. She also had a subjective period of amenorrhea of 2 months duration. Pregnancy test was positive a few days prior to her current presentation. She reported that she had a history of treatment for pelvic inflammatory disease three months prior to her current conception. At presentation to our hospital, she was acutely ill-looking in pain, tachycardic, and hypotensive. Pelvic ultrasound showed an adnexal mass, hemoperitoneum, and an intrauterine pregnancy at 7 weeks + 5 days gestation. With the impression of ruptured ovarian cyst to rule out heterotopic pregnancy emergency, an explorative laparotomy was done which was pertinent for significant hemoperitoneum, ruptured left tubal ectopic pregnancy, and intact left ovarian cyst."
  },
  {
    "id": "multiclinsum_gs_en_32.txt",
    "fulltext": "This is the case of a 36-year-old woman from the Oromia region’s West Arsi zone, who presented with a 6-month history of snoring, dysphonia, and cough, as well as significant but unquantified weight loss, fatigue, and low-grade and intermittent fever, for which she had visited various health facilities with no noticeable improvements in her symptoms. She has had diabetes for the past 5 years and is on Metformin 500 mg twice a day with poor glycemic control. The physical findings at the presentation, including the throat examination, were unremarkable. The random blood sugar level was 300 mg/dl at the time of presentation (elevated). Laryngoscopy revealed an irregular tumor on the anterior one-third of the vocal cord bilaterally, involving the anterior commissure. The biopsy result revealed actinomycotic granules with abscess formation. The patient was then started on Penicillin G (for 1 month), with the resolution of her symptoms during follow-up, and then on Amoxicillin for the next 6 months, which was discontinued when she had fully recovered from her symptoms and the mass had been cleared on follow-up laryngoscopy.\n\nUp on investigation, the complete blood count, erythrocyte sedimentation rate, renal function tests, and liver function tests were all within normal ranges. Serology tests for the Human Immunodeficiency Virus (HIV), Hepatitis B surface Antigen (HbsAg), and Hepatitis C virus RNA (HCV RNA) revealed negative. Her random blood sugar level was 300 mg/dl, which is high, and her glycemic control was similarly poor on the follow-up chart.\n\nHer otolaryngology exam was unremarkable, but a flexible laryngoscopy revealed irregular mass in the anterior one-third of the vocal cord on both sides, with involvement of the anterior commissure.",
    "summary": "Our case was a case of a 36-year-old woman from the Oromia region's West Arsi zone, who presented with a 6-month history of snoring, dysphonia, and cough, as well as significant but unquantified weight loss, fatigue, and low-grade and intermittent fever, for which she had visited various health facilities with no noticeable improvements in her symptoms. She has had diabetes for the past 5 years and is on Metformin 500 mg twice a day with poor glycemic control. The physical findings at the presentation, including the throat examination, were unremarkable. The random blood sugar level was 300 mg/dl at the time of presentation (elevated). Laryngoscopy revealed an irregular tumor on the anterior one-third of the vocal cord bilaterally, involving the anterior commissure. The biopsy result revealed actinomycotic granules with abscess formation. The patient was then started on Penicillin G, and there was a resolution of her symptoms during follow-up, and then on put on Amoxicillin for the next 6 months, which was discontinued when she had fully recovered from her symptoms and the mass had been cleared on follow-up laryngoscopy."
  },
  {
    "id": "multiclinsum_gs_en_473.txt",
    "fulltext": "A 48-year-old male was admitted to our hospital from a psychiatric facility with somnolence, cerebellar ataxia, and dysarthria of 3 days' duration. He had no fever in the previous month. He reported snorting escitalopram and clonazepam in the previous days, as well as intranasal disulfiram (1-2 g daily with a maximum dose of 10 g daily in the previous 48 hours) for recreational purposes in the past 2 months.\n\nHe had a history of untreated hypertension and paranoid schizophrenia, which had led to three hospitalizations for exacerbations due to treatment omission. He was taking olanzapine 10 mg/8 hours and paliperidone 100 mg intramuscular monthly for schizophrenia, as well as clonacepam 0.5 mg/24 hours and escitalopram 15 mg/24 hours. He was also receiving oral disulfiram 250 mg daily for chronic alcoholism despite an active drinking pattern.\n\nOn arrival to the emergency department, respiratory rate was 20 breaths/minute, oxygen saturation in room air was 98%, heart rate was 85 beats/minute, blood pressure was 177/100 mmHg, and temperature was 36.2°C. The patient was stuporous and disoriented with a Glasgow Coma Scale of 13/15. Cardiovascular, respiratory, and abdominal examination was unremarkable. A myotic, hyporesponsive pupil, profuse blinking, marked dysarthria, and unsteady gait were noted on neurologic examination. There were no clinical signs of intracranial hypertension or meningeal irritation.\n\nBlood analysis showed hyperchloremic metabolic acidosis (pH: 7.28; real bicarbonate: 16.4 mmol/L), polyglobulia and macrocytosis. Renal function and liver profile were normal. No other findings of interest were found. Toxicological study was negative for ethanol, methanol and ethylene glycol. Urine toxic screen by immunoassay was positive for benzodiazepines. Computed tomography revealed mild, nonspecific symmetrical hypodensities of both the pallidum and posterior arms of the internal capsule, cerebral atrophy and chronic lacunar infarcts.\n\nThe patient was admitted to the hospital because of suspected encephalopathy related to a drug intoxication (presumably benzodiazepines), without ruling out other diagnostic possibilities. This first hypothesis was based on the fact that it was a hypnotic-sedative syndrome in a patient who reported consumption of benzodiazepines and who had a positive qualitative study in the urine.\n\nPlasma levels of diazepam, nordiazepam and clonazepam were requested, all in therapeutic or subtherapeutic range (72 ng/mL, 412 ng/mL and negative, respectively). An EEG showed diffuse slow activity, without focal or epileptiform alterations. The examination of the cerebrospinal fluid showed a mild hyperproteinemia and all microbiological studies were negative.\n\nThe patient's history was difficult to collect as the information provided was often contradictory. In this regard, the explanation for the negative clonazepam levels was that the patient could not be guaranteed to have actually taken the clonazepam. Based on these plasma levels, it was most likely that he had not. On the other hand, the fact that the plasma levels of diazepam and nordiazepam were positive was consistent with the information provided by the patient. In retrospect, diazepam vials were found in the patient's home. Plasma levels in the therapeutic range do not exclude the possibility of adverse effects, but they make their severity and the clinical course followed by the patient less likely. Benzodiazepines probably contributed to the picture, but causation could not be attributed given these plasma levels.\n\nOn the other hand, hyperchloremic acidaemia with normal lactate levels in the clinical setting of this patient led us to consider the diagnosis of a metabolic disorder, especially an organic acidaemia, a disorder of the beta-oxidation of fatty acids or a disorder of the urea cycle. The systematic study in plasma and urine of fatty acids, acylcarnitines, acylglycines and carnitine was negative. In addition, the ammonium levels were normal and hypoglycaemia with hypocetosis was not found. The acidaemia resolved in less than 24 hours without specific measures, which made the hypothesis of a metabolic disorder very unlikely. In addition, during the initial stabilisation, the patient had received intensive serum therapy with 0.9% NaCl, which could have contributed to the acidaemia.\n\nWithin 24 hours, he developed a progressive decrease in level of consciousness with rapidly progressive respiratory failure requiring endotracheal intubation and mechanical ventilation and was transferred to the intensive care unit.\n\nRespiratory examination and chest X-ray suggested aspiration pneumonia, and he was treated accordingly. To investigate the etiology of the encephalopathy, a brain MRI was performed. It revealed a large, bilateral, heterogeneous hyperintense signal in both globus pallidus, the posterior arm of the internal capsule and the putamen, in both FLAIR and T2. The T1-weighted sequence showed a hypointense area in the same areas.\n\nBased on these findings, the case was reclassified as disulfiram-induced encephalopathy, as the radiological pattern had been previously described in the literature in other cases of disulfiram intoxication, as well as in cases of carbon monoxide intoxication (although this was not the clinical setting). The diagnosis of disulfiram encephalopathy was made by exclusion criteria. According to the algorithm of Naranjo et al [5], with a score of 4 out of 10, it was considered possible to attribute causality to disulfiram in this case. In turn, the published cases of disulfiram encephalopathy present important similarities with this case. However, there are no cases described of inhaled disulfiram, as it is not an approved route of administration. Unfortunately, disulfiram plasma levels could not be performed.\n\nThe patient's respiratory status improved gradually over the next two weeks until he was extubated. After withdrawal of sedation, neurological examination revealed difficulties in supination, intentional tremor and dysmetria in the finger-nose test, as well as proximal weakness in the upper and lower limbs. Subsequently, the patient showed neurological improvement. Ocular motility restriction and weakness resolved within a few days, but persisted with mild tremor and slight dysmetria. Due to the critical patient's myopathy, gait was not explored until two weeks later, when a complete resolution of ataxia was observed.\n\nThe patient was discharged with a mild residual intentional tremor. The brain MRI control at two months showed an evolution of the symmetric areas of cytotoxic edema to necrosis.\n",
    "summary": "A 48-year-old patient with chronic enolism who reported intranasal inhaled use of a very high dose of disulfiram without concomitant intake of alcohol developed acute encephalopathy with rapidly progressive respiratory failure. Neuroimaging revealed extensive bilateral symmetrical involvement of both pale nuclei, a characteristic finding in this intoxication. Neurological recovery was slow. Two months after intoxication, the patient had a slight residual intentional tremor and a magnetic resonance showed an evolution of the symmetrical areas of cytotoxic edema to necrosis.\n"
  },
  {
    "id": "multiclinsum_gs_en_506.txt",
    "fulltext": "35-year-old male with a history of complete rupture of the anterior cruciate ligament 10 years ago. He had conservative management with immobilization for four weeks and subsequent physiotherapy for six months with partial improvement of symptoms. At the end of conservative management, he performed daily activities without apparent limitations until one month prior to reassessment, with 6/10 knee pain on the EVA scale and a sensation of instability when going down the stairs and intermittent oedema, with no new mechanism of injury. On physical examination, there was pain on palpation over the lateral joint line and anterior surface of the knee; anterior flexion of 85° and posterior flexion of 100°, full extension. Strength of the knee muscles was 5/5 with pain referable to the anterior aspect of the knee. In the special manoeuvres to clinically assess the knee joint, anterior drawer, Lachman, Lelli's tests were positive; lateral and medial McMurray, Steinman and Apley tests were positive. A simple magnetic resonance scan of the right knee was requested, and the following was found: absence of the anterior cruciate ligament, osteoarthrosis grade III-IV of the medial femorotibial compartment, osteoarthrosis grade II of the lateral femorotibial compartment, thinning of the posterior horn and lateral meniscus with minimal residual portion, horizontal tear of the posterior horn and lateral meniscus, posterior cruciate ligament oedema with change in mucoid degeneration. Radiographic measurements were performed for the intercondylar notch and alpha angle, in axial and sagital section, respectively. A decision was made to carry out diagnostic and therapeutic management by knee arthroscopy. Prior to the surgical procedure and with the patient under general anaesthesia, the pivot shift test was performed, which was positive with a grade III. Arthroscopy was carried out, with evidence of a closed notch, complete, inveterate rupture of the anterior cruciate ligament, pinching of the posterior cruciate ligament, rupture of the posterior horn and lateral meniscus, chronic, inveterate rupture of the medial meniscus, anterior cruciate ligament release, free intraarticular bodies, chondral lesion of 1 cm2 in the lateral femoral condyles in the load-bearing area, osteoarthrosis grade IV of the medial compartment of the knee, subquadricepital synovitis. During arthroscopy, a notchoplasty was performed, release of the posterior cruciate ligament, debridement of the osteophytes in the anterior tibial spine, partial meniscectomy of the lower flap of the posterior cruciate ligament and lateral meniscus, partial meniscectomy of the posterior meniscus, extraction of free intraarticular bodies, posteromedial, medial and subquadricepital, remodelling of the chondral lesion in the lateral femoral condyles in the load-bearing area, debridement of the chondral in the periphery of the lateral femoral condyles (periarthrosis), subquadricepital synovectomy.\nThe degree of arthrosis was considered to be a reason not to perform ACL tunnels to avoid future complications in definitive knee arthroplasty surgery. After surgery, the use of passive knee mobilizer from 0° extension to 100° flexion, as well as walking with assistance of crutches was indicated.\nThe patient was discharged from the hospital without complications the day after the surgery and began physiotherapy for muscle strengthening and stability. The patient reported being asymptomatic at the three-, six-, and nine-month follow-up visits, and was able to carry out his daily activities without limitations, as well as low-impact sports activities without impediment.\n",
    "summary": "We present the case of a 35-year-old patient with an unhealed rupture of the ACL for 10 years. Initially, conservative management progressed to knee instability and pain in the medial and lateral joint line, as well as increased volume and functional limitations. After diagnostic studies, it was decided to perform diagnostic-therapeutic arthroscopy and close monitoring was continued for associated pathology.\n"
  },
  {
    "id": "multiclinsum_gs_en_244.txt",
    "fulltext": "Patient presentation. A 43-year-old male patient, with a history of drug and alcohol abuse and a failed cardioversion for AF, experienced increasing breathlessness, cough and fatigue. A respiratory tract infection was initially suspected, and Amoxicillin 500 mg three times daily was prescribed. Over the next eight days, the patient’s condition deteriorated, with the development of new left-sided chest pain. A PE was suspected. Rivaroxaban 15 mg twice daily was prescribed and the patient was referred to Same Day Emergency Care (SDEC). Upon assessment at SDEC the following day, a twelve-lead electrocardiogram (ECG) confirmed AF, consistent with the patient’s history of AF from 10 years prior. The patient reported experiencing orthopnea and a history of three unsuccessful cardioversion attempts over the 10 years since being diagnosed with AF, with the most recent attempt occurring three years ago. The patient also reported that he had stopped taking sotalol 160 mg twice daily at least a year ago and had been taking it inconsistently for a few years before that, mistakenly believing his symptoms had improved. While he was open about this, he could not remember the exact dates when he started or stopped the medication. The patient’s social history revealed chronic drug and alcohol abuse, which likely contributed to his non-adherence to AF medication.\n\nA twelve-lead electrocardiogram (ECG) confirms atrial fibrillation in the patient.\n\nInvestigations/Differential diagnoses. The patient scored 4/10 on the Borg Rating of Perceived Exertion (RPE) at rest, a scale commonly used to assess perceived exertion, including the respiratory component, as part of overall physical effort. The patient exhibited a dry, irritable cough with concurrent left chest pain. Examination revealed an irregular pulse and bilateral basal wheezing. Despite these symptoms, the patient believed it was merely a severe case of the flu.\n\nThe differential diagnosis included community-acquired pneumonia (CAP), PE, pleuritis, aortic dissection and pneumothorax. The patient’s blood pressure was 154/92, heart rate 126 and oxygen saturation (SpO2) 95%. The patient’s laboratory results showed several abnormalities. An elevated C-reactive protein (CRP) level of 10 mg/l (normal ≤5 mg/l) suggested inflammation, and a significantly raised D-dimer level of 993 ng/ml (normal ≤250 ng/ml) indicated a possible thromboembolic event, warranting further investigation to rule out PE. The N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) level of 6,374 ng/l (normal 0-399 ng/l) was highly indicative of HF, and an elevated Troponin T level of 161 ng/l (normal ≤14 ng/l) indicated cardiac injury.\n\nCAP was ruled out based on the lack of consolidation on the chest X-ray and only slightly raised CRP levels, making pleurisy due to CAP unlikely as well. The absence of pain triggered by coughing, chest wall movements and sneezing further supported this. Aortic dissection and pneumothorax were also excluded based on clinical examination and investigations. The patient’s clinical scoring results indicated a low probability of PE with a low Wells score of less than 2 and negative YEARS algorithm results. The patient’s lab results indicated significant cardiac stress and potential HF. Chest CT or CT Pulmonary Angiogram (CTPA) are the gold standard for diagnosing PE. However, a discussion with the radiologist concluded that neither chest CT nor CTPA was necessary, as the chest x-ray indicated acute pulmonary oedema, strongly suggesting HF. This, along with the clinical presentation, required immediate hospital admission.\n\nChest X-ray findings: Five years ago, the X-ray showed normal cardiopulmonary structures. The recent X-ray, following referral to Same Day Emergency Care (SDEC), revealed an enlarged heart and prominent pulmonary vasculature, consistent with signs of pulmonary congestion.\n\nManagement plan/Follow-up. The patient was initially transferred to the cardiology team and admitted to the hospital, where he remained as an inpatient for five days. The initial management plan included immediate rate control with a stat dose of Bisoprolol 2.5 mg and sotalol was considered inappropriate due to its lack of efficacy and potential pro-arrhythmic effects and prolongation of cardiac repolarisation. To reduce congestion and off-load fluid, the patient received stat doses of intravenous (IV) furosemide 40 mg and oral spironolactone 25 mg. An urgent cardiac echo was performed on the second day of admission, confirming HF with an ejection fraction (EF) of less than 35% and a Simpson’s method EF of below 20%.\n\nThe cardiology team reviewed the need for antico-agulation, considering the patient’s ORBIT score of 0, indicating a 2.4% annual risk of bleeding (low risk), and a CHA2DS2-VASc score of 1, indicating a 0.6% annual risk of stroke (low to moderate risk) and a 0.9% annual risk of stroke or transient ischaemic attack (TIA). Given these risk levels, anticoagulation was not indicated. Following his hospitalisation, the patient was discharged to the outpatient heart failure clinic (HFC) with a diagnosis of HFrEF.\n\nUpon follow-up with the HFC, the patient was pharmacologically optimised with dapagliflozin 10 mg tablet (oral, once daily), digoxin 125 micrograms (oral, once daily), eplerenone 25 mg tablet (oral, once daily), furosemide 40 mg tablet (oral, once daily), apixaban 2.5 mg tablet (oral, twice daily) and bisoprolol 5 mg tablet (oral, once daily). During his treatment, the patient’s clinical progress showed significant improvement with optimised medical management. The patient no longer experienced orthopnoea and his weight decreased from 94 to 86 kg. The patient’s blood pressure decreased to 124/65, heart rate to 65, and SpO2 increased to 98%. A follow-up appointment was scheduled to discuss the initiation of angiotensin receptor-neprilysin inhibitors (ARNIs) alongside other therapies. Additionally, the patient participated in shared decision-making regarding medication adherence and received education on self-care for his condition.\n\nThe patient was contacted for a telephone follow-up, during which he reported notifying the Driver and Vehicle Licensing Agency (DVLA) about his condition due to his role as a truck driver. As a result, he has been temporarily reassigned to an office job while his health is improving. He also confirmed strict adherence to his medication regimen and reported no side effects.",
    "summary": "A 43-year-old male experienced increasing breathlessness, cough, and fatigue. Initially suspected to have a respiratory infection, his persistent symptoms raised concern for PE. The patient had a history of AF, unsuccessful cardioversion, and long-term non-adherence to beta blockers. Initial assessment revealed persistent respiratory symptoms and elevated levels of C-reactive protein, D-dimer, N-terminal pro-B-type natriuretic peptide, and Troponin T. Chest X-ray showed pulmonary congestion, and echocardiogram confirmed a severely impaired ejection fraction (EF <20%). While the differential diagnosis included community-acquired pneumonia, PE, and HF, the final diagnosis was worsening AF and HF with reduced EF, not PE."
  },
  {
    "id": "multiclinsum_gs_en_453.txt",
    "fulltext": "31-year-old male, involved in a high-energy traffic accident (50 km/h), driving a motorcycle. The patient was a hospital trauma surgeon and had no relevant medical history or previous injuries to the ankle. Initially evaluated by a multidisciplinary medical team in the emergency department who ruled out thoracoabdominal injuries after the examination and blood analysis and radiographs of the chest, pelvis and spine. During the secondary evaluation of the patient, the affected limb was examined and radiographs of the ankle were performed. He presented moderate swelling and soft tissue haematoma at the medial and lateral aspect of the ankle. During the physical examination, the patient presented pain and impotency with any mobilisation. No instability was detected during the ligament examination. The radiographs of the ankle did not show acute bone injuries. The clinical case was classified as a sprain of the ankle and anti-inflammatory pharmacological therapy, cryotherapy and semi-compressive elastic bandage was indicated. The patient was authorised to bear weight on the affected limb. No suspicion of posterior tibial tendon rupture was detected and this injury was not noticed. After the improvement of soft tissue swelling, the patient performed self-examination of the ankle by palpating the mobile tubular structure at the medial aspect of the ankle and pain when attempting inversion of the foot. He returned to the emergency department and an MRI was indicated to extend the study. The MRI image showed an avulsion of the flexor retinaculum with posterior tibial tendon rupture associated with partial rupture of the deltoid ligament, complete rupture of the peroneal-astragalus ligament. The anterior aspect of the deltoid ligament was not reduced with the neutral position of the ankle. The flexor retinaculum was sutured with double sutures of resorbable material, reinsertion of the posterior region of the deltoid ligament and fascial tissue with two tapes and two 3.5 mm metallic arpons. In addition, reinsertion of the anterior region of the deltoid ligament was performed with a Mason Allen type suture with tape and a 3.5 mm metallic arpons. After the stability of the tendon was verified, the ankle was immobilised for three weeks to protect the repair of the flexor retinaculum with a double supracondylar plaster cast. After the operation, the patient was able to bear weight on the affected limb with a double supracondylar plaster cast for one month. After this time, partial weight bearing was initiated. The patient was able to walk with a rigid orthosis and daily rehabilitation sessions with magnetotherapy at home. One month after the operation, the patient did not have pain during walking with partial weight bearing with a rigid orthosis. Six weeks after the operation, the patient was able to bear weight with no need for orthesis or canes, with good tolerance. Two months after the start of rehabilitation, the patient presented a deficit of 10° for plantar flexion (50°) and a 5° deficit for dorsiflexion with respect to the contralateral ankle (30°) without presenting deficits in other ranges of movement. Three months after the operation, the patient was able to walk in a toe-off position and started sports activities prior to the trauma. The functional result according to the American Orthopaedic Foot and Ankle Society (AOFAS) scale for the hindfoot and ankle is 97 points out of 100, so we can consider a good postoperative functional result.\n",
    "summary": "A 31-year-old man with no significant medical history was involved in a high-energy motor vehicle accident. He had a dislocated posterior tibial tendon that went unnoticed. Early diagnosis allowed for primary flexor retinacular repair and anatomic reduction of the tendon.\n\nResults: The patient was able to return to sport three months after the injury with good functional outcome.\n"
  },
  {
    "id": "multiclinsum_gs_en_565.txt",
    "fulltext": "A 4-year-old girl was admitted to our hospital with a 2-day history of fever, chest pain, and agitation. Her past medical history was unremarkable, and she had a negative family history of primary immunodeficiency disease. She had a temperature of 37.9 °C, a heart rate of 190 beats per minute, and an oxygen saturation of 97% in room air. Physical examination revealed clouding of consciousness and lip swelling. Laboratory tests showed a white blood cell count of 49 × 103/L (neutrophils, 90.5%, and atypical lymphocyte, 1.0%), a C-reactive protein concentration of 32.6 (normal range: 0–0.5) mg/dL, a lactate dehydrogenase concentration of 434 (normal range: 80–220) U/L, an aspartate aminotransferase concentration of 31 (normal range: 8–35) U/L, an alanine aminotransferase concentration of 20 (normal range: 5–40) U/L, and an anti-streptolysin O concentration of 1908 (normal range: 0–200) IU/mL. Chest X-rays revealed decreased permeability throughout the right lung field, and computed tomography (CT) revealed a right sided pleural effusion, fluid collection in the retropharyngeal and mediastinal areas, cervical lymphadenopathy, and marked hepatosplenomegaly. The patient was diagnosed with empyema, retropharyngeal abscess, and mediastinitis. She required admission to the intensive care unit due to respiratory failure. To improve her dyspnea, a chest tube was inserted, and meropenem treatment was initiated. The pleural fluid was turbid and exudative, with Gram-positive cocci. The culture of the fluid was positive for S. pyogenes. The patient’s condition improved temporarily, but on day 5 in our hospital, she developed a fever again. A repeat CT scan showed exacerbation of fluid retention in the retropharyngeal area and the mediastinum, for which the patient underwent drainage and debridement of necrotic tissue in the retropharynx and mediastinum. In the operation, the otolaryngology–head and neck surgery team performed retropharyngeal drainage and debridement with a left neck incision and two drainage tubes inserted, followed by the drainage and debridement of the mediastinal abscess by thoracic surgery team, using a bilateral video-assisted thoracic surgery (VATS) approach, with the two chest drain tubes (24 Fr) inserted on each side. The bilateral VATS procedure was sufficient for the drainage of the mediastinal abscess, including the retrosternal abscess, without using median sternotomy. The drainage tubes in the retropharyngeal space and the bilateral chest drain tubes were extubated on postoperative day 6. After detection of S. pyogenes, the patient was started on an intravenous drip of penicillin and clindamycin, after which she continued to recover steadily. The presence of cervical lymphadenopathy and marked hepatosplenomegaly at the time of diagnosis suggested the involvement of EBV. Serological tests for EBV revealed IgM and IgG antibodies specific to the EBV viral capsid antigen, but the patient was negative for IgG antibodies reactive with the EBV nuclear antigen, findings that are indicative of primary EBV infection at the time of the DNM onset. Finally, she was diagnosed with DNM and empyema following primary EBV infection. She had postoperative complications, including a catheter-related bloodstream infection and drug fever, but was discharged after 85 days in our hospital. She underwent immune function testing (immunoglobulins and complements), which revealed no deficits. At follow-up 1 year later, she was doing well.",
    "summary": "A 4-year-old girl was admitted to our hospital with a 2-day history of fever and chest pain. Computed tomography (CT) revealed a right sided pleural effusion, fluid collection in the retropharyngeal and mediastinal areas, cervical lymphadenopathy, and marked hepatosplenomegaly. She was diagnosed with empyema, retropharyngeal abscess, and mediastinitis. To improve her dyspnea, a chest tube was inserted, and antibiotic treatment was initiated. Her condition improved temporarily, but on day 5 in our hospital, she developed a fever again. A repeat CT scan showed exacerbation of fluid retention in the retropharyngeal area and the mediastinum, for which she underwent drainage and debridement of necrotic tissue in the retropharynx and mediastinum. The presence of cervical lymphadenopathy and marked hepatosplenomegaly suggested the involvement of EBV. Serological tests for EBV revealed primary EBV infection at the time of the DNM onset. Finally, she was diagnosed with DNM following primary EBV infection. At follow-up 1 year later, she was doing well."
  },
  {
    "id": "multiclinsum_gs_en_279.txt",
    "fulltext": "A patient in her early 30s, G2P1001 with intrauterine pregnancy at 12 weeks’ gestation was initially admitted to an inpatient psychiatric unit seven months after delivering her first child due to new-onset psychosis and starvation ketosis. According to her husband, she had been self-isolating, not eating, and not taking care of her infant in the weeks after the birth of her first child. Her past medical history included hypothyroidism, inflammatory bowel disease, and anemia of chronic disease, but no prior psychiatric illness. Her thyroid stimulating hormone (TSH) level confirmed appropriate levothyroxine dosing. Her psychotic symptoms did not improve after initial inpatient treatment with olanzapine, mirtazapine, and haloperidol, and she continued to deteriorate with ongoing refusal to eat and 10 kg weight loss, which was a 20% loss from her weight at presentation. Her pregnancy was also complicated by an ultrasound diagnosis of multiple fetal anomalies at 17- and 20-weeks’ gestation, including double outlet right ventricle, transposition of the great arteries, and intracranial ventriculomegaly. The patient and her husband (i.e., her surrogate decision-maker) were informed of these findings and counseled on management options including prenatal genetic screening tests and amniocentesis, which they declined. They were also counseled on the options of pregnancy continuation, adoption, and termination, and they decided to continue the pregnancy.\n\nPostpartum psychosis was eventually determined to be the patient’s most likely psychiatric diagnosis, given that the onset of her mental illness occurred after the birth of her first child and then persisted into her current short-interval pregnancy. Therefore, at 20 weeks’ gestation, she was started on lithium, the first-line treatment for postpartum psychosis. At 26 weeks’ gestation, she developed symptoms of an upper respiratory infection and significantly decreased her oral intake of fluids due to pain with swallowing. Her dehydration led to volume depletion and impaired renal clearance of lithium, which precipitated lithium toxicity with serum lithium levels as high as 3.90 mmol/L (therapeutic range: 0.8–1.2 mmol/L) [3]. She then developed respiratory failure due to aspiration pneumonia in the setting of lithium toxicity, and she was admitted to the intensive care unit (ICU) where she was intubated, started dialysis for lithium-induced AKI, and received norepinephrine, midodrine, and piperacillin/tazobactam for presumed septic shock. Blood, respiratory, stool, and urine cultures ultimately came back negative for growth; however, all the cultures were collected after antibiotic therapy had already been initiated. One week after ICU admission her fevers resolved, her chest X-ray showed interval decrease in multifocal patchy airspace opacities, her white blood cell count down-trended from 81.8 K/cumm to 19.1 K/cumm, her lithium level decreased to <0.10 mmol/L, and her serum creatinine improved from 2.58 mg/dL to 0.64 mg/dL. However, at 27 weeks’ gestation, she developed multiple mild-range blood pressures more than 4 h apart and intermittent severe-range blood pressures, which persisted for two days after vasopressors were discontinued. On the same day when her blood pressures became elevated, she also developed elevated LFT’s (AST 58 U/L, ALT 36 U/L), which rapidly increased to AST 413 U/L, ALT 281 U/L over the next 24 h. Liver ultrasound showed hepatomegaly with an otherwise normal- appearing liver. Due to concern for medication side effect as the underlying etiology of her elevated LFT’s, piperacillin/tazobactam was discontinued, and her sedative was switched from Propofol to dexmedetomidine.\n\nAfter these medication changes, her AST initially slightly down-trended to 323 U/L while ALT up-trended 346 U/L; however, her LFT’s subsequently increased again to AST 506 U/L, ALT 510 U/L. In addition to rapidly rising LFT’s, her labs were notable for an elevated LDH of 603 U/L, an elevated protein/creatinine ratio of 2.83, and up-trending platelet count in the 400s K/cumm. During this time, she continued to have intermittent mild-range blood pressures off vasopressors. However, she had normal serum creatinine, serum glucose level, and coagulation profile, and her peripheral blood smear did not show evidence of hemolysis. During extubation trial, she was noted to have rhythmic jerking of her bilateral upper extremities that was initially concerning for seizure activity vs. agitation; however, she subsequently had a normal electroencephalogram and computed tomography scan of the head. Due to the overall clinical picture concerning for PE with severe features, the patient received a betamethasone course for fetal lung maturity and intravenous magnesium sulfate for seizure prophylaxis, then underwent cesarean delivery at 27w2d. On postpartum day #1 her LFT’s began down-trending to AST 359 U/L, ALT 471 U/L, and by postpartum day #8 her blood pressures returned to normal with AST 19 U/L, ALT 96 U/L. At her outpatient postpartum checkup one month after delivery, she continued to have normal blood pressures with AST 15 U/L, ALT 15 U/L.\n\nThe neonate was small for gestational age with a birthweight of 840 g (3%), although the estimated fetal weight measured appropriate for gestational age on prenatal ultrasounds. The neonatal 1 min Apgar score was 0 and 5 min Apgar score was 1. The infant had respiratory distress syndrome and required extensive resuscitation including chest compressions for 10 min and intubation. Postnatal imaging confirmed multiple anomalies including septo-optic dysplasia, double inlet left ventricle with a highly underdeveloped right ventricle, and an interrupted aortic arch. The infant eventually deteriorated due to cardiac complications and demised after palliative extubation was performed on day of life #66.",
    "summary": "A patient in her early 30s, G2P1001 with intrauterine pregnancy at 12 weeks’ gestation was admitted seven months after delivering her first child due to new-onset psychosis and starvation ketosis. She was started on lithium for postpartum psychosis at 20 weeks’ gestation. She subsequently developed respiratory failure at 26 weeks’ gestation due to aspiration pneumonia in the setting of lithium toxicity, requiring admission to the intensive care unit (ICU) and intubation. She received antibiotics and vasopressors for suspected septic shock in addition to dialysis for lithium-induced acute kidney injury. One week after ICU admission, her sepsis resolved, her serum creatinine levels returned to normal, and her respiratory status improved. However, after vasopressors were discontinued, she suddenly developed persistently elevated blood pressures with proteinuria and elevated liver function tests (LFT’s). Due to concern for preeclampsia with severe features and rapidly increasing LFT’s, the patient underwent cesarean delivery at 27 weeks’ gestation."
  },
  {
    "id": "multiclinsum_gs_en_16.txt",
    "fulltext": "A 4-month-old girl was admitted to our institution for evaluation and management of poor growth. She was the fourth baby of consanguineous parents; one of her brothers died at the age of 2 months due to sudden infant death syndrome with the other brothers being normal. She was delivered by cesarean section at 38 weeks gestation due to intrauterine growth retardation. Her birth weight was 1240 g, her length was 37.3 cm and her head circumference was 30.5 cm. At the age of 12 days, she was admitted to the neonatal ward for suspected sepsis for a week and discharged in good general condition. On examination, she was found to be severely growth retarded with normal mentality, her weight was 2.5 kg, her length was 47 cm while the head circumference was 36 cm (all growth parameters below the 3rd centile). Clinical examination revealed abnormalities of the craniofacial region with elfin facies, protruding, deformed ears, big widely placed eyes, depressed nasal bridge, overgrown gum, prominent nipples, umbilical hernia, abdominal distension, dark skin (acanthosis nigricans), lipodystrophy, wrinkled hairy loose skin, and wrinkled loose skin and abnormal body proportions with very big feet and palm. Examination of the genitalia showed a big clitoris without palpable gonads. Cardiac auscultation revealed a murmur suggestive of ventricular septal defect (VSD) which was confirmed by echocardiography. The rest of the systemic examination was within normal limits. Investigations revealed hypoglycemia with fasting blood glucose ranging between 33 mg% to 46 mg%, and high levels of postprandial glucose ranging between 299 mg% and 476 mg% in repeated measurement, insulin level was high (345 uIU/ml, N: 2–25 uIU/ml) and C-peptide levels (22 ng/mL). FT4 level was 1.4 ng/dL (normal range:0.7 to 2.0), TSH level was 3.2 uIU/mL (normal range: 0.4 to 5.0), ACTH, cortisol, and 17 hydroxyprogesterone levels were normal. The assay of basal GH level was high (29.4 ng/mL), on the other hand, the level of IGF‐1 was low (30 μg/L), normal level (82–166 μg/L), and insulin-like growth factor-binding protein three was 0.15 mg/L (N: 0.81–1.9). MRI of the abdomen was normal. An echocardiographic study revealed a VSD with no evidence of cardiomyopathy. The chromosomal study was normal [46, XX]. A molecular genetics study revealed IR gene mutation responsible for the occurrence of DS. The parents were heterozygous carriers of this mutation. According to the above-mentioned data, a diagnosis of DS was made. Our patient accomplished control of blood glucose that was maintained between 78 and 146 mg/dl and glycated hemoglobin (HbA1c) of 7.8% on insulin glargine 1.6 unit/kg divided into two doses per day,with frequent nasogastric formula milk feeding. She was discharged from the hospital with the recommendation of follow-up in the outpatient clinic for repeating echocardiography and arranging the schedule for treatment by rhIGF-1.",
    "summary": "We hereby report a case of a 4 month -old girl infant with DS. The patient exhibited dysmorphic facial features, severe growth retardation, fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemia which are the hallmarks of DS. The diagnosis of DS was confirmed by genetic analysis. The patient was treated with high-dose insulin and frequent nasogastric formula milk feeding to achieve reasonable glycemic control."
  },
  {
    "id": "multiclinsum_gs_en_476.txt",
    "fulltext": "He is a 27-year-old male, born and residing in Mexico City, with apparently healthy parents and three siblings. He received the BCG vaccine at birth, but had an adverse reaction two months later with adenitis in both axillae and non-healing at the site of vaccination; he improved with rifampicin for eight months, but had a keloid scar. At nine months, he developed oral and diaper area candidiasis. Although both resolved with treatment, they were recurrent. The oral candidiasis persists to date, affecting his tongue and gums. At seven years of age, he developed scalp tinea, which resolved with unspecified treatment. Since the age of 10, he has had rosacea on his face, initially with papules and erythema on the skin of his cheeks and nose, and currently with chronic changes. At 15 years of age, he developed onychomycosis, receiving multiple antifungal treatments, with no improvement and persistence to date. He has had ocular rosacea since childhood, and also suffers from asthma and allergic rhinitis.\n\nHis skin tests were positive for mites, epithelia of animals and pollen. Topical steroids and inhaled bronchodilators were administered. Because of the chronic nature of candidiasis, an immune system disorder was considered, HIV infection was ruled out and he was informed that he had a chronic granulomatous disease (the diagnosis was not known on what it was based). At 26 years of age, he presented with fever, weight loss, asthenia, adynamia, hyporexia, cough, haemoptysis, dyspnoea and a gluteal abscess. In the emergency department, the patient was in a poor general condition, with malnutrition, pale skin and mucous membranes, respiratory distress, oxygen saturation of 87%, rosacea on the face, tongue and oral mucosa with white plaques, erythema on the gums, a scar from the BCG vaccine 5 cm in diameter, pulmonary hypoventilation, and onychomycosis on the hands and feet.\n\nThe chest tomography showed images corresponding to a right pleural effusion and multifocal pneumonia. The ultrasound of the gluteus showed a deep abscess. The laboratory results showed anemia, leukocytosis at the expense of neutrophilia and elevation of the C-reactive protein. The dihydrorhodamine test was normal, ruling out the previously established diagnosis of chronic granulomatous disease. The culture of the sample taken from the oral cavity and the blood culture had growth of Candida albicans; in the culture of sputum, C. albicans and C. krusei were obtained; the culture of bronchoalveolar liquid was negative.\n\nVancomycin was initiated for the abscess, which improved. The patient received ceftriaxone, clarithromycin, and fluconazole, but the fever persisted. A pleural biopsy was performed, in which M. tuberculosis was detected by PCR. The intensive phase of the antituberculous, or antimycobacterial, regimen was initiated with isoniazid, rifampicin, pyrazinamide, and ethambutol, with adequate improvement. During this hospitalization, he also developed herpes zoster, which resolved with 10 days of valaciclovir. The patient is currently completing his antituberculous treatment.Reevaluating the case, given the history of infection with the bacillus of Calmette-Guérin, tuberculosis, herpes zoster, mucocutaneous candidiasis, and rosacea, the diagnosis was oriented toward an increase in the function of STAT1 (Figure 4). A panel of genes of innate immunity errors was requested, by new generation sequencing, and the pathogenic variant c.961A>G (p.Arg321Gly) was found in the STAT1 gene, associated with an increase in the function of STAT1. His parents and three brothers do not carry the WT/WT) gene STAT1.\n",
    "summary": "This report is about a patient who had increased function of the STAT1 factor in his first year of life. He is now 27 years old and has had a history of infection with Calmette-Guérin bacillus and Mycobacterium tuberculosis, chronic mucocutaneous candidiasis, tinea capitis, and facial and ocular rosacea. HIV infection was ruled out. Based on clinical manifestations, an innate immunity defect was suspected, specifically with increased function or activity of STAT1. The diagnosis was corroborated by sequencing of multiple genes associated with innate immunity defects. In this patient, the pathogenic variant c.961A>G (p.Arg321Gly) in the STAT1 gene was found, previously reported as a function-enhancing mutation.\n"
  },
  {
    "id": "multiclinsum_gs_en_396.txt",
    "fulltext": "A 20-year-old male quarterback for a University varsity football team was tackled by another player in the first quarter, injuring his right lower extremity. He was found to have a right posterior hip dislocation upon assessment by the team surgeon. A closed reduction was performed on the sideline. Neurovascular status was intact before and after reduction. However, the hip remained unstable and required two further reductions. He was subsequently transferred to a Level I trauma centre for further investigations and management.\n\nX-rays of the pelvis demonstrated a posterior fracture dislocation of the right hip. Under conscious sedation, he underwent closed reduction of the hip and was placed in a knee immobilization splint with the hip and knee in extension. CT of the pelvis post-reduction demonstrated comminuted fractures of the femoral head and a fracture of the posterior acetabular wall, consistent with a Pipkin IV injury. He was admitted to hospital and underwent surgical management one day post-injury.\n\nSurgical management\nThe patient was positioned lateral decubitus. A Gibson approach to the right hip was utilized, along with a greater trochanter digastric osteotomy. The damaged portions of the gluteus minimus muscle were debrided. The posterior wall acetabular fracture was visualized, with detached labrum noted to be attached to the fracture. Anterior surgical dislocation of the hip was performed. Free comminuted chondral cancellous fragments were removed from the acetabulum. The femoral head fracture was fixed with two 3.0 mm partially-threaded headless compression screws. The infra-foveal femoral head was microfractured using multiple 2.5 mm drill holes in the region where there was unreconstructible chondral injury. The hip was reduced. Primary repair of the labrum was performed using two suture anchors.\n\nA 3-hole 1/3 tubular plate was utilized as a spring plate over the small posterior wall fragment, secured with a 3.5 mm cortical screw. A 7-hole posterior wall reconstruction buttress plate was then contoured and applied across the spring plate. The greater trochanteric osteotomy was reduced and secured using 4.5 mm and 3.5 mm cortical screws. Fluoroscopy images demonstrated appropriate reduction and implant placement. Piriformis and external rotator tendons were repaired through bone tunnels. Soft tissues were repaired and closed accordingly.\n\nRehabilitation\nPostoperatively, the patient was restricted to foot-flat weightbearing to the right lower extremity, no more than 70 degrees of hip flexion, and no hip adduction or internal rotation past neutral for 6 weeks. 6 weeks of DVT prophylaxis with enoxaparin in hospital and ASA 81 mg PO BID upon discharge was prescribed. The patient was discharged from hospital at 1-week post-surgery. X-rays at 2 weeks post-op demonstrated hardware in place with congruent hip joint.\n\nAt 6 weeks post-op, X-rays of the right hip demonstrated healed greater trochanter osteotomy and some disuse osteopenia of the femoral head. He was cleared to start progressive weightbearing as tolerated with 25 % weight increase weekly until full weightbearing in 1 month. Hip range of motion restrictions was removed and he was started on strengthening of the hip abductors, extensors, adductors, and flexors and his targeted return to sport program.\n\nAt 4 months post-surgery, x-rays continued to demonstrate a well-reduced hip with symmetrical congruent weightbearing surface, maintained hardware, without evidence of avascular necrosis. Mild heterotopic ossification in the supraacetabular region was noted. He was cleared for impact exercise including jogging.\n\nReturn to sport\nAt 6 months post-surgery, the patient was performing pain-free jogging, swimming, and weight training. On physical examination, he had 120 degrees of hip flexion, 45 degrees of external rotation, and 20 degrees of internal rotation, comparable to the contralateral side. No popping or crepitus was noted with hip range of motion. He was cleared for return to sport specific training. At 10 months post-injury, the patient returned to full-time play as the starting quarterback of his University varsity football team. He remained pain-free and completed the entire season with no complications at 1-year post-injury.",
    "summary": " We report a case of a 20-year old male quarterback who sustained a Pipkin type IV fracture dislocation during a football game. He underwent immediate closed reduction, transfer to a Level I trauma centre, surgical management, and progressive rehabilitation. Clinical and radiographic assessments were carried out periodically for 1 year. At 10 months post-injury, the athlete returned to full-time play as the starting quarterback of his University football team. He completed a pain-free season at 1-year post-injury. Clinical and radiographic evaluations demonstrated appropriate healing with no complications."
  },
  {
    "id": "multiclinsum_gs_en_12.txt",
    "fulltext": "Female, 61 years old, Caucasian, married, two children, reported worsening of psoriasis symptoms after initiation of L-methylfolate 15 mg daily for adjunctive treatment of depression. She had reported depression and psoriasis since the age of 20. Since the age of 41, the patient had no recurrence of psoriatic lesions.\n\nShe had a history of depressions and was prescribed lithium carbonate, but it was avoided due to psoriasis. In 2000, she showed improvement of the depressive condition with venlafaxine 225 mg daily. In 2016, due to mood swings, she was given lamotrigine 100 mg daily and, to improve her sleep, quetiapine 50 mg daily.\n\nThese were the current doses, with improvement in depression, quality of life and no significant adverse effects.\n\nIn January 2019, a polymorphism in the MTHFR gene was detected with a heterozygous mutation in C677T, and the patient was prescribed 15 mg of L-methylfolate daily. Before the end of the first week of use of L-methylfolate, psoriatic lesions appeared, which had not manifested themselves for 20 years. The patient was reported to the psychiatrist, who withdrew the medication, and 4 days later, the psoriatic lesions began to remit, disappearing completely after a few weeks. The patient remained without new records of manifestations until early 2020.\n",
    "summary": "Female patient, 61 years old, in remission of psoriasis for 20 years. She presented a relapse of psoriasis in the form of plaques a few days after the start of treatment with L-methylfolate at a daily dose of 15 mg.\n"
  },
  {
    "id": "multiclinsum_gs_en_521.txt",
    "fulltext": "A 24-year-old male patient came to the Oral Medicine Clinic, Dental Hospital Universitas Padjadjaran, with the chief complaint of dry and sore mouth for one month after taking medication from the psychiatry department. He was diagnosed with GAD and had been taking a compounded antidepressant from a psychiatrist, namely sertraline 50mg, sulpiride 50mg, and clobazam 10mg. Since three days ago, the patient had stopped taking the drug because he felt his mouth was getting uncomfortable History of recurrent oral ulceration and allergies was denied. He brushed his teeth and tongue twice daily, every morning and night, before bed. He denied the habits of smoking and alcohol consumption.\n\nThe patient consulted the psychiatry department because he felt stressed and anxious since being infected with COVID-19 about six months ago. He underwent hemorrhoid surgery in the same year, which intensified his complaint. The patient frequently used internet-based search engines to look for information on his condition and disease, which caused him to feel uncontrollably anxious. The patient worked for a private company with a very high work target at one point. The patient felt quite depressed and unable to self-regulate his psychological condition. He had a poor diet, lacked sleep, and rarely exercised.\n\nThis study has received approval and written informed consent from the patient to publish data and images. This study complied with the Declaration of Helsinki. The institution has approved the publication of this study. The extraoral examination showed dry and exfoliative lips. The intraoral examination revealed a depapilation surrounded by a white plaque on the dorsum of the tongue, frothy saliva, and a dental mouth mirror sticking to the tongue and buccal mucosa. The Oral Hygiene Index Simplified (OHI-S) from Green and Vermillion was used as a clinical parameter for evaluating oral hygiene conditions. The patient had plaque and stains in all regions of the teeth and calculus in some regions of the teeth, resulting in moderate oral hygiene with a score of 2.2.\n\nThe objective measurement of xerostomia can be done by assessing salivary flow rate (sialometry) or from the patient’s clinical condition using the Clinical Oral Dryness Score (CODS). The spitting method was used for salivary flow rate assessment in the unstimulated condition, collected between 8 to 11 am. Navazesh et al, stated that the subjects are required to fast, not smoke, not chew gum, and not perform any oral procedures at least one hour before the examination. Saliva is allowed to accumulate on the floor of the mouth and the subject spits it out into the graduated test tube every 60 seconds, for 5 minutes, and is quantified volumetrically using the indicator on the test tube. The salivary flow rate was stated as mL/min (normal = 0.3 to 0.4 mL/min).The patient’s unstimulated salivary flow rate was obtained at 0.28 mL/min.\n\nThe objective assessment of xerostomia using CODS obtained a cumulative score of three, categorized as mild xerostomia. The Depression, Anxiety, and Stress Scale-21 items (DASS-21) questionnaire was used to estimate the psychological condition and screen for common mental disorders. The DASS-21 questionnaire showed an extremely severe level of anxiety (score = 13). Based on anamnesis and clinical examinations, the established oral diagnoses were GT with mild xerostomia and exfoliative cheilitis.\n\nCase Management\nPharmacological and non-pharmacological therapies were conducted to manage this patient. Pharmacological therapy was 0.2% hyaluronic acid gel, 0.025% hyaluronic acid mouthwash, and petroleum jelly 100% given for two months. Oral hygiene instruction and healthy lifestyle counseling were given as non-pharmacological approaches. Oral hygiene instructions include brushing teeth and tongue twice daily, in the morning after breakfast and at night before bed. The patient was also instructed to consume small but frequent amounts of a minimum of 1.5 liters of water daily, eat a nutritionally balanced diet, get enough rest, and exercise regularly. Patients were also referred back to psychiatrists regarding complaints and management of the patient’s GAD condition, however, he did not follow our instructions. He felt his mouth was getting uncomfortable due to the psychiatric medication.\n\nThe periodic treatment visits in this patient showed encouraging results at each control visit. This article reports three follow-up visits: two weeks after the first visit (first follow-up), four weeks after the second visit (second follow-up), and three months and ten days after the third visit (third follow-up).\n\nAt the first follow-up visit (two weeks after the first visit), the patient still had a sore tongue, and the oral cavity and lips were still dry. The patient has used the medication as instructed, the mouthwash has run out, and the gel medication remains in stock. There were dry and exfoliated lips, frothy saliva, dental mirror sticks on the buccal mucosa and dorsum of the tongue, and depapilation surrounded by a white plaque on the dorsum of the tongue. CODS and salivary flow rate as the supporting examinations can only be carried out at this visit. The CODS assessment resulted in a score of three, which is mild xerostomia, and the unstimulated salivary flow rate was 0.28 mL/min, which is hyposalivation. The DASS-21 questionnaire obtained a score of 29 with an anxiety score of 13, described as extremely severe anxiety.\n\nAfter four weeks, the patient visited for a second follow-up. The patient felt that the appearance of islands on the tongue remained but with a reduced level of pain, however, the dryness of the lips and mouth had improved. The patient has used mouthwash and topical medication as instructed. The objective examination revealed depapilation surrounded by a white plaque on the dorsum of the tongue. The CODS assessment resulted in a value of zero, which is normal, and the unstimulated salivary flow rate was 0.34 mL/min, which has reached normal values. The DASS-21 questionnaire obtained a score of 28 with an anxiety score of 10, described as severe anxiety.\n\nAfter three months and ten days, the patient no longer complained of oral dryness, the CODS was decreased to zero, and the unstimulated salivary flow rate increased to more than 0.3 mL/min. There was an improvement in xerostomia, and the GT became asymptomatic, with a greater reduction of the DASS in this patient. The DASS questionnaire obtained a score of 7 for anxiety, described as moderate anxiety. Until this fourth visit, the patient had not visited a psychiatrist and did not continue taking antidepressant medication. DASS assessment in this patient showed favorable progress in reducing anxiety scores at every visit. Supplementary extra-oral and intra-oral documentation taken during the third follow-up visit (three months and ten days). Furthermore, we educated the patients to consume one tablet of multivitamins daily, maintain oral hygiene, maintain a healthy lifestyle, and consult a mental health expert about their psychological condition.",
    "summary": "A 26-year-old male patient complained of dry and sore mouth for one month after taking medication from the psychiatry department, was diagnosed with GAD, and had already consumed the antidepressant sertraline. Extraoral examination showed dry and exfoliative lips. Intraoral examination showed white plaque with depapilation on the dorsal tongue, frothy saliva, buccal mucosa and dorsal tongue sticking to the dental mirror. The unstimulated salivary flow rate was <0.2 mL/min (sialometry method). The Depression, Anxiety, and Stress Scale-21 (DASS-21) questionnaire was used to estimate the psychological condition and showed an extremely severe level of anxiety (score = 13). The established oral diagnoses were GT with mild xerostomia and exfoliative cheilitis.\n\nCase management: For two months, patients received hyaluronic acid gel and mouthwash, as well as a non-pharmacological approach to healthy lifestyle counseling. There was an improvement in xerostomia, and the GT became asymptomatic, with a reduction of DASS score in this patient."
  },
  {
    "id": "multiclinsum_gs_en_481.txt",
    "fulltext": "A 55-year-old female patient with a medical history of rheumatoid arthritis and uterine myomatosis was diagnosed with a thyroid gland calcification. Thyroid biopsy was performed, and papillary thyroid carcinoma was detected. Total thyroidectomy was performed with positive resection margins and no signs of lymph node invasion. Radioactive iodine ablation was performed, and further imaging did not show signs of metastases. Thyroid hormone replacement was initiated, and regular follow-up was performed (with no abnormalities), which included thyroid ultrasound, thyroglobulin, and antithyroglobulin antibodies.\n\nIn the following years, TSH and thyroid hormone levels began with unusual pattern concentrations that continued for almost 7 years. TSH varied in most measurements between the normal range (0,02-40 uUI/L), but total T4 (212-295 nmol/L), free T4 (1,84-3,99 ng/dL), and total T3 (1,98-3,72 nmol/L) were consistently high or in the upper normal limit.\n\nSubsequently, symptoms such as right hemibody tremor, rigidity, and hypokinesia were observed, and Parkinson’s disease was diagnosed. Initial treatment consisted of selegiline and pramipexole. Additionally, TSH levels increased above the upper normal limit. Therefore, a sella turcica MRI was performed finding a partial empty sella and alpha-subunit was found within normal limits, ruling out a pituitary adenoma. Parkinson’s symptoms continued to progress with a wide stepping gait, cogwheel rigidity, and tremor at rest in the right hand. Consequently, selegiline was replaced by rasagiline, and rotigotine was added; however, the latter was discontinued due to the emergence of a papular rash in the area of administration. Levodopa/carbidopa was started because of the worsening of symptoms and thyroid function tests showed TSH (0,29-3,44 uUI/L), total T3 levels (1,65-1,99 nmol/L) and free T3 (3,12-3,99 pg/mL) within normal limits. Nevertheless, total T4 (287-373 nmol/L) and free T4 levels (2,2-3,9 ng/dL) steadily increased.\n\nRecently, the patient presented with hyperphagia and overspending, which was probably related to pramipexole. The medication was discontinued, and safinamide was added. In the latest medical follow-up, a thyroid ultrasound was performed, and lymph node mapping detected a nodular lesion in the thyroid bed measuring 8.8 x 7.3 millimeters. Moreover, thyroglobulin levels rose from 1 to 4 uUI/L in the last year. Biopsy confirmed the presence of atypical follicular cells. Thyroid function tests were abnormal with suppressed TSH (0,09 uUI/L), normal total T3 (1,87), and elevated free T3 (4,17 pg/mL) and total T4 (387,6 nmol/L). Thyroid hormone replacement was adjusted, and TSH concentration was later normalized.\n\nThe patient underwent lymph node resection, which was positive for malignancy. In the upcoming weeks, radioactive iodine will be administered. Over the years, thyroid function tests showed that free T4 and total T4 levels steadily increased, while TSH was mostly high or within the normal limits, suggesting a possible thyroid hormone resistance syndrome. Moreover, total T3 levels were abnormally elevated until levodopa/carbidopa was initiated, and the concentrations decreased below the upper normal limit. TSH levels also decreased without rising again above the upper normal limit, indicating a possible influence of levodopa on thyroid function.",
    "summary": "he present study describes a 55 year-old female diagnosed with surgically resected papillary thyroid carcinoma. During the endocrinology consults, elevated thyroid hormone levels were detected without an adequate TSH response, and THR was suspected. Moreover, Parkinson's disease was diagnosed, and treatment with levodopa/carbidopa was initiated. Following this regimen, her TSH and total T3 levels were subsequently normalized, which suggests a potential effect of this agent on the normalization of these hormone levels in the blood. In this case, the role of levodopa was crucial to regulate the TSH concentration which was required to carry out the resection of a tumoral remnant."
  },
  {
    "id": "multiclinsum_gs_en_66.txt",
    "fulltext": "The 62-year-old female patient came to Unpad Dental Hospital with complaints of a lump on the corner of the left lip and pain. Anamnesis showed that the patient had a fever and was somewhat weak at the beginning before the complaint of the lump. Initially in the form of a white spot since 6 weeks ago then getting bigger, painful and broken. When it broke, the patient squeezed the lump until a pus-like liquid came out. The lump had shrunk but never completely disappeared. The patient went to the clinic and was given gentamicin ointment, but there was no change. The patient’s occupation. The patient denied a history of recurrent thrush and food or drug allergies. Smoking and alcohol consumption were not present.\n\nOn extraoral examination, a lump was found on the left corner of the lip, there was a 1 × 2 cm lump, filled with purulent exudate, and sore. The lip also looked dry and flaky. Intraoral found white plaque on the entire dorsum of the tongue can be scraped without leaving reddish areas, and on the teeth, there are cervical caries in several teeth.\n\nFirst visit, the patient was given pharmacological therapy in the form of chlorhexidine gluconate mouthwash 0.2%, which was swished twice a day 10 mL and then discarded, and given a vaseline album to be applied to the upper and lower lips twice a day. Non-pharmacological therapy is given in the form of advice to get enough rest, maintain diet and oral hygiene and not use lipstick alternately. The patient was asked to do an anti-HSV-1 IgG serology test.\n\nThe following day the patient’s serology test results came out and was found to be HSV-1 reactive with a result of 122 (Positive > 25) The patient was then prescribed acyclovir 400 mg five times a day for 7 days and added a multivitamin to be taken once a day. Mouthwash and vaseline albums were continued to be used, additional education was given to the patient to avoid triggering factors such as emotional stress, fatigue, spicy food and sun exposure.\n\nThe next follow-up, 10 days after taking acyclovir, was carried out via text conversation using the Whatsapp application because the patient still did not have time to return for control. Acyclovir and multivitamins are taken regularly and now that the lump is no longer painful and sore and has started to shrink but has not disappeared completely, the patient is advised to stop taking acyclovir and chlorhexidine gluconate mouthwash 0.2% and continue taking multivitamins and using vaseline albums.\n\nFollow-up 3 months later, the lesions seemed to have disappeared, the pain and soreness had completely disappeared. The patient has not taken any medication, and in the past 3 months, the lesions have not reappeared.",
    "summary": "History and Clinical Findings\nA 62-year-old woman presented with complaints of a lump at the corner of her left lip, which had disappeared but reappeared. Six weeks ago, the lump started as a white spot, then gradually enlarging, becoming painful, and ruptured. The patient went to the clinic for treatment and was given gentamicin ointment, but there was no improvement. Extraoral examination showed a nodule in the corner of the left lip measuring 1 × 2 cm, filled with purulent exudate. Serological examination revealed reactive anti-HSV-1 IgG results, leading to a diagnosis of Herpes Labialis.\n\nCase Management\nPharmacological therapy comprised antivirals and multivitamins. The lesion resolved after 10 days of treatment with no reported recurrence during the three-month evaluation."
  },
  {
    "id": "multiclinsum_gs_en_221.txt",
    "fulltext": "A 45 years old woman was admitted for NYHA class II-III exertional dyspnea associated with typical cardiac chest pain lasting for 1 week. She had no previous medical history apart from arterial hypertension treated with Lisinopril 10 mg od, and she was physically active. No family history of heart muscle disease or sudden cardiac death was present. Physical examination was unremarkable.\n\nECG was in sinus rhythm at 63 bpm, with a normal atrioventricular and intraventricular conduction. There was no Q-waves or ST-segment changes but diffuse deep T wave inversion was present from V2 to V6, and in leads DI, DII, aVL and aVF. QTc (Bazett) interval was severely prolonged to 570 ms. Initial routine blood tests including haemogram, renal and thyroid function tests were normal. A slight troponin increase was present (hsTnT 19 mcg/L, Normal < 14 mcg/l) together with a severe increase in NT-proBNP levels (6085 ng/l, Normal < 125 ng/l). Echocardiography showed a non-dilated left ventricle with localized left ventricular hypertrophy of the apex and inferior septum (maximal wall thickness of 22 mm). LVEF was 72% with no regional wall motion abnormalities, and there was complete obliteration of the apex in systole. The left atrium was not dilated and the other parameters of diastolic function were within normal range (E/A ratio of 1; mean E/e’ ratio 7,5). No valve disease was noted. Coronary angiogram showed unobstructed coronary arteries. Cardiac magnetic resonance performed at the 4th hospital day also showed non-dilated hypercontractile LV with a LVEF of 74% and no regional wall motion abnormalities. Maximal LV wall thickness was 17 mm at the inferior apical segment and wall thickness was normal in the basal segments. Using T2-mapping sequences, the T2-relaxation time of the myocardium was increased in the mid to apical segments (between 58 and 63 ms) but remained normal in the basal segments (between 45 and 51 ms). There was no late gadolinium enhancement (LGE). Additional blood tests performed in the work-up of cardiac infiltration of myocarditis were normal, including serum and urine electrophoresis was within limits, serology for Lyme disease, HIV, HAV, HBV, and HCV, anti-nuclear antibody and rheumatoid factor.\n\nThe combination of apical hypertrophy with systolic apical obliteration and deep T-wave inversion in the front ECG leads is typically associated with the apical form of hypertrophic cardiomyopathy (apHCM). However the clinical picture was not completely characteristic for apHCM, as myocardial oedema and severe QTc prolongation are usually not associated with this diagnosis. Considering the relatively acute presentation of the symptoms, the mild increase in hsTnT together with a severe increase in NT-proBNP, we considered a differential diagnosis of Takotsubo cardiomyopathy at a subacute stage (i.e. after recovery of the apical hypokinesia and ballooning). Other less likely diagnosis included myocarditis and coronary artery spasm.\n\nCardiac monitoring did not reveal any significant arrhythmia and the symptoms resolved after few days under low-dose betablocker treatment (metoprolol 25 mg od). The patient was discharged after 8 days and the discharge ECG showed partial normalization of T-waves inversion and the QTc interval improved to 489 ms.\n\nAfter 2 months, the patient remained asymptomatic with no clinical signs of heart failure. Cardiac troponin T and NT-pro BNP levels were 8 ng/L and 85 pg/L, respectively. ECG was in sinus bradycardia (45 bpm) and the profound changes observed at admission almost completely resolved: the pathological T-wave inversion was no more observed and the QTc interval was normal (440 ms). Both echocardiography and CMR showed a non-dilated left ventricle with a normal LVEF, and disappearance of apical hypertrophy and systolic obliteration. On CMR, No LGE was observed, and T2 relaxation times were normal in all myocardial segments (relaxation times 45–50 ms) indicating regression of the apical myocardial oedema. Considering this remarkable evolution, we concluded that the apical wall thickening initially detected was only related to severe myocardial oedema but not to myocardial hypertrophy. HCM could be confidently excluded, as hypertrophy is not reversible in this situation. We made a final diagnosis of Tako-tsubo cardiomyopathy at a subacute stage, a stage, where systolic function already recovered but the apical myocardium was still severely oedematous. The typical ECG evolution characterized by transient profound T-wave inversion and QT prolongation also supported this diagnosis.",
    "summary": "A 45-years old woman presented for dyspnea and cardiac chest pain. ECG showed deep T-wave inversion while CMR showed normal ejection fraction, hypertrophy and systolic obliteration of the apex suggesting apical HCM. Myocardial oedema was noted at the apex. Complete regression of hypertrophy and myocardial edema was observed after 2 months, and a final diagnosis of subacute Takotsubo was made."
  },
  {
    "id": "multiclinsum_gs_en_43.txt",
    "fulltext": "Male, 33 years old, with asthma and allergic rhinitis, on treatment with inhaled and nasal corticosteroids and with known allergy to Dermatophagoides pteronyssinus and Dermatophagoides farinae .\n\nHe had an anaphylactic reaction at the age of 25 with angioedema of the face and lips, dyspnoea, cough and dysphagia a few minutes after eating a mushroom pizza. There was no other trigger present, such as drugs or insect bites. The patient also denied exercise or alcohol in the hours leading up to the episode. Since then, the patient has avoided mushrooms or any food containing mushrooms.\n\nThe patient reported two subsequent episodes of labial angioedema, without any other symptoms, following accidental contact with mushroom sauce.\n\nSerum total IgE (ImmunoCAP™, Phadia, ThermoFisher Scientific, Uppsala, Sweden) and specific IgE (ImmunoCAP™, Phadia, ThermoFisher Scientific, Uppsala, Sweden) were measured for aeroallergens (Dermatophagoides pteronyssinus , D. farinae , Lepidoglyphus destructor , cat and dog dander), moulds (Aspergillus fumigatus and Alternaria alternata ) and fungi.\n\nWe also performed skin tests with commercial extracts (LETI Laboratories, Madrid, Spain) of D. pteronyssinus (100HEP/mL); D. farinae (100HEP/mL); L. destructor (10HEP/mL); Olea europaea pollen (30HEP/mL), Corylus avellana (30HEP/mL) and Platanus occidentalis (30HEP/mL); cat and dog dander (30HEP/mL); A. fumigatus (150ug protein/mL); A. alternata (30HEP/mL); Cladosporium herbarum (150ug protein/mL); Candida albicans (125ug protein/mL); grass pollen (30HEP/mL); cow's milk (1,600ug protein/mL); eggs (1,400ug protein/mL); wheat flour (1,900ug protein/mL); tomato (10HEP/mL) and mushrooms (10HEP/mL). Histamine was used as a positive control (10mg/mL).\n\nIn addition to skin tests with commercially available extracts, a prick-to-prick test was performed with A. bisporus raw and cooked.\n\nImmunoblotting was performed by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) to assess the molecular mass of the IgE-binding proteins of A. bisporus .\n\nRESULTS\nTotal IgE was 240kU/L and specific IgE was positive for mushrooms (0.76kUA/L), Dermatophagoides peteronyssinus (30.90kUA/L) and L. destructor (2.33kUA/L).\n\nSkin tests were positive for extract of mushrooms (7 mm), D. pteronyssinus (10 mm), D. farinae (8 mm) and L. destructor (7 mm).\n\nThe prick-prick test was positive for A. bisporus white raw (9mm) and cooked (11mm) and A. bisporus brown raw (14mm) and cooked (11mm).\n\nImmunoblotting of A. bisporus extract revealed two major bands of IgE binding of approximately 10kDa and 27kDa.\n",
    "summary": "Male, 33 years old, with asthma and allergic rhinitis triggered by mites, reported an episode of angioedema of the face and lips, dyspnoea, cough and dysphagia at the age of 25 years, minutes after eating a mushroom pizza (Agaricus bisporus). The patient denied the use of medicines, stings of hymenoptera, or any other possible triggers or cofactors that could be present. Since then, he avoids all types of mushrooms, until the occurrence of an accidental contact with mushroom sauce, which resulted in angioedema of the lips minutes after. The immunoallergological study included the determination of total and specific IgE for mushrooms, skin tests for aeroallergens, possible food allergens and mushroom extracts, prick-to-prick test with A. bisporus raw and cooked and SDS-PAGE immunoblotting . The study revealed a specific IgE for mushrooms of 0.76kUA/L, a positive skin test for mushroom extracts and a positive prick-to-prick test for white and brown A. bisporus (raw and cooked). The immunoblotting identified two IgE-reactive proteins of 10kDa and 27kDa. We thus reported a case of anaphylaxis by ingestion of A. bisporus , probably explained by primary sensitization to mushrooms. We detected two IgE-reactive proteins of 10kDa and 27kDa as the possible responsible allergens.\n"
  },
  {
    "id": "multiclinsum_gs_en_191.txt",
    "fulltext": "A 36-year-old previously healthy female was stung once by an unknown Hymenoptera that resulted in local swelling and erythema at dorsum of her right hand. Spiking fever started within 6 hours despite sting site gradually became unidentifiable. She visited a local clinic where oral steroid (prednisolone 20 mg/day) and antibiotics were prescribed. She came to our emergency department 3 days later for persistent on-and-off fever. She presented with high temperature (38.9°C), tachycardia, and hypotension (blood pressure 80/52 mmHg) at triage. Electrocardiography showed atrial fibrillation with rapid ventricular rate around 130 beats per minute and diffuse ST elevation. Chest radiography showed normal cardiothoracic ratio without signs of infiltrates or congestion. Hemogram did not show eosinophilia, leukocytosis, leukopenia, or left shift. MB isoenzyme of creatinine kinase (CK-MB) and cardiac troponin-I elevated to 96.0 ng/mL and 8.0 ng/mL, respectively. C-reactive protein was 10.5 mg/L and procalcitonin was 0.32 ng/mL. NT-proBNP was 20 700 pg/mL. Echocardiography showed global hypokinesia of left ventricle with an ejection fraction of 30.6%, and no pericardial effusion. Emergent cardiac catheterization did not reveal coronary artery lesions or vasospasm. Intra-aortic balloon pumping was inserted during the procedure for cardiogenic shock. Hypotension progressed accompanied with ventricular tachycardia and ventricular fibrillation, then in-hospital cardiac arrest followed. Manual cardiopulmonary resuscitation was unsuccessful for 25 minutes and percutaneous cardiopulmonary support (PCPS, CAPIOX® Centrifugal Pump Controller SP-200, Terumo) was used. Spontaneous circulation was established 25 minutes later with full recovery of consciousness.\n\nRapid influenza antigen test (Directigen EZ Flu A+B test; BD, Franklin Lakes, NJ, USA), sputum cultures, blood cultures, and serology tests for respiratory viruses sampled at admission were all negative. On hospital day 2, serum levels of CK-MB and troponin-I peaked at >303 ng/mL and >81 ng/mL, respectively. Follow-up echocardiography 24 hours after initiation of PCPS showed deteriorated left ventricular function, persistent closure of aortic valves and intra-cardiac thrombi in both left atrium and left ventricle, about 24 hours after initiation of mechanical support. On day 3, shock progressed with multi-organ failure. Continuous venovenous hemodialysis was applied due to metabolic acidosis and oliguria. On day 4, right ventricular function also became seriously depressed and electric activity of heart gradually disappeared. PCPS was therefore shifted to bi-ventricular mechanical supports via cannulations to right atrium, pulmonary trunk, apex of left ventricle, and ascending aorta. Both systems were established using MEDTRONIC Affinity CP Centrifugal blood pumps. Due to pulmonary hemorrhage with severe consolidation of bilateral lungs, a membrane oxygenator was used to achieve adequate oxygenation. Blood flow rate was set at 3.5 L/minute that could maintain mean arterial blood pressure at around 65 mmHg. Endomyocardial biopsy of left ventricle was performed and pathology revealed significant inflammation composed of mainly lymphocytes and some eosinophils. Myocyte damage with necrosis was present but not extensive. In terms of ventilator settings, driving pressure and plateau pressure were set at around 15 and 30 cmH2O respectively for lung protection. Fiber bronchoscopy was used repeatedly to remove obstructing blood clots in the major airway. On hospital day 13, electric activity of the patient’s heart remained absent, and both blood pumps were shifted to Levitronix Centri-Mag (Levitronix LLC, Waltham, MA, USA) ventricular assist systems for better support. The patient was transferred to a transplant center and registered as a candidate for heart transplantation. On day 14 another cannula was inserted into the left common femoral vein for inflow augmentation of right VAD. From day 14 to day 48, the patient suffered from episodes of massive bleeding from the mediastinum and vagina, sternum wound infection with abscess formation, pressure sore infections, and progressive hyperbilirubinemia. Her condition stabilized after debridement, surgical hemostasis, and strong antibiotics use. She underwent 5 courses of therapeutic plasma exchange to prevent antibody mediated rejection and received orthotopic heart transplantation on day 49. Pathologic study of the patient’s heart showed pancarditis of both ventricles and no specific change of the 3 coronary arteries. VA ECMO was kept till day 58 for post-operative heart failure. Repeated endomyocardial biopsy after transplantation showed no evidence of cellular or humoral rejection. She experienced episodes of septic shock under immunosuppression thereafter and received exploratory laparoscopy and appendectomy on day 93. Extubation was performed on day 96 and she was discharged on day 101. She remained clinically stable at 3-month follow-up.",
    "summary": "Patient: Female, 36-year-old\n\nFinal Diagnosis: Cardiogenic shock • myocarditis\n\nSymptoms: Fever\n\nMedication: —\n\nClinical Procedure: Mechanical circulatory support\n\nSpecialty: Surgery\n\n\nCase Report:\n\nWe reported a case of a 36-year-old female who developed fever and cardiogenic shock 3 days after a bee sting. Cardiac angiography showed patent coronary arteries and severely compromised left ventricular function. Her hemodynamics remained unstable under high dose inotropic agents and intra-aortic balloon pump support. In-hospital cardiac arrest occurred 4 hours after admission and she received extracorporeal cardiopulmonary resuscitation. Her peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) was shifted to bilateral ventricular assisted devices (VAD) due to progressive right heart failure. The endomyocardial biopsy result was compatible with the picture of hypersensitivity myocarditis. Her heart went into persistent standstill under mechanical circulatory support. She underwent heart transplantation on hospital day 49 and remained clinically stable 6 months after discharge."
  },
  {
    "id": "multiclinsum_gs_en_270.txt",
    "fulltext": "A 38-year-old Iranian male patient presented to the emergency department of Kowsar Hospital, Semnan, on 2 October 2021, with chief complaints of severe abdominal pain and lower extremity edema. The pain, originating in the umbilical region and spreading across the entire abdomen, prompted the visit. Vital signs were recorded as follows: blood pressure (BP) = 130/90 mmHg, heart rate (HR) = 80 bpm, and temperature (T) = 37 °C. Abdominal examination revealed normal bowel sounds, slight tenderness in the inguinal region, and tympanic sounds. Also, he was noted to have congenital SBS with a measured total small bowel length of approximately 185 cm, significantly shorter than the normal range, and an absence of the omentum.\n\nOn 10 August 2021, the patient underwent a right hemicolectomy and ileostomy owing to abdominal pain associated with a diagnosis of intestinal obstruction. Subsequently, on 21 September 2021, the patient had a colostomy removed and was hospitalized for 6 days (including 3 days in the intensive care unit [ICU]). Post-discharge, the patient experienced abdominal pain and edema, with an escalation of symptoms on 1 October 2021. Nausea was reported upon admission, but without vomiting, and there were no complaints related to urination. Due to postprandial pain and poor appetite, the patient’s nutritional intake was compromised. No fever, chills, or dyspnea were reported. Lower extremity edema was noted (2+), with no clubbing or cyanosis observed. Other vital signs were within normal ranges (pulse rate 82 beats/minute, blood pressure 110/70 mmHg, respiratory rate 18 breaths/minute, temperature 37 °C). Abdominal tenderness hindered a complete examination owing to severe pain. Examination of the head, neck, and chest revealed no specific findings.\n\nFull blood count indicated leukocytosis (hemoglobin 11.7 g/dL, white cell count 19.23 × 103/µL, platelets 406 × 103/µL, RBC 4.30 × 106/µL, and hematocrit [HTC] 34.3%), while arterial blood gas analysis showed metabolic alkalosis (pH 7.56, partial pressure of oxygen [PO2] 204.5 mmHg, partial pressure of carbon dioxide [PCO2] 31.9 mmHg, base excess [BE] 7.0 mmol/L, and bicarbonate [HCO3] 29.1 mmol/L).\n\nAbdominal and chest X-rays of the 38-year-old male with congenital short bowel syndrome and absence of the omentum. Supine abdominal radiograph demonstrating dilated loops of bowel and absence of the omentum, with no evidence of air-fluid levels. Also, chest X-ray showed no significant abnormalities, confirming normal cardiopulmonary findings. Upright abdominal radiograph revealed evidence of gaseous distension and loops consistent with the patient’s diagnosis.\n\nA contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis was recommended. Fecal secretion from the patient’s sutures raised concerns about postoperative peritonitis due to anastomotic leakage, prompting immediate surgical intervention. The patient underwent emergency laparotomy, drainage, and double barrel jejunostomy.\n\nThe patient’s recovery was uneventful, with oral intake of clear fluids permitted on postoperative day 2 and full fluids on postoperative day 4.\n\nFor congenital absence of omentum and short bowel syndrome, treatment options encompass nutritional support, such as total parenteral or enteral nutrition. Severe cases may necessitate surgical intervention to lengthen the remaining bowel or perform an intestinal transplant. Strategies for short bowel syndrome resulting from congenital absence of omentum may involve nutritional support, along with enhancing the expression of transport proteins ( such as Na+/glucose cotransporters, Na+/H+ exchangers) to facilitate intestinal adaptation. Human interventions include glutamine and growth hormone treatment or glucagon-like peptide administration, though multicenter studies are required for conclusive evidence.",
    "summary": "This case report presents a unique confluence of these rare conditions in a 38-year-old Iranian male with a prior history of intestinal obstruction requiring right hemicolectomy and ileostomy. He subsequently presented to the emergency department experiencing intense abdominal pain and swelling in his lower extremities. Laboratory investigations revealed an elevated white blood cell count and metabolic alkalosis. During the surgical exploration prompted by his acute presentation, both congenital absence of the omentum and short bowel syndrome were confirmed. A jejunostomy was performed, but unfortunately, this intervention resulted in severe malabsorption and subsequent cachexia. This case sheds light on the rare occurrence of anastomotic leakage and subsequent peritonitis following right hemicolectomy and ileostomy in a patient with the combined conditions of congenital short bowel and congenital absence of the omentum."
  },
  {
    "id": "multiclinsum_gs_en_397.txt",
    "fulltext": "We report the case of a 42-year-old neuroscientist with a 23-month history of positional headaches following a lumbar puncture (LP) performed in February 2021 for suspected Multiple Sclerosis (MS), which was ultimately ruled out. The patient initially experienced position-dependent headaches localized at the back of the head and neck, accompanied by intermittent dizziness and tinnitus. Despite conservative treatments, including bed rest, caffeine tablets, IV hydration, and five non-targeted high-volume epidural blood patches (EBP), the symptoms persisted, with only temporary improvement lasting about six weeks. Over time, the patient’s condition worsened, leading to cognitive difficulties such as brain fog and an impaired work ability.\n\nDiagnostic imaging was performed, and a high-resolution T2Space fat-saturated MRI revealed a small, nodular, hyperintense structure adjacent to the dorsal dural sac at the L3-L4 level, suggesting a possible post-puncture ‘arachnoid bleb’ corresponding to the alleged puncture site. A subsequent dynamic myelography and post-myelography CT on 03/05/2022 demonstrated unremarkable intrathecal contrast distribution without evidence of an epidural contrast leak or structural irregularities, particularly at the L3-L4 level, even during delayed imaging.\n\nThe MRI findings indicated the presence of an ‘arachnoid bleb’ at the suspected puncture site. Given the persistent, debilitating symptoms and lack of long-term improvement from the blood patches, a decision for surgical exploration at the L3-L4 level was made.\n\nMicrosurgical exploration identified an arachnoid bleb as a cause of a low-flow CSF leak. The patient gave his consent for the surgical management. The video depicts Neomenbranes overlaying the dura mater. Underneath, we identified an Arachnoid bleb and CSF oozing out, washing a layer of blood away. The CSF leaked like a tear, and we had the impression of a weeping dura. Treatment was performed by bipolar shrinking of the bleb; the dura was sealed and reinforced using a collagen Matrix—TachoSil (Takeda Pharmaceuticals, Zurich, Switzerland), a Dural substitute, and fibrin glue. The patient’s symptoms gradually improved following the surgery.",
    "summary": "We report a 42-year-old Neuroscientist with a 23-month history of positional headaches after a lumbar puncture (LP). Multiple Sclerosis was ruled out, but chronic orthostatic headache and tinnitus developed. Bed rest, caffeine tablets, IV hydration, and five high-volume epidural blood patches did not lead to improvement. However, brain fog and reduced ability to work ensued. A dynamic myelography did not reveal a CSF leak or a CSF-venous fistula, but a high-resolution T2Space Fat-saturated MRI detected an arachnoidal bleb at the alleged L3-L4 level. Microsurgical exploration identified the arachnoid bleb as a low-flow CSF leak. The video depicts Neomenbranes overlaying the dura mater appearing as a web and CSF oozing, washing a layer of blood away. CSF was leaking like a tear, and we had the impression of a weeping dura. Treatment involved bipolar shrinking, reinforcement of the dura and fibrin glue. The patient's symptoms improved slowly post-surgery."
  },
  {
    "id": "multiclinsum_gs_en_549.txt",
    "fulltext": "A 72-year-old woman presented to the emergency department with constant and gradually increasing epigastric abdominal pain for the past 10 days. The pain worsened following meals and was associated with nausea and retching. Within the past 24 hours, she had become unable to tolerate significant oral intake, and the pain had migrated to the right upper quadrant of her abdomen. Her medical history is significant for secondary progressive multiple sclerosis (MS) for the past 27 years, treated unsuccessfully at another institution with an experimental bilateral percutaneous transluminal jugular venoplasty 11 years prior. She also has hypertension treated with hydrochlorothiazide, and depression treated with citalopram, but no history of trauma, abdominal surgeries, or cardiovascular disease.\n\nUpon presentation to the emergency department, she appeared quite uncomfortable, although her vital signs were within normal limits with a temperature of 36.5°C, a heart rate of 68 beats/min, blood pressure of 123/71 mm Hg, and an oxygen saturation of 92% on room air. Her abdomen was tender in the right upper quadrant with a positive Murphy’s sign. No abdominal masses were appreciated, and she had no peritoneal signs. She underwent laboratory testing, which demonstrated a leukocyte count of 12,000/μL with 84% neutrophils and a hemoglobin of 10.7 g/dL. Her serum liver enzymes, lipase, and liver function tests were all within normal limits. She underwent abdominal ultrasound, which demonstrated a positive sonographic Murphy’s sign, a 5 mm thickened gallbladder wall, and stones in the gallbladder lumen, but with no pericholecystic fluid or gallbladder distension. She had an incidental note of a complex cystic lesion seen in the left upper quadrant felt to be dilated bowel; however, bowel gasses obscured the pancreas and aorta. She was initially diagnosed with acute calculous cholecystitis, but an abdominal computed tomography (CT) was requested, given the unexpected finding in her left upper quadrant. The CT scan revealed a large hematoma (20 cm diameter) in the mid-abdomen adjacent to the pancreas and transverse colon mesentery, associated with a small 1.1×0.6 cm aneurysm of the MCA. No extravasation of contrast was seen and there were no signs of colonic ischemia. Given her clinical stability at this point, an angiogram with embolization of the mesenteric aneurysm was initially attempted through the superior mesenteric artery (SMA). The exact site of the aneurysm could not be reached due to acute angle of the culprit branch. Only proximal coils into small vessels potentially supplying the area were placed.\n\nThis was considered an incomplete embolization and as expected, the bleeding continued.\n\nThe patient was subsequently taken for urgent laparotomy. Given the size of the hematoma and its status overlying the superior mesenteric artery and supraceliac aorta, an aortic CODA balloon catheter (Cook Incorporated, Bloomington, IN) was positioned (but not deployed) within the distal descending thoracic aorta prior to performing the laparotomy. This was performed as a safeguard in case emergent proximal aortic control was required and to minimize the extent of hemorrhage in the event of exsanguination. Within her upper abdomen, a large, contained hematoma was identified at the root of the transverse colonic mesentery. The left and right colon were fully mobilized, and the transverse colon was divided to facilitate access to the aneurysm. The haematoma cavity was entered, the clot was evacuated, and the bleeding MCA was identified and ligated. No further bleeding was identified, and the endovascular balloon was never inflated. At this point, a large section of the transverse and distal ascending colon appeared ischemic, requiring extended right hemicolectomy, leaving the descending and sigmoid colon intact. Throughout the operation, the patient remained hemodynamically stable, so a stapled ileocolic anastomosis was performed without fecal diversion. Of note, there were some adhesions to the gallbladder, however the gallbladder itself appeared grossly normal, and was left in situ.\n\nPost-operatively, 24 hours after her operation, the patient had a sudden rise in her heart rate to 100 beats/min and a drop in her hemoglobin to 6.0 g/dL. She was emergently resuscitated with blood products, and underwent a repeat CT angiogram, which demonstrated the persistence of her MCA aneurysm, just proximal to the site of ligation during her operation. She underwent repeat angiography through the SMA, which demonstrated two remaining branches of the MCA, one supplying the bleeding aneurysm, which had been ligated distally during the preceding laparotomy. Due to their tortuosity, these branches were difficult to cannulate and the bleeding vessel could not be selectively embolized. Upon discussion with the teams involved, there were limited operative options. As a result, a plan was made to place a covered stent in the SMA across the ostia of the inflow of the MCA. This effectively stopped the bleeding, and the remainder of the SMA remained patent. For the rest of her hospital stay, she had no further bleeding episodes. Her hospital course was complicated by a prolonged post-operative ileus for 14 days requiring total parenteral nutrition supplementation. She also developed a deep vein thrombosis in her right brachial vein on a post-operative day seven, requiring anticoagulation. Her presumed cholecystitis was mild, likely secondary to her large bleed, and was managed with parenteral antibiotics for 14 days. She made a full recovery and was discharged home 21 days after her index operation. At her 6-month follow-up visit, she continued to do well without any symptoms of biliary colic.",
    "summary": "We present the case of a 72-year-old woman with a ruptured middle colic artery aneurysm presenting with signs and symptoms more suggestive of acute calculous cholecystitis. Her co-existing bleed was confirmed on CT angiogram. Coil embolization was initially attempted unsuccessfully. She underwent laparotomy, a middle colic artery ligation, and extended right hemicolectomy with intra-aortic balloon placement for emergency proximal vascular control. Post-operatively, she had a re-bleed that was successfully managed with covered stent placement in the proximal superior mesenteric artery after an unsuccessful re-attempt at coil embolization. Her apparent associated cholecystitis was managed with antibiotics and resolved uneventfully."
  },
  {
    "id": "multiclinsum_gs_en_307.txt",
    "fulltext": "65-year-old woman, native of Mérida, Venezuela, with a history of open appendectomy, who presents a current illness of 4 months of evolution characterized by abdominal pain of insidious onset, mild intensity, stabbing, initially generalized, but after 3 months it is localized in the right iliac fossa, which is why she goes to the doctor, who prescribes medical treatment, with partial improvement of the condition. In view of the persistence of the symptoms and the appearance of a palpable mass in the right iliac fossa, she goes to the gastroenterology department of our institution, where a colonoscopy is performed that reports a subepithelial tumour in the cecal region.\n\nShe also has altered bowel patterns, alternating between constipation and diarrhea, a recent fever (15 days), and an intolerance to oral (solid) food, which is why she was referred to the general surgery department.\n\nThe physical examination found her in stable clinical condition, afebrile, hydrated, with adequate skin and mucous colouration; abdominal examination, flat abdomen, hydroaerolic noises present, soft, depressible, with a palpable mass in the right iliac fossa of 5 × 5 cm, mobile, painful to the touch and without signs of peritoneal irritation; rectal examination, anus without alterations, sphincter with preserved tonicity, rectal ampoule with smooth walls in which no tumors were palpable, and with scanty soft faeces inside; gynecological examination, without alterations; rest of the physical examination, without alterations.\n\nA computed tomography with double contrast (oral and intravenous) was requested, in which the loss of the usual configuration in the ileocecal region with an important increase in the volume of the cecum was evident, and the incursion of the ileum into the right colon was observed in a long pathway that extends from the transverse colon to the splenic angle, where a saccular formation filled with oral contrast was observed. During the arterial phase, the cecal region did not show changes in its density and vascular pathways were observed throughout the interior of the colon accompanied by adipose tissue, but a double enhancement was evident in the region of the splenic angle of the transverse colon. It was concluded that the findings were suggestive of intestinal intussusception secondary to neoplasia.\n\nIn view of the tomographic findings and the physical examination, the patient was taken to the operating table, where there was a small amount of free yellow liquid in the abdominal cavity. Intestinal ileus-colic intussusception was observed up to the hepatic angle of the transverse colon. When the intussusception was reduced, a 10 cm tumour was observed in the ileo-caecal valve and a 10 cm tumour in the small intestine that invaded the serosa, was hardened and compromised the intestinal lumen, and multiple adenopathies of various sizes (no > 2 cm) were observed in the mesentery of the right colon, with no evidence of liver lesions. The Cattell-Braasch manoeuvre, right hemicolectomy up to the emergence of the right colic artery, closure of the transverse colon stump and formation of an ileo-transverse anastomosis, was performed. The cavity was washed and drained, and the abdominal cavity was closed by planes. The surgical procedure was completed without complications and the patient had a favourable clinical evolution. She began to eat by mouth 48 hours after the operation. She was discharged 5 days after the operation, the drain was removed 10 days later and the patient was monitored by the general surgery department, without any complications in her evolution.\n\nThe sample studied showed a neoplastic lesion characterized by the proliferation of tubular structures with endothelial-type lining that shows eosinophilic cytoplasm, vesicular nuclei without nucleoli, intracytoplasmic vacuoles, which present endothelial lumens, some with erythrocytes, and isolated mitoses (three in 40 high-power fields). This area shows an increase in fibrous connective tissue. In the periphery, there is a significant neutrophilic and lymphocytic polymorphonuclear inflammatory infiltrate with areas of necrosis, cellular debris and extravasated erythrocytes. Special PAS (Periodic Acid-Schiff) and Gomori trichrome stains were performed, which showed the presence of fibrous connective tissue around the neoplastic lesion areas described; the thick intestine sections with mucous lining were unchanged, as was the mesentery. Findings in the small intestine consistent with HE of intermediate malignancy.\n",
    "summary": "65-year-old woman with chronic abdominal pain. Computed tomography was performed and an incursion of the ileum into the right colon was observed. She was taken to the operating table with a finding of ileocolic intestinal intussusception due to a small intestinal tumour, with an anatomopathological result of epithelioid haemangioendothelioma.\n"
  },
  {
    "id": "multiclinsum_gs_en_112.txt",
    "fulltext": "This is an 8-month-old male patient born to a para 3 mother. The mother had ANC follow-up, but it was irregular, and it was at a rural health center with a poor setup where she could not get obstetric ultrasonography. The delivery was at home with a traditional birth attendant. After delivery, the parents noticed a swelling on the occipital part of the head. It increased in size progressively to attain the current size. The parents went to the health center, where they referred them to the primary hospital, which then referred them to our center. The swelling had no discharge, and the patient has no fever, vomiting failure to suck, high-pitched cry, abnormal body movement, or lethargy. Upon examination of the patient, there is a giant 40cm by 35cm cystic, transilluminating to light, tender, occipital area mass on the area of the torcula of the sinuses. There is a palpable bone defect at the sac’s base. The anterior and posterior fontanels are not open. The baby is playful, alert moving all extremities, sucking well, and has stable vital signs. The patient was then investigated with a CBC, blood group, renal and liver function tests that were in normal range, and brain MRI revealed a huge occipital T1 hypointense and T2 hyperintense sac content with multiple flow voids showing torcula, superior sagittal sinus, and transverse sinus, and a part of right occipital lobe brain tissue with a bone defect at the base of the sac. After getting informed written consent, the patient is put on the operating table with the head hanging beyond the operating table edge on the side of the anesthesia machine, with one anesthetist holding the head and the sac hanging beyond the table, and is intubated with the first attempt. After intubation, the patient was put in a prone position with the aid of a horseshoe Mayfield. Hair shaved and cleaned with soap and water, and one assistant holding the mass with a sterile gloved hand, the skin is then cleaned and draped. Initially, we made a transverse skin incision, drained the CSF, and the sac collapsed. Then, dysplastic brain tissue was resected, and venous sinus, tumor, torcula and other viable-looking brain tissue were gently reduced to the skull gently. Dura dissected, trimmed, trimmed and closed as a watertight primary. We did not recommend cranioplasty in a giant occipital encephalocele with a high risk of postoperative hydrocephalus; hence, we did not close the bone defect. After that, the skin was trimmed and closed in two layers. Postoperatively, the patient stayed in the neurosurgery ward for seven days with no hydrocephalus and no neurologic deficit. The patient is then followed at an outpatient clinic every 2 weeks with no surgery-related or neurologic complications.",
    "summary": "This is a case of an 8-month old male infant born to a mother who had no regular antenatal care. After the baby presented with progressively increasing posterior head mass which is cystic, transilluminating, tender and size is 40cmX35cm imaging demonstrated small brain tissue mainly part of right occipital lobe with most of the sac being occupied by cerebrospinal fluid. Repair done and dysplastic brain tissue resected then healthy-looking brain tissue and Dural sinuses reduced to the skull, then patient stayed in the hospital and closely followed for hydrocephalus for seven days and discharged with no hydrocephalus and no neurologic deficit."
  },
  {
    "id": "multiclinsum_gs_en_196.txt",
    "fulltext": "A 63-year-old woman with a history of obesity and hypertension presented to the emergency department of a secondary hospital with a 7-day history of fever, dry cough, hyposmia, and myalgia. She was alert on admission with a respiratory rate of 22 cycles per minute, pulse of 90 beats per minute, and oxygen saturation of 90%. Laboratory tests revealed lymphopenia (1.55 x 109) and elevated C-reactive protein levels (10.62 mg/dL). A polymerase chain reaction test for COVID-19 was performed on a nasopharyngeal and throat swab, which was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).\n\nThe patient rapidly deteriorated with fever, prostration and worsening dyspnoea. Arterial blood gas analysis revealed severe respiratory failure, while a chest radiograph showed bilateral pulmonary infiltrates. The patient was intubated and ventilated, but her respiratory condition continued to deteriorate despite the best critical care, including prone position ventilation and neuromuscular blockade. Her post-intubation chest computed tomography scan revealed extensive bilateral multifocal ground glass opacities with no signs of pulmonary embolism. The initial ventilator settings were: volume-controlled ventilation with tidal volume of 360mL (6mL/kg ideal body weight), respiratory rate of 14 breaths per minute, end-expiratory positive airway pressure (PEEP) of 14cmH2O and static compliance of 44cmH2O.\n\nOn the second day of admission, arterial blood gas showed pH of 7.34, partial pressure of carbon dioxide (PaCO2) of 53 mmHg, partial pressure of oxygen (PaO2) of 102 mmHg and bicarbonate (HCO3) of 29.7 mmol/L, with a PaO2/FiO2 ratio of 98. She met the criteria for indication of VV-ECMO and was transferred to the intensive care unit (ICU), which had an established program for VV-ECMO. The procedure was performed safely, with no complications. Analysis of the arterial blood gas 3 hours after the start of VV-ECMO showed pH of 7.386, PaCO2 of 43 mmHg, PaO2 of 94.3 mmHg and HCO3 of 25.4 mmol/L, without any abrupt change in PaCO2. Early nutrition and rehabilitation were initiated after the introduction of VV-ECMO. On the 14th day of admission, the patient developed ventilator-associated pneumonia caused by Pseudomonas aeruginosa, and was subjected to 7 days of antibiotic therapy with ceftazidime and vancomycin, with a favorable response. On the 20th day of admission, her chest radiograph and compliance improved, and the patient was successfully removed from the VV-ECMO after 455 hours of support, and tracheostomized 7 days later. The patient maintained good renal function throughout the admission.\n\nOn the 34th day of admission, after 7 days of weaning from sedation with positive evolution of his neurological condition, a generalized limited epileptic seizure occurred, which led to diagnostic investigation.\n\nInvestigation\nLaboratory blood tests revealed decreased levels of C-reactive protein (6.11mg/dL), procalcitonin (0.07ng/mL), fibrinogen (307ng/mL) and ferritin (2,802ng/mL), but increased levels of D-dimer (18,021ng/mL) and interleukin 6 (10.4pg/mL) in the day preceding the development of symptoms. None of the drugs administered to the patient was associated with SEPR, i.e. immunosuppressive, immunomodulatory and chemotherapeutic drugs.\n\nA magnetic resonance (MR) scan of the brain was performed, and the fluid attenuated inversion recovery (FLAIR) images demonstrated symmetrical and confluent hyperintensity affecting the juxta- and subcortical white matter, primarily in the occipital and parietal regions, but also involving the frontal, temporal, and left cerebellar regions. Deep gray nuclei were preserved, and there was no evidence of any area of contrast-enhancing restriction. Susceptibility-weighted images showed multiple punctate microhemorrhages affecting the superficial and deep white matter, but sparing the area of hyperintensity in FLAIR. The punctate microhemorrhages predominantly involved the juxtacortical white matter and corpus callosum (especially the knee and splenium). In addition, there were three subacute hemorrhages less than 1 cm in the outer capsules with hyperintensity in T1.\n\nThe cerebrospinal fluid sample was negative for SARS-CoV-2 and had protein levels (31 mg/dL), glucose (74 mg/dL) and lactate (1.89 mmol/L) within normal limits.\n\nOutcome\nThe patient had an almost complete recovery of neurological deficits, despite myopathy of the critical illness, and was discharged after 44 days in hospital, being referred to a secondary hospital for rehabilitation, and had almost returned to her previous mental condition.\n",
    "summary": "A 63-year-old woman presented to the emergency department with a history of acute fever, prostration and dyspnoea. She was diagnosed with severe COVID-19 and acute respiratory distress syndrome. Despite intensive clinical support, she met the criteria for extracorporeal membrane oxygenation. On day 34, after 7 days of weaning from sedation with positive evolution of her neurological condition, she presented a limited generalised tonic-clonic seizure, not related to a hydro-electrolytic or metabolic imbalance, which led to the need for diagnostic investigation. Her brain imaging tests revealed a syndrome of posterior reversible encephalopathy.\n"
  },
  {
    "id": "multiclinsum_gs_en_380.txt",
    "fulltext": "A 31-year-old pregnant woman who had previously undergone a Cesarean section was referred to our department‘s ultrasound unit for a second-trimester morphological ultrasound screening. The patient had an unremarkable family history and did not use any drugs and without previous exposure to teratogens during the first trimester of pregnancy. Serological tests for various infectious diseases were negative, and a previous ultrasound exam at 14 weeks was normal. The triple test for fetal abnormalities was also negative at 16 weeks.\n\nDuring the 20th-week ultrasound scan, a male singleton fetus with a composite sonographic age of 20 weeks and 2 days was observed to have significant edema of the lower limbs, and normal amniotic fluid. A follow-up exam in 2 weeks was recommended, along with tests for TORCH and indirect Coombs testing.\n\nHowever subcutaneous edema on both lower limbs was again observed during the 23-week morphology ultrasound scan, suggesting a possible diagnosis of MS. Due to the persisted lymphedema in the lower limbs an amniocentesis was performed.\n\nSubsequent testing revealed that the male karyotype was normal (46, XY), and molecular analysis for Noonan‘s syndrome was negative. Nucleotide sequencing of the amniotic fluid was performed with Illumina sequencing by 150 bases. Bioinformatics system was applied ((North-Oehler Aligarh, GATX) while additionally checking for the existence of deletions/duplications/CNVs) (Copy Number Variations) in the FLT4 gene was performed. The analysis identified a c.3116C>A p. (Ala1039Asp) mutation, that is a not known pathogenic variant in the FLT4 gene, confirming the diagnosis of hereditary lymphedema type 1A – Milroy disease. Maternal blood analysis confirmed maternal mutation and genetic counseling followed.\n\nCesarean section was performed at 38 weeks and 6 days of gestational age, and a male neonate weighing 3,850 g and measuring 46 cm with an Apgar score of 9/10 was born. Both lower limb edema was recognized after delivery. Histopathological examination of the placenta, umbilical cord, and amniotic sac showed no signs of chorionamnionitis or other pathology.",
    "summary": "We present a case report of a first-described mutation of a male fetus diagnosed prenatally with Milroy syndrome through amniocentesis. The fetus had bilateral lower limb edema, and genetic testing confirmed the diagnosis of Milroy syndrome. The patient was closely monitored throughout the pregnancy, and after delivery, the infant was managed with appropriate therapies, including compression garments and manual lymphatic drainage. The parents were provided with appropriate counseling and support."
  },
  {
    "id": "multiclinsum_gs_en_216.txt",
    "fulltext": "This was a 36-year-old female patient diagnosed with keratoconus, she was medically fit with no prior history of ocular surgeries or trauma, denies smoking and steroid use. However, she admits to frequent and vigorous eye rubbing. Upon examination, the patient had an uncorrected visual acuity (UCVA) of 20/70 in the right eye and 20/200 in the left eye. She had a normal intraocular pressure, and slit-lamp examination was unremarkable apart from bilateral splinter-shaped cortical cataract sparing the visual axis. Splinter-shaped cataracts were noted pre-operatively in both eyes, however, slit-lamp photographs were taken post-operatively. Fundus examination was normal. Based on Krumeich classification of keratoconus,1 she had stage III keratoconus in the right eye and stage IV in the left eye. Patient had a best spectacle-corrected visual acuity (BSCVA) of 20/30 in the right eye with −6.50 sph −4.50 cyl at 25 and 20/80 in the left eye with −7.00 sph −6.00 cyl at 20. The left eye was fitted with hard contact lens and found to have a visual acuity of 20/25. Patient underwent uneventful lamellar keratoplasty (LKP) in the left eye and had an uncorrected visual acuity of 20/40 and BSCVA of 20/25 with minimal refractive error at the last follow-up visit 10 years post LKP, and the splinter cortical cataract remained stable with no progression. She underwent implantation of implantable collamer lens (ICL) in the right eye with UCVA of 20/30 post-operatively. At 18-months post-op visit the patient maintained her uncorrected and best corrected visual acuity with no progression in the cataract morphology.",
    "summary": "Thirty-six-year-old female patient diagnosed with keratoconus was followed in the outpatient department and sought to be independent of glasses in the right eye. Upon examination she was found to have bilateral splinter cortical cataract not involving the visual axis. She had the best spectacle corrected visual acuity of 20/30; she underwent uneventful implantation of ICL in the right eye with an uncorrected visual acuity of 20/30 post-operatively with no progression of the cataract during the follow-up period."
  },
  {
    "id": "multiclinsum_gs_en_94.txt",
    "fulltext": "A 29-year-old right-handed Kurdish male was diagnosed with Sturge–Weber syndrome (SWS) and poorly controlled epilepsy since infancy. Since birth, significant hemangioma formations have been obvious on the right side of his face. At 11 months of age, following hospitalization for two circumcision and hernia surgeries, the first generalized seizure occurred. Since the first episode, he has been treated with phenobarbital escalating to a total dosage of 250 mg daily. During his teenage years and beyond, the frequency of his seizures decreased to twice a month. He also acknowledged that the clinical presentations of his seizures have changed since the age of 15–16 years. Witnesses reported that the majority of the former seizures began with left-sided paresthesia, without marching and convulsions, followed by loss of consciousness, with hand automatism and then left versive. He said irrelevant words in some of these attacks and occasionally had left-side Todd’s paresis. The second seizure type has appeared since the patient’s adolescence, starting as an epigastric aura, followed by impaired awareness and hand automatism. He had no recollection of his episodes after the auras. While these two types of auras have never occurred at the same time, second-type seizures have accounted for the majority of his seizures in recent years.\n\nThe physical and neurological examinations did not reveal any significant positive findings, nor did the patient have a positive family history of SWS or epilepsy. He had no history of tobacco, alcohol, or cigarette smoking. He and his parents were not evaluated for genetic disorders. Prior evaluations, including complete blood count (CBC) and metabolic panel, were normal. Neuropsychological tests showed that his overall intellectual function and verbal and performance IQ are reduced on average. Regarding memory function, his verbal memory was better than his visual memory. He had average performance on working memory, visuospatial, and executive functions.\n\nBrain MRI with contrast and epilepsy protocol demonstrated tumor signals in the right temporal lobe’s ventral dimension of the para-hippocampus gyrus with right mesial temporal lobe sclerosis and SWS vascular lesions. Atrophy and high signal intensity in the right hippocampus with obliteration of hippocampus head digitation showed shrinkage of this area with sclerotic changes versus the left side (mesial temporal sclerosis; MTS).\n\n\nA 9 × 10 mm high signal heterogeneous lesion with an intercortical cystic component without post-contrast enhancement, in the ventral aspect of the right Parahippocampal gyrus was also shown, suggesting a low-grade glioma (LGG). Atrophy of the right parietal lobe compared to the left side with cortical atrophy and sulci dilation was also noted. Prominent leptomeningeal enhancement in the right parietal lobe, secondary atrophy with mild enlargement of the ipsilateral choroid plexus, and dilation of parenchymal veins, in favor of SWS, were seen.\n\nLong-term video-electroencephalography monitoring (LTM)\n7 days after medication withdrawal, one of his typical seizures was captured. The patient was asleep when the seizure started. Then he developed grimacing, followed by staring and impaired awareness. Afterward, he started left-hand automatism. The whole event took ~ 120 seconds without post-ictal Todd’s paresis. The electroencephalographic ictal pattern started about 10 seconds before the clinical manifestations of the seizure, appearing as right anterior temporal 4 –5 Hz rhythmic theta, and spreading to the left temporal regions occurred after ~ 10 seconds. There was postictal right temporal delta slowing. The patient developed bradycardia during the seizure, which continued afterward. Thus, we ended medication withdrawal and stopped further seizure evaluation Interictally, independent right anterior temporal epileptiform discharges were recorded. Although previous electroencephalographic studies are not available, we think that our patient has developed temporal lobe epilepsy in recent years on the basis of expressed seizure-semiology including oro-alimentary symptoms and abdominal-visceral sensations.\n\nPhenobarbital was deemed not to be the most appropriate medication for the type of seizures, so it was gradually reduced to 100 mg daily, and 2000 mg daily of levetiracetam was added. In follow-up visits, we carefully monitored the adverse effects of the drugs and seizure manifestations. Despite the frequency of his seizures and drowsiness having decreased to half, the patient noted that his irritability and aggressiveness increased. No suicidal warning is documented. After discussing the pros and cons of surgical treatment with the patient, he developed a positive attitude toward that. Especially because it could allow him to reduce the medications he requires and to improve seizure control. Therefore, we have planned a fluorodeoxyglucose positron emission tomography (FDG-PET) scan to localize the epileptogenic zone more precisely, before scheduling him for surgery. The patient’s treatment was disrupted as a result of the need to obtain the essential funds for the PET scan and surgical operation.",
    "summary": "In this report, we present a 29-year-old Kurdish male with Sturge-Weber syndrome showing evidence of sclerotic changes in the medial part of the right temporal including the hippocampus in magnetic resonance imaging, in addition to a low-grade glioma. He used to have seizures, starting with left dominant somatosensory aura, before puberty. Interestingly, the semiology has changed to an epigastric aura afterward. Therefore, we assumed that there could be a new seizure onset zone. Seizures from the right mesial temporal region were recorded during long-term electroencephalogram monitoring admission. This finding was compatible with lesions found in the right temporal lobe."
  },
  {
    "id": "multiclinsum_gs_en_214.txt",
    "fulltext": "A 40-year-old female underwent routine fetal echocardiographic screening at the 22nd week of gestation. The pregnancy was normal without any maternal complications, such as hypertension, diabetes, eclampsia, or infections during gestation. In addition, screening for Down syndrome revealed a low risk that did not indicate a need to conduct amniocentesis for a chromosomal abnormality test. However, the fetal ultrasound demonstrated severe TR, based on Vmax = 3.8 m/s, with estimated diameters of the cardiac chambers of LV = 11 × 19 mm, RV = 19 × 24 mm, LA = 12 × 10 mm, and RA = 13 × 16 mm. Subsequently, the female was referred to a pediatric cardiologist for advice. Because the age of the female was 40, which is a high-risk factor for birth defects, and since TR is quite commonly observed in fetal ultrasound screening, the cardiologist suggested genomic sequencing analysis of free fetal DNA in maternal blood. However, the parents refused this analysis.\n\nThe baby was born safely in our institute, and the first echocardiography examination postnatally demonstrated good heart function and normal structure as well as normal sizes of the 4 chambers. However, 6 months later, the baby was brought to our department due to excessive sweating and decreased milk consumption. The physical examination showed that the body temperature of the girl was 36.8°C, her heart rate was 150 beats per minute, and her respiration rate was 42 beats per minute. The blood pressure of the four limbs was as follows: 92/44 mmHg at the right upper limb, 96/58 mmHg at the left upper limb, 101/60 mmHg at the right lower limb, and 103/54 mmHg at the left lower limb. In addition, she presented a critically ill face, her lips and complexion were pale, excessive perspiration, and coarse breath were noted, but there were no rales. On auscultation, her heart boundaries were enlarged, the apex was shifted, and grade I systolic murmur was heard in the 2nd intercostal space on the left-sternal border. Routine blood examination, liver and kidney function tests, electrolytes, routine examination of urine and stool, blood gas analysis, blood ammonia analysis, pyruvate analysis, thyroid function analysis and metabolic disease detection showed no obvious abnormalities. The chest X-ray showed signs of pulmonary infiltration, and the heart size was significantly increased. Electrocardiogram (ECG) showed sinus tachycardia, axis deviation, and ST-T wave changes (II, III, AVF, decrease in current at the V5 lead not less than 0.05 mV, short T wave). Moreover, the echocardiography presented a dramatic phenotype of severe TR, an extremely enlarged left ventricle, and reduced density of the interventricular septum and left ventricular posterior wall. The LVEF dropped to 22%, and FS decreased to 10%. We excluded the possibility of myocarditis based on a series of negative blood test results and history of collections. After administration of digoxin, hydrochlorothiazide, spironolactone diuresis, captopril, and L-carnitine, the symptoms of heart failure were controlled. The genomic sequence was determined, and 3 pathogenic gene mutations located in 2 genes, cardiac troponin T (TNNT2) c.548G>A:p.Arg183Gln, desmoplakin (DSP) c.3146C>T: p.Ser1049 Leu, and DSP c.5213G>A: p.Arg1738Gln, were identified, all of which are very important for cardiomyocyte development and maturation postnatally. This result could explain why this kind of DCM progressed so rapidly.\n\nDuring the follow-up, the patient still suffered from poor heart function and an enlarged left ventricle. The latest echocardiography report (1 year and 6 months old) showed the 4 chamber sizes to be LV = 40 mm, RV = 8 mm, LA = 18 mm, and RA = 28 mm and low cardiac pump function of EF = 28% and FS = 13%. Concomitantly, the parents placed the patient on the waiting list for heart transplantation. The patient provided informed consent for publication of the case.",
    "summary": "Patient concerns:\nA case of severe TR was found via the fetal ultrasound screening. After birth, this child suffered severe heart dysfunction, and echocardiography confirmed a DCM phenotype within a very short time.\n\nDiagnosis and intervention:\nA 40-year-old female received routine fetal echocardiographic screening, which demonstrated that the fetus presented severe TR. Six months after birth, the baby experienced severe heart failure, as the EF dropped to 22% with an extremely large LV chamber. The genomic sequence had been determined, and 3 pathogenic gene mutations located in 2 genes, cardiac troponin T (TNNT2) c.548G>A, desmoplakin (DSP) c.3146C>T, and DSP c.5213G>A, were identified. Finally, the patient was diagnosed with DCM. This child received digoxin, hydrochlorothiazide, spironolactone diuresis, captopril, and L-carnitine, and the symptoms of heart failure had been controlled as the patient waited for heart transplantation.\n\nOutcomes:\nDuring the follow-up, the patient still suffered from poor heart function and an enlarged left ventricle. Concomitantly, the parents placed her on a waiting list for heart transplantation."
  },
  {
    "id": "multiclinsum_gs_en_377.txt",
    "fulltext": "The 12-year-old male patient was referred to the Stomatology Service because he had noticed a nodule in the posterior midline of the tongue during self-examination, although he did not know exactly when it had appeared or if it had grown since then. The clinical examination revealed a mobile, voluminous, pedunculated mass on the dorsum of the tongue, approximately 1 cm in diameter, displaced to the posterior part of the oral cavity, in close contact with the oropharyngeal region, with a color and texture similar to the adjacent mucosa. The patient's mother reported that he had never had health problems previously.\n\nThe lesion was excised under local anesthesia without complications. The surgical piece was sent for anatomopathological analysis supervised by an oral pathologist. The microscopic analysis revealed a polypoid lesion covered by stratified keratinized squamous epithelium, containing cuts all over its length that suggested the formation of cutaneous appendages and the presence of various tissues, including seromucinous salivary glands, cartilage tissue, lymphoid hyperplasia, muscle and adipose tissue. All the tissues were mature and without a degree of atypia. The histopathological findings were compatible with the diagnosis of PP. The postoperative course was uncomplicated and the patient was monitored for 18 months, showing no clinical signs of tumor recurrence. The report of this case was approved by the Research Ethics Committee under protocol 2.283.697 on September 19, 2017 (Federal University of Goiás).\n",
    "summary": "Male patient, 12 years old, referred to the Department of Stomatology with a nodule in the posterior region of the midline of the tongue. The patient was unable to report when the lesion appeared and whether it had grown since then. The clinical examination revealed a pedunculated, voluminous and mobile mass on the dorsum of the tongue, measuring approximately 1.0 cm in diameter. The patient's mother reported that he had never had any previous health problems. An excisional biopsy was performed and the material was sent for anatomopathological analysis, with the findings being consistent with the diagnosis of PP.\n"
  },
  {
    "id": "multiclinsum_gs_en_249.txt",
    "fulltext": "This is a case of a 23-year-old male with an unremarkable medical history who was referred with unexplained dyspnea. Prior to his current illness, he was in good health and had no difficulty performing daily activities. Both of his parents had diabetes, and his grandfather passed away from a heart attack at the age of 74. Additionally, upon further review of his family history, we discovered that the patient’s uncle has a history of acromegaly.\n\nThe patient’s condition started 2 weeks prior to admission when he started complaining of fever, nasal congestion, and rhinorrhea. Three days later, he started complaining of vomiting, diarrhea, and abdominal pain. After being admitted to the internal medicine ward, we were consulted for marked palpitations, dyspnea, and orthopnea.\n\nDuring the examination, his temperature was slightly elevated at 37.9°C, blood pressure of 150/90 mmHg, heart rate was 110/min, and respiratory rate was 22/min. Auscultation revealed fine basal lung crepitations with bilateral mild expiratory rhonchi. Additionally, an early diastolic murmur was detected. His neck veins were congested, yet not pulsating, and there was no lower limb edema or ascites.\n\nLaboratory findings were notable for an elevated level of Brain Natriuretic Peptide (BNP) (340 pg/mL). Additional findings included bilateral mild pleural effusion and cardiomegaly observed in the chest X-ray. The ECG revealed sinus tachycardia with inverted T waves in leads V3 and V4. Transthoracic echocardiography (TTE) showed a mildly dilated and hypertrophied left ventricle (LV), slightly impaired LV systolic function with an ejection fraction of 48% by M-mode, impaired diastolic function, moderate mitral valve regurgitation, and severe aortic valve regurgitation. The aortic root was markedly dilated, with diameters of 3.2 cm at the annulus, 4.9 cm at the sinus of Valsalva, and 7.5 cm at the Sino tubular junction (STJ).\n\nConsequently, CT aortography was performed, confirming the echocardiographic measurements of the aortic root diameters. Moreover, it revealed dilation of the ascending aorta with a diameter of 10 cm and the descending aorta with a diameter of 2.5 cm. The patient was initiated on the following medications: Furosemide (20 mg every 8 hours), Ramipril (1.25 mg once daily), and Empagliflozin (10 mg once daily). Within 10 days, the patient experienced slight improvement in symptoms, particularly dyspnea, and reported better sleep. A follow-up chest X-ray showed partial resolution of the pleural effusion.\n\nInitially, we considered connective tissue disease like Marfan or Ehlers-Danlos syndrome. However, the patient lacked the typical physical features and associated signs of these conditions. Additionally, his pulmonary function test was normal, which would likely be abnormal in a multisystem connective tissue disorder. Laboratory results showed normal ESR and C-reactive protein levels, reducing the likelihood of vasculitis as a cause of the aortic root dilatation. The autoimmune panel, including ANA and RF tests, was also negative.\n\nAcromegaly was then considered as the potential cause of LV hypertrophy and aortic root dilation, especially considering his family history of the condition. Therefore, insulin-like growth factor 1 (IGF-1) level was ordered and was elevated (320 ng/ml), and the GH level remained above normal (1.1 ng/ml) after an oral glucose tolerance test confirming the diagnosis of acromegaly. A T2-weighted brain MRI image showed a 7 × 4 mm hyperintense mass in the Sella turcica, consistent with a pituitary microadenoma.\n\nSubsequently, the surgery decision was taken after obtaining consent from the patient. Following a normal coronary angiography, the patient underwent a composite graft replacement procedure, involving the aortic valve, aortic root, and ascending aorta (Bentall Procedure). A mechanical valve was utilized, and the patient began taking Warfarin at a daily dose of 3 mg, with close monitoring to achieve a target INR of 2 to 3.\n\nFollowing consultation with the endocrinologist, the patient began receiving monthly injections of Octreotide acetate. A comprehensive follow-up plan was established, which included monitoring the functioning of the valve, assessing LV function, ensuring medication compliance, and checking IGF-1 and INR values. Apart from mild exertional dyspnea, he remained asymptomatic for 8 weeks after the surgery. During this period, follow-up echocardiograms showed the replaced aortic valve functioning normally without any leakage or dysfunction. The aortic root and ascending aorta were also stable, with no signs of dilation, aneurysm, or other complications. There was no progression of his LV hypertrophy either. His most recent IGF-1 level was 290 ng/ml which is mildly reduced than the first, and he has been maintained on Octreotide without significant adverse effects.",
    "summary": "This report presents a case of a 23-year-old male with no significant medical history, who presented with severe dyspnea after a chest infection. He lacked distinct physical features of genetic or endocrinal disorders, but his uncle had acromegaly. Echocardiography revealed left ventricular hypertrophy and massive aortic root dilation. Elevated insulin-like growth factor 1 (IGF-1) confirmed the diagnosis of acromegaly. The patient underwent a Bentall procedure, and his acromegaly was managed with octreotide and regular follow-ups."
  },
  {
    "id": "multiclinsum_gs_en_95.txt",
    "fulltext": "Clinical presentation\nA 68-year-old Chinese female individual was hospitalized owing to severe, persistent, and colicky abdominal pain that occurred 6 h after engaging in physical labor. The intensity of the pain compelled her to adopt a knee-chest position. She reported a significant weight loss over the preceding 12 months. A total of 11 years prior, she had undergone a “left inguinal hernia repair” in the absence of any abdominal trauma. At the time of admission, she exhibited lower abdominal tenderness, yet without pronounced muscular rigidity.\n\nImaging\nAbdominal computed tomography (CT) imaging disclosed findings consistent with mesenteric volvulus accompanied by intestinal obstruction, suggesting a potential for intestinal necrosis. A high-density mass within the right mesentery raised the possibility of a tumor.\n\nLaboratory tests\nThe patient had a white blood cell count of 19.9 × 109/L with a neutrophil percentage of 86.7%. Her hemoglobin level was 130 g/L, blood lactate was 1.7 mmol/L, lactate dehydrogenase was 236.4 U/L, and creatine kinase was 77.5 U/L. Tumor markers included a carcinoembryonic antigen level of 0.89 ng/ml and a carbohydrate antigen 19–9 level of 6.2 U/ml.\n\nDiagnosis\nHer diagnosis was of intestinal volvulus with necrosis, without ruling out a mesenteric tumor.\n\nSurgical situation\nThe intraoperative exploration exposed a substantial accumulation of turbid, purulent fluid within the abdominal cavity; the majority of the small intestine was purplish-black and grayish-white. After conversion to laparotomy, a firm mass with an irregular surface and limited mobility was identified at the base of the small intestine mesentery, resulting in a 1440° (four full turns) clockwise rotation of the mesenteric root. A segment of approximately 400 cm of the small intestine, extending from 5 cm above the duodenojejunal flexure to 3 cm below the ileocecal junction, was determined to be entirely necrotic. In an effort to manage the abdominal infection, a complete resection of the small bowel was carried out, along with the creation of a jejunostomy at the proximal jejunum.\n\nPostoperative pathology\nPostoperative pathology findings described a mesenteric mass measuring 4.0 cm × 3.5 cm × 3.0 cm. The mass was firm and hard, resisting sectioning. Microscopic examination revealed significant calcification, accompanied by a proliferation of fibrous tissue, chronic inflammatory cell infiltration, and areas of fat necrosis. The mesentery also showed signs of congestion, stasis, and hemorrhage. Three lymph nodes were sampled, and no tumor metastasis was detected.\n\nDue to the prompt intervention, the patient was spared from developing severe septic shock. However, the development of short bowel syndrome is now certain. The patient is projected to require long-term total parenteral nutrition or home parenteral nutrition, and may be a candidate for isolated intestinal transplant at an appropriate future date.",
    "summary": "A 68-year-old Chinese female individual was hospitalized because of severe abdominal pain that occurred 6 h after engaging in physical labor. An abdominal computed tomography examination revealed volvulus of the mesenteric root and the presence of a mixed-density mass in the right mesentery, with the possibility of a neoplastic process not ruled out. Emergency surgical exploration confirmed that the small mesenteric tumor served as a pivot, with the mesenteric root twisted 1440°, leading to total necrosis of the small intestine. As a result, total small intestine resection and enterostomy were performed. Postoperative pathological examination of the mesenteric tumor revealed fat necrosis, excessive calcification, peripheral fibrous tissue hyperplasia, and chronic inflammatory cell infiltration, consistent with a diagnosis of sclerosing mesenteritis. The patient's life was saved through timely surgical intervention. However, owing to the development of short bowel syndrome, she will require long-term dependence on parenteral nutrition."
  },
  {
    "id": "multiclinsum_gs_en_338.txt",
    "fulltext": "A 26-year-old woman was referred by a neurologist for progressive, sequential, and bilateral vision loss and blurriness over the course of 1 month starting with and more prominent in the right eye without any painful eye movements. She had a past medical history of clinically isolated syndrome involving the spinal cord. Her sensory symptoms had started 7 years prior to presentation involving her left foot and migrating over a period of weeks to reach a level distal to the waist. Her magnetic resonance imaging (MRI) of the brain and spine had revealed one lesion in the infratentorial region and another in the thoracic spinal cord. Follow-up MRIs identified temporally distinct new enhancing lesions at the C4, C6-C7, T2, and T7-T8 levels. Additional workup revealed negative results for anti-aquaporin-4 and myelin oligodendrocyte protein (MOG) antibodies. She was not receiving any medications at the time of presentation and her history for smoking and alcohol drinking was unremarkable. Her family history was insignificant for hereditary causes of vision loss including LHON.\n\nNeuro-ophthalmological examination revealed a best corrected visual acuity (VA) of 20/100 OD and 20/30-2 OS. Her VA demonstrated gradual improvements during subsequent follow-ups. Ishihara color plates revealed that she was able to read only 1 out of 17 color plates in the right eye and 14 out of 17 color plates in the left eye. There was no relative afferent pupillary defect. Optical coherence tomography (OCT) demonstrated an average retinal nerve fiber layer thickness of 83 microns OD and 93 microns OS with slight temporal thinning. Dilated fundus exam showed pallor of both optic nerves with cup to disc ratio of 0.2.\n\nThe differential diagnosis for her visual symptoms included bilateral optic neuropathies, such as optic neuritis or LHON. Nutritional deficiencies were ruled out due to normal complete blood count, B12, folate. She proceeded with prednisone 1,250 mg PO daily for 3 days followed by 60 mg and a taper by 10 mg every 5 days; however, at follow-up visit, she did not report any improvements in her symptoms. Additional workups revealed mild T2 hyperintensities on the right side of the optic chiasm and three new cerebral white matter lesions (splenium; 2 lesions of left parietal periventricular white matter) on MRI. MRI findings and oligoclonal bands detected with lumbar puncture confirmed the diagnosis of MS. On subsequent follow-ups, her Humphrey visual field testing showed bilateral central scotomas in both eyes. Slowly progressive nature, sequential involvement of the eyes, symmetrical central scotomas, symptoms unresponsive to steroids, and hyperintensities in optic chiasm detected by MRI were suggestive of LHON. Dilated fundus exam revealed temporal pallor. The genetic testing for three primary mutations were negative; however, she was heterozygous for c.152A>G variant of DNAJC30 gene associated with arLHON. She was also tested positive for c.1239C>T variant in UQCRC1 gene with autosomal dominant pattern of inheritance. She was diagnosed with Harding’s syndrome and she was started on idebenone 300 mg PO TDS daily which led to improvements in her symptoms. Her VA demonstrated gradual improvements over yearly follow-ups (her latest corrected VA was 20/40-2 OD and 20/20-2 OS) and OCT metrics and examination remained stable with bilateral temporal pallor. The visual fields and OCTs 4 years after follow-up are shown.",
    "summary": "We present a 26-year-old woman with progressive, sequential, painless, bilateral visual loss which was unresponsive to steroids, and two temporally distinct episodes of neurological disturbance suggestive of central nervous system demyelination. Thorough investigations including serological tests ruled out other causes, including negative neuromyelitis optica and myelin oligodendrocyte protein (MOG) antibodies and nutritional deficiencies. MRI detected areas of demyelination within the spinal cord and brain (infratentorial and periventricular areas). After genetic analysis revealing c.152A>G (p.Tyr51Cys) mutation at the DNAJC30 gene, LHON was suggested. She was prescribed with idebenone and her visual acuity resolved to normal at 4-year follow-up."
  },
  {
    "id": "multiclinsum_gs_en_393.txt",
    "fulltext": "A 59-year-old female with recurrent bilateral urolithiasis presented with right flank pain, fever, and fatigue. A right double-J stent had been placed a year earlier for a symptomatic pelvic stone but was not followed up. She had right heart failure, poorly controlled type 2 diabetes, and chronic kidney disease (creatinine nadir: 18 mg/L).\nClinically stable, she had a Glasgow Coma Scale of 14/15 (slightly altered verbal response), fever (38.3 °C), right flank tenderness, and 800 cc urine output over 24 h.\nLaboratory results revealed acute kidney injury, with a serum creatinine level of 107 mg/L (normal: 6–12 mg/L) and blood urea of 3 g/L (normal: 0.15–0.45 g/L). Inflammatory markers were elevated, with a C-reactive protein level of 300 mg/L (normal: <5 mg/L) and a white blood cell count of 17,000/mm3 (normal: 4000–10,000/mm3). Additionally, the patient exhibited normocytic anemia (hemoglobin: 7.6 g/dL; normal: 12–16 g/dL) and mild hyperkalemia (serum potassium: 5.4 mEq/L; normal: 3.5–5.1 mEq/L). Urinalysis and urine culture were negative for bacterial infection.\nA non-contrast abdominopelvic CT scan revealed right-sided hydronephrosis, a calcified double-J stent coiled at both ends, and a 35 × 28 mm right pelvic stone (588 UH). The left kidney is reduced in size, with hydronephrosis and a 12 × 7 mm pelvic stone (531 UH).\n\nDue to severe obstructive pyelonephritis, notably caused by the encrusted stent, an urgent bilateral percutaneous nephrostomy was performed, leading to significant clinical improvement and normalization of inflammatory markers and renal function.\nThree days later, the patient experienced a generalized seizure associated with dysarthria. Urgent brain CT showed ischemic lesions in the right frontal and left occipital lobes, indicating an embolic stroke. She was started on enoxaparin (0.4 cc daily) and Kardegic (160 mg daily) for stroke prevention.\nDespite neurological improvement, four days later the patient developed progressive mucocutaneous pallor, tachycardia (110 beats per minute), hypotension (80/50 mmHg), and gross hematuria from the urinary catheter. Hemoglobin levels dropped from 7.5 g/dL to 4.4 g/dL, raising suspicion of active bleeding. Fluid resuscitation, intravenous vasopressors, and blood transfusions were administered, stabilizing her condition for a contrast-enhanced CT angiography scan.\nThe CT scan revealed a 17 mm thick, heterogeneous middle polar collection with contrast extravasation in the arterial and portal phases, indicating active bleeding from the upper and middle pole arteries. Intraluminal clots were also present in the renal pelvis and bladder. A diagnosis of post-nephrostomy arteriovenous fistula, exacerbated by anticoagulation therapy for the stroke, was made.\nUrgent renal arteriography via right femoral artery access using a 5-French diagnostic catheter was performed. Selective angiography revealed an AVF at the lower pole of the kidney with early venous drainage into the inferior vena cava, along with a small pseudoaneurysm. Superselective embolization using 3 mm and 5 mm microcoils successfully occluded the fistula, with Gelfoam particles used to prevent retrograde bleeding. A final contrast injection confirmed complete occlusion of the fistula, restoring arterial integrity and halting the hemorrhage.\n\nPost-embolization, the patient was closely monitored in the ICU. Hemodynamics remained stable, and a collegial decision was made to reintroduce anticoagulation with INR monitoring to manage the ischemic stroke while balancing the bleeding risk. Hematuria resolved, renal function normalized, and the nephrostomy remained functional.\nA multidisciplinary approach was taken for definitive treatment. The first stage involved endoscopic laser lithotripsy of the calcified lower loop of the JJ stent, insertion of a second JJ stent in parallel with the encrusted one, and removal of the nephrostomy, which was successfully completed. The second stage, scheduled six weeks later, included flexible right ureteroscopy to free the upper loop of the calcified JJ stent, fragmentation of the right pelvic stone using laser lithotripsy, and complete removal of the encrusted stent. Unfortunately, the patient's health declined due to multiple factors, including heart failure, poorly controlled diabetes, chronic kidney disease, and a previous stroke, which postponed the completion of the planned second treatment stage.",
    "summary": "A 59-year-old female with recurrent bilateral urolithiasis, right heart failure, poorly controlled type 2 diabetes, and chronic kidney disease presented with right flank pain, fever, and fatigue. She had previously undergone right double-J stent placement but was lost to follow-up. A CT scan revealed hydronephrosis, a calcified stent, and a 22 mm pelvic stone, leading to the performance of a percutaneous nephrostomy. The patient developed an embolic stroke three days later and subsequently presented with hematuria, hypotension, and significant anemia. CT angiography confirmed an AVF with active bleeding, which was successfully treated with embolization."
  },
  {
    "id": "multiclinsum_gs_en_36.txt",
    "fulltext": "A 46-year-old male patient was admitted to the emergency department of our tertiary care hospital, presenting with dyspnoea and palpitations. The patient’s electrocardiogram showed tachycardia characterized by a wide QRS complex, with a heart rate of 234 beats per minute. An intravenous dose of amiodarone was administered promptly (a loading dose of 300 mg of amiodarone was given through intravenous infusion over 30 min. Amiodarone is the only intravenous antiarrhythmic drug available in our region, whereas procainamide is not available). After administering amiodarone, the follow-up electrocardiogram displayed a sinus rhythm of 110 beats per minute, with no ST abnormalities or electrical alternans. After a thorough patient history assessment, the patient reported experiencing shortness of breath for the past week, which had intensified in the last hour and was accompanied by palpitations. The patient’s extensive medical history did not indicate any episodes of fever, weight loss, or abdominal pain. Five years earlier, the patient underwent coronary angiography due to an acute coronary syndrome, resulting in the implantation of a stent in the right coronary artery. The initial physical examination revealed a blood pressure of 118/70 mmHg and an oxygen saturation of 92%. The patient exhibited tachypnoea with a respiratory rate of 31 breaths per minute. Diminished S1 and S2 heart sounds were noted during cardiac auscultation, with no additional sounds. There was no evidence of pretibial oedema or hepatomegaly. However, the physical examination indicated jugular venous fullness. Upon lung auscultation, both lungs moved equally during respiration, and no rales or rhonchi were detected.\n\nThe patient’s laboratory results showed no abnormal parameters except for an elevated NT-proBNP value of 2722 ng/L (with a standard value below 300 ng/L). The haemograms were within the normal range, including white blood cell, lymphocyte, neutrophil, and platelet counts. The serum electrolytes, liver function, and renal function tests were also within normal limits.\n\nThe emergency transthoracic echocardiogram (TTE) revealed a left ventricular ejection fraction of 60% with no regional wall motion abnormalities. A pericardial effusion measuring 2.4 cm at its widest point was observed surrounding the heart adjacent to the right ventricle. No reciprocal variation was noted in the mitral and tricuspid valves with diastolic collapse. Although the patient did not exhibit signs of tamponade syndrome, pericardiocentesis was performed due to the patient’s tachycardia and tachypnoea. Following the procedure, the patient’s tachycardia and tachypnoea improved. No diagnostic features were identified on the chest X-ray. The pericardial fluid was haemorrhagic and classified as exudative upon analysis. Upon reviewing the patient’s admission ECG, the absence of fusion and escape beats and an initial R wave duration shorter than 40 ms in aVR were evaluated as findings suggestive of SVT. The absence of RS in all precordial leads and the QS wave morphology in V6 on the admission ECG suggested VT. In this case, an electrophysiology study was planned to clarify the diagnosis. While awaiting the cytology results of the pericardial effusion, the patient was scheduled for a diagnostic electrophysiological study due to the presence of wide QRS tachycardia. During the electrophysiological study, it was noted that the signal amplitude recorded through the lead positioned in the right atrium was low, making successful atrial pacing impossible. Following the induction of the patient’s tachycardia via a catheter placed in the coronary sinus, high-transition atrial tachycardia with aberrant conduction was detected. Due to the patient’s weak right atrial signal and pacing difficulties, echocardiography and cardiac MRI were planned to rule out pathologies affecting the right atrial tissue. The follow-up echocardiography showed completely normal right ventricular function. Subsequently, the patient was scheduled for transoesophageal echocardiography.\n\nTransoesophageal echocardiography revealed masses with heterogeneous echogenicity extending from the superior vena cava to the right atrium. We also noted a hyperechoic formation that we could not distinguish as either a mass or a thrombus, extending from the right atrium to the right ventricle and measuring 70 × 35 mm in diameter. Meanwhile, the pathological examination of the pericardial fluid indicated large lymphoid cells containing B cells, as shown by positive immunocytochemical staining for CD20.\n\nCardiac MRI revealed a mass lesion measuring ∼63 × 30 × 79 mm, extending from the right atrium to the superior vena cava and the right atrial appendage. It infiltrated the free wall of the right ventricle, the pericardium, and the right atrial wall, showing distinct diffusion restriction in some areas. The lesion notably constricted the lumen of the superior vena cava at its entry point to the atrium. The patient’s cardiac MRI raised suspicion of cardiac lymphoma.\n\nThe patient’s PET-CT scan showed a dense cluster of hypermetabolic lymph nodes in the mediastinum and a hypermetabolic mass extending from the right atrium towards the superior vena cava. To assess for bone marrow invasion, a bone marrow aspiration was conducted. As a result, no bone marrow involvement was found.\n\nIn the histopathological examination of the excisional lymph node taken from the mediastinal lymph nodes, staining with CD20 and PAX-5 was observed. Internal control staining with CD10 was not observed. Positive staining with MUM1, negative staining with BCL 6 and CD30, and positive staining with BCL 2 were observed. The biopsy result was reported as diffuse large B-cell lymphoma. After diagnosing diffuse large B-cell lymphoma, the patient was referred to a haematology clinic and started on R-CHOP chemotherapy. The patient underwent six cycles of combination chemotherapy (R-CHOP: rituximab, cyclophosphamide, anthracycline, vincristine, and prednisone. The patient is currently in their sixth month of follow-up, with chemotherapy treatment ongoing.",
    "summary": "A 46-year-old male patient presented to the emergency department of our hospital with complaints of dyspnoea and palpitations. The patient's electrocardiogram revealed a tachycardia characterized by a wide QRS complex and a heart rate of 234 beats per minute, and an intravenous infusion of amiodarone was immediately started. In the cardiac MRI performed, a mass lesion was observed, which was ∼63 ∗ 30 ∗ 79 mm in size, extending from the right atrium to the superior vena cava and right atrial appendage, infiltrating the free wall of the right ventricle, pericardium, and right atrial wall, and showing distinct diffusion restriction in places. The patient's cardiac MRI was documented with a suspicion for cardiac lymphoma. The patient was referred to haematology clinic and started on rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy.40070801"
  },
  {
    "id": "multiclinsum_gs_en_411.txt",
    "fulltext": "A 70-year-old man was referred to our hospital after a jaundice was reported by another physician. Blood examination revealed elevated hepatobiliary enzymes and increased levels of tumor markers (CA19-9, 444.3 U/mL; carcinoembryonic antigen (CEA), 15.5 ng/mL). Contrast-enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography revealed Bismuth classification II13) bile duct wall thickening from the confluence of the right and left hepatic ducts to the confluence of the choledochal ducts, with intrahepatic bile duct dilation. The tumor had partially reached the intrapancreatic bile duct. Hilar lymph node enlargement was observed, and lymph node metastasis was suspected. No distant metastases were observed. A biopsy of the common bile duct stenosis revealed adenocarcinoma, and the patient was diagnosed with hilar CC (cT3N1M0, Stage III C). Subtotal stomach-preserving pancreatoduodenectomy with right lobe hepatectomy was planned as radical resection. CT volumetry revealed the following: total liver volume (TLV) = 1350 mL, standard liver volume (SLV) = 1118.2 mL, remnant liver volume (RLV) = 483 mL, RLV/TLV = 35.8%, and RLV/SLV = 43.2%. Trans-ileocolic right portal vein embolization was performed14) because of concerns about an insufficient remaining liver volume.\n\nHowever, a CT performed 1 month after trans-ileocolic right portal vein embolization revealed enlarged para-aortic lymph nodes that were considered metastatic, and radical resection was judged to be unsuitable. Therefore, the decision was made to administer systemic chemotherapy. Following the treatment protocol of the TOPAZ-1 study,5) cisplatin (25 mg/m2) and gemcitabine (1000 mg/m2) were administered on days 1 and 8 of each 21-day cycle for 8 cycles, and durvalumab (1500 mg) was administered on day 1 of each cycle. The patient was followed up with monthly tumor marker measurements and CT scans every 3 months. At the end of the 4th course, the CA19-9 and CEA levels decreased to the normal range. Positron emission tomography-CT revealed vanishing fluorodeoxyglucose accumulation in the para-aortic lymph nodes. Systemic chemotherapy was deemed to be significantly effective, and radical resection was considered. Then, when the chemotherapy response was confirmed, the possibility of surgery was explained to the patient. The patient strongly preferred radical surgery over continued chemotherapy, and the decision was made to proceed with radical surgery.\n\n\nSecond CT volumetry before surgery showed the following: TLV = 1231 mL, SLV = 1167.6 mL, RLV = 745 mL, RVL/TLV = 60.5%, and RLV/SLV = 63.8%. Endoscopic retrograde cholangiopancreatography biopsies of the original left hepatic duct and the cephalic portion of the intrapancreatic bile duct were negative for malignancy. An open right lobe hepatectomy and extrahepatic biliary reconstruction were also performed. The operative time was 10 h 40 min, blood loss was 460 g, and the weight of the resected liver was 474 g. Visually, a well-defined white sclerotic lesion proliferating along the right hepatic duct was observed. Histologically, there was no evidence of carcinoma, fibrous stroma-rich fibrotic scarring associated with treatment, or lymph node metastasis. The final TNM classification (UICC-8th) was ypT0N0. One month after surgery, a Grade 3 skin disorder appeared, and the patient was treated by the dermatology department. The patient showed no recurrence 10 months after surgery.",
    "summary": "A 70-year-old man was diagnosed with hilar CC (cT3N1M0, Stage III C) based on biopsy of the common bile duct stenosis and computed tomography (CT) and magnetic resonance cholangiopancreatography scans. Initially, a right lobe hepatectomy and subtotal stomach-preserving pancreatoduodenectomy were planned. However, there were concerns about an insufficient functional remnant liver volume. Trans-ileocolic portal embolization of the right portal vein branch was performed. On a preoperative CT scan 1 month later for liver volumetry, swelling of the para-aortic lymph nodes was observed, which was judged as distant metastasis, and radical resection could not be performed. After 8 courses of durvalumab plus gemcitabine and cisplatin therapy, vanishing fluorodeoxyglucose accumulation in the para-aortic lymph nodes was observed on positron emission tomography-CT. The possibility of resection was reevaluated, and a right lobe hepatectomy and extrahepatic biliary reconstruction were performed as conversion surgeries. Histological examination confirmed the absence of residual tumors or lymph node metastases. Ten months after surgery, the patient was free of recurrence."
  },
  {
    "id": "multiclinsum_gs_en_140.txt",
    "fulltext": "The authors have read the case report (CARE) Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016). An Asian woman in her early 80s presented with a palpable and painless mass in the distal phalanx of the left thumb. The patient noticed that mass 2 years ago, and the mass swelled progressively in the 2 years and its growth accelerated in the past 6 months, which prompted the woman to go to the hospital for medical assessment. Upon physical examination, the patient had a swollen left hand thumb, giving it a drumstick appearance. The patient claimed a history of type 2 diabetes and hypothyroidism with no known trauma or any masses elsewhere. Our patient did not have Ollier’s disease, Maffucci syndrome, or hereditary exostosis and had no evidence of prior enchondroma. The results of routine blood tests and biochemical tests were normal. To further clarify the diagnosis, the patient received medical imaging examinations. The radiograph showed a mass in the distal phalanx of the left thumb with osteolytic bone destruction. In computed tomography (CT) images, osteolytic destruction of the distal phalanx of the thumb with a local soft tissue density mass was observed. Magnetic resonance imaging (MRI) also showed cortical destruction of the distal phalanx of the thumb and a local soft tissue signal mass of approximately 20 mm × 19 mm × 26 mm with isosignal intensity in the T1-weighted image (T1WI) and heterogeneously high signal intensity in the T2-weighted image (T2WI). The mass invaded the interphalangeal joint. In addition, the patient underwent ultrasound examination. Ultrasound imaging demonstrated a hypoechoic mass (25 mm × 18 mm × 22 mm) with patchy calcification in the distal phalanx of the left thumb. The mass had a clear margin and irregular shape. The bone cortex around the mass is discontinuous and not smooth. Color Doppler showed a dot blood flow signal within the mass. Subsequent chest radiography and bone scans did not reveal any metastatic lesions.\n\nWith the above imaging findings, the patient received amputation of the left thumb distal phalanx to achieve radical excision of the mass. The lesion tissues were stained with hematoxylin-eosin (HE). Microscopically, blue-stained cartilaginous matrix was found, and chondrocytes showed obvious heteromorphism. The caryocinesia was observed, with invasive growth accompanied by a few bone trabeculae. Pathologic findings are consistent with a chondrogenic tumor, showing intermediate-locally aggressive behavior. Combined with tumor location (appendicular skeleton, not the axial skeleton), imaging findings (a mass with osteolytic bone destruction), and an aggressive clinical behavior (rapid growth in the last 6 months), the tumor was diagnosed as an ACT. The postoperative x-ray examination showed a good surgical outcome. After the surgery, the patient experienced an improvement in her symptoms and reported a better quality of life. During the 3-year follow-up, there was no evidence of recurrence detected by MRI or CT scans. Informed consent was obtained from the subject described in this report.",
    "summary": "We report a case of an Asian woman in her early 80s who presented to our hospital with a painless mass in the distal phalanx of the left thumb. Radiography and computed tomography (CT) showed osteolytic destruction and cortex thickening in the distal phalanx with extension into soft tissue. Magnetic resonance imaging (MRI) demonstrated a local soft tissue signal mass with isosignal intensity in T1 and heterogeneous high-signal intensity in T2. Color Doppler ultrasound suggested that the tumor was hypovascularized. The patient underwent amputation, and histological analysis revealed an ACT. The patient’s symptoms improved postoperatively, with no recurrence as of the 3-year follow-up."
  },
  {
    "id": "multiclinsum_gs_en_520.txt",
    "fulltext": "We report the case of a male newborn from an investigated high-risk pregnancy. The birth was natural, with a birth weight of 2980 g and an Apgar score of 9 and 10 at 1 and 5 min, respectively, with a good postnatal transition. He was readmitted to the hospital at ten days of life with severe general status. The echocardiography revealed critical stenosis of the aortic valve, severe systolic biventricular dysfunction, and pulmonary hypertension. Prostaglandin E1 was initiated in high-dosage continuous infusion (0.15 mcg/kg/min). He was transferred to the Neonatal Intensive Care Unit of the MS Curie Children’s Hospital at 13 days of age with a severe general condition and hemodynamic instability. The patient was immediately intubated and mechanically ventilated due to respiratory distress. Intravenous central venous lines were placed for nutrition and medication administration. Central arterial lines were inserted for continuous invasive blood pressure monitoring and femoral artery cannulation for cardiac catheterization.\n\nAfter five hours of admission, we performed diagnostic cardiac catheterization using 2 mL/kg iohexol 300 for iodinated contrast, which was subsequently followed by balloon aortic valvuloplasty (4.3 mm aortic ring, Tyshak II balloon size 4/20 mm, inflated to nominal pressure 4. 5 atm, twice), which improved hemodynamic parameters (preprocedural femoral blood pressure 17/10/12 mmHg/postprocedural left ventricular pressure 74/19/24 mmHg, ascending aortic pressure 68/40/50 mmHg). Post-procedure, the patient experienced mild hypotension, metabolic acidosis, and decreased urine output despite inotropic-vasoactive support (epinephrine and dopamine) and diuretic support (furosemide, and aminophylline). The next day, cardiac ultrasound showed a unicuspid aortic valve with a severely restricted opening, an abdominal aortic velocity of 0.2 m/s, severe biventricular systolic dysfunction, and severe pulmonary hypertension.\n\nThe following day after the aortic balloon valvuloplasty, the multidisciplinary team decided that a reintervention through open heart surgery was necessary for the residual severe aortic valvular stenosis. The surgery lasted 5 h (55 min of cardiopulmonary bypass and 40 min of aortic clamping). After the procedure, the patient remained hemodynamically unstable with low cardiac output syndrome despite increased vasoactive-inotropic support and presented heavy active bleeding on the chest tubes, requiring several transfusions with blood products and tranexamic acid administration. Postoperative echocardiography revealed moderate residual aortic valvular stenosis, severe biventricular systolic dysfunction, and pulmonary hypertension.\n\nOn the second postoperative day (day four after cardiac catheterization), the patient became oligo-anuric despite increased diuretic support in continuous infusion (furosemide, aminophylline, and ethacrynic acid), with generalized edema and significant positive fluid balance. Serial renal function tests revealed a rising trend in creatinine and urea levels. As the patient presented stage 3 AKI according to the neonatal KDIGO (Kidney Disease Improving Global Outcomes) classification, continuous renal replacement therapy was initiated the following day, and diuretic medication was discontinued. Vascular access for the CRRT procedure was obtained through a double-lumen 6Fr catheter inserted by the Seldinger technique at the patient’s bedside under ultrasound guidance into the right femoral vein. Anticoagulation therapy for the circuit was initiated with heparin in a continuous infusion, and the activated clotting time was maintained between 180 and 200 s. Continuous veno-venous hemodiafiltration was well tolerated, and the patient remained hemodynamically stable, allowing the increase in the fluid removal and the decrease in the vasoactive support. There was a serial fall in creatinine levels, and urine output was re-established after 4 h. Continuous renal replacement therapy (CRRT) was maintained for 75 h. Sternal closure was performed on site in the NICU on postoperative day 5, while the patient was on CRRT, without major hemodynamic impact.\n\nSeveral complications developed during hospitalization have been reported for the patient despite solving AKI: the prolonged need for inotropic and vasoactive support (77 days), initial extubating failure and prolonged need for invasive mechanical ventilation (71 days), pulmonary edema due to sustained mitral regurgitation, and three episodes of pulmonary hemorrhage due to coagulopathy and high capillary hydrostatic pressure. In addition, he developed acute liver failure after heart failure exacerbation two weeks after surgery. Persistent conjugated hyperbilirubinemia recovered after two months of treatment with ursodeoxycholic acid, alpha lipoic acid, phenobarbital, cholestyramine and serial albumin administration, vitamin K, and fresh frozen plasma. The day after cardiac surgery, a 2-grade intraventricular hemorrhage was noted, but without any apparent clinical significance. He was discharged from the hospital at 3 months and 25 days with mild residual aortic valve stenosis and grade 2 aortic regurgitation. At hospital discharge, renal function tests and blood pressure were normal for age.",
    "summary": "A term neonate without a prenatal diagnosis of congenital heart disease and with a good postnatal transition was transferred at 13 days of life to the MS Curie Emergency Hospital for Children, Newborn Intensive Care Unit, from a regional hospital where he was admitted at 10 days of life with severe general status, respiratory distress, cyanosis, and arterial hypotension. The cardiac ultrasound detected critical aortic valve stenosis, hypoplastic descending aorta, acute heart failure, and pulmonary hypertension. The patient was intubated and mechanically ventilated and received antibiotherapy (meropenem, vancomycin, and colistin), inotropic and vasoactive support (epinephrine, norepinephrine, dopamine, and milrinone), and diuretic support (furosemide, aminophylline, and ethacrynic acid). A balloon aortic valvuloplasty was performed several hours after admission, but after two days the patient required reintervention by open heart surgery due to relapsing severe aortic stenosis. He developed oligo-anuria, generalized edema, and altered renal function tests on the second postoperative and fourth day post-contrast media administration. Continuous renal replacement therapy was initiated for 75 h, leading to almost instant improvement in blood pressure, then diuresis and creatinine levels. The patient required long-term treatment for heart, respiratory, and liver failure. He was discharged at almost four months of age with normal renal function tests, blood pressure, and good urine output without diuretic support."
  },
  {
    "id": "multiclinsum_gs_en_463.txt",
    "fulltext": "A 65-year-old Japanese woman who presented with dyspnea visited a nearby hospital and was hospitalized for heart failure and pneumonia in October 2017. Urine immunoelectrophoresis revealed the presence of Bence Jones protein type λ. Direct fast scarlet staining showed amyloid deposition in the muscularis mucosa, and in the vessel walls of the submucosa in the rectum. Thus, she was diagnosed as AL amyloidosis when she was 58-years-old. She was treated with melphalan plus dexamethasone (Mel-Dex), and subsequently with lenalidomide plus dexamethasone (Len-Dex). Echocardiography before admission revealed the following findings: left ventricular end-diastolic diameter, 45.1 mm; left ventricular end-systolic diameter, 31.4 mm; ejection fraction, 57.9%; interventricular septal thickness, 12.9 mm; left ventricular posterior wall thickness, 12.7 mm; E/A ratio, 2.16; deceleration time, 169 ms; and E/e' 23.6. Extensive thickening of the left ventricle and the interventricular septum, and diastolic dysfunction (restrictive pattern) were observed, and these abnormalities were consistent with cardiac amyloidosis. After admission, she started treatment including antimicrobials and diuretics. Her renal function gradually deteriorated, and serum creatinine levels (sCr) rose to 2.0 mg/dL. She developed respiratory failure in spite of the treatment and required tracheal intubation. Her respiratory condition improved after changing the antimicrobials and adjusting the dose of diuretics, and she was successfully extubated. However, since her renal function worsened rapidly and her sCr reached 10.77 mg/dL, she was transferred to our hospital for nephrological care including renal replacement therapy (RRT). On admission to our hospital, her height was 151.0 cm, and her body weight was 53.8 kg. Her body temperature was 37.1 ℃, her blood pressure was 108/68 mmHg, and her heart rate was 105 beats/minute with a regular rhythm. Physical examination revealed coarse crackles of the bilateral lower lung fields and pitting edema of her lower extremities. Arterial blood gas analysis on 7 L of O2 via OxyMask™ indicated a pH of 7.342, PaO2 77.9 Torr, PaCO2 25.7 Torr, and HCO3− 13.6 mmol/L. Other clinical laboratory data, which are summarized in Table ​Table1,1, are as follows: white blood cell count, 6.8 × 103/μL with 77.7% neutrophils; hemoglobin level, 10.3 g/dL; platelet count, 19.5 × 104/μL; sCr, 11.42 mg/dL; estimated glomerular filtration rate [9], 3.0 mL/min/1.73 m2; blood urea nitrogen, 117 mg/dL; total protein without M-protein, 5.6 g/dL; albumin, 2.2 g/dL; C-reactive protein, 2.24 mg/dL; kappa free light chain (FLC), 130.0 mg/L; lambda FLC, 193.0 mg/L; FLC ratio, 0.67; brain natriuretic peptide (BNP), 441.5 pg/mL; N-terminal pro-B-type natriuretic peptide (NT-proBNP), 37,377.0 pg/mL; troponin T (cTnT), 0.152 ng/mL; immunoglobulin G, 1325 mg/dL; immunoglobulin A, 712 mg/dL; and immunoglobulin M, 46 mg/dL. Serum complement factors 3 and 4, and complement hemolytic activity were normal. Antinuclear antibodies, rheumatoid factor, and anti-neutrophil cytoplasmic antibodies were negative. Her urinalysis revealed proteinuria of 1.29 g/gram urinary creatinine and < 1 red blood cell/high-power field. Computed tomography showed bilateral pleural effusions and infiltrating lesions indicating pneumonia in both lungs. Echocardiography after admission showed the following findings: left ventricular end-diastolic diameter, 41.8 mm; left ventricular end-systolic diameter, 28.7 mm; ejection fraction, 59.6%; interventricular septal thickness, 14.8 mm; left ventricular posterior wall thickness, 14.5 mm; E/A ratio, 1.14; and E/e' 14.75. Extensive thickening of the left ventricle and the interventricular septum, and diastolic dysfunction were observed, and thus she was diagnosed as heart failure with preserved ejection fraction (HFpEF). She was classified as class IV of the New York Heart Association functional classification, and group C (Wet-Cold) of the Nohria-Stevenson classification. She was also diagnosed with advanced cardiac amyloidosis after cardiologic consultation. We started treatment with antimicrobials, noradrenaline, dobutamine, and continuous hemodiafiltration (CHDF). The settings of CHDF were as follows: blood flow rate 60–80 mL/min, dialysate flow rate 100–300 mL/h, and filtration rate 100–300 mL/h. Her general condition gradually stabilized, and she was switched to intermittent hemodialysis (HD). HD was performed for 4 h with a blood flow rate of 100–120 mL/min, using a polyethersulfone dialyzer (PES-15Eαeco, Nipro Corporation, Osaka, Japan). However, she developed thrombocytopenia, and anti-heparin–platelet factor 4 (PF4) antibodies became positive (1.1 U/mL; negative value was below 0.9 U/mL) on the 14th day after admission. We discontinued heparin due to suspected heparin-induced thrombocytopenia (HIT), and administered a heparin-free dialysis regimen and argatroban. In addition, she had intradialytic hypotension (IDH). Under these circumstances, it was difficult to continue HD, and thus we switched the RRT to PD. A PD catheter was inserted under local anesthesia on the 16th day after admission. From the 2nd postoperative day, continuous ambulatory PD was initiated, and we adjusted the PD regimen based on the patient’s volume status. The PD regimen was finally fixed to automated peritoneal dialysis utilizing 4 L of neutralized buffered 1.35% glucose peritoneal dialysate (Midpeliq 135L, Terumo Corporation, Tokyo, Japan) and a final dwell of 1 L 7.5% icodextrin peritoneal dialysis solution (Nicopeliq, Terumo Corporation, Tokyo, Japan) per day. The fluid removal by PD was approximately 500 mL/day, and we were able to manage the patient’s volume status successfully by this regimen. The urine volume was approximately 1000 mL/day with the administration of furosemide 160 mg/day, spironolactone 50 mg/day, and tolvaptan 15 mg/day and did not change during hospitalization, indicating good residual renal function. She was discharged home on the 44th day after admission. The BNP and NT-proBNP levels had improved to 195.1 pg/mL and 12,922.0 pg/mL at discharge, respectively. Since then, she has been followed up as an outpatient, and she continues PD for 2 years without any serious symptoms or complications. She has a good quality of life and enjoys traveling around Japan. The results of echocardiography after discharge were as follows: left ventricular end-diastolic diameter, 42.9 mm; left ventricular end-systolic diameter, 31.0 mm; ejection fraction, 54.1%; interventricular septal thickness, 16.4 mm; left ventricular posterior wall thickness, 11.4 mm; E/A ratio, 0.71; and E/e' 8.57. These findings were similar to those during hospitalization although the diastolic dysfunction was slightly improved.",
    "summary": "A 65-year-old woman was hospitalized for heart failure and pneumonia in a nearby hospital. She had been previously diagnosed as light chain (AL) amyloidosis and treated with melphalan plus dexamethasone (Mel-Dex), and lenalidomide plus dexamethasone (Len-Dex). She started treatment including antimicrobials and diuretics, but her renal function worsened progressively, and she was transferred to our hospital for nephrological care. She was treated with antimicrobials, noradrenaline, dobutamine, and continuous hemodiafiltration. Her general condition gradually stabilized, and she was switched to intermittent hemodialysis (HD). However, HD was discontinued due to intradialytic hypotension and the development of heparin-induced thrombocytopenia. Her renal replacement therapy was switched to peritoneal dialysis (PD), which enabled good volume control and stable cardiac function. She was discharged and is still in good condition, without serious complications and achieving a considerably better prognosis than was predicted."
  },
  {
    "id": "multiclinsum_gs_en_277.txt",
    "fulltext": "A three-year-old girl, bedridden with a chronic neurological condition (congenital Zika virus syndrome), was admitted for treatment of a tracheitis episode. She had undergone tracheostomy and gastrostomy two years earlier for treatment of chronic pulmonary aspiration, recurrent episodes of pneumonia, and swallowing disorders. A low-pressure, continuously inflated plastic balloon cannula was prescribed because the child required intermittent positive pressure ventilation.\n\nThe patient presented with two episodes of self-limited bleeding to the tracheostomy with an interval of 48 hours, initially attributed to aspirative trauma. A new episode 48 hours after the initial report with bright blood projectile, suggestive of arterial bleeding, was then described by the mother, requiring surgical evaluation. The patient did not have physiological instability or severe anaemia.\n\nA provisional diagnosis of TIF was given by the pediatric surgical team. Immediate angiography confirmed the diagnosis and revealed TIF affecting the bifurcation of the innominate artery (IA) and the right tracheal wall with a small amount of contrast near the fistula.\n\nThe patient was treated with the endovascular placement of four expanded polytetrafluoroethylene (PTFE)/nitinol (Viabhan®) stents in the right carotid artery (5×50 and 6×100 mm) and right subclavian artery (5×25 and 5×100 mm), crossing the transition to the AI in the Y configuration. One stent (5×25 mm) migrated accidentally, becoming close to the iliac bifurcation. This dislodged stent was not retrieved, as the team considered that attempts to remove it would entail an unfavorable risk-benefit ratio. No neurological worsening, right arm ischemia or complications related to the dislodged stent were detected after surgery. Angiographic control, including new angiotomography four months after surgery, showed normal blood flow in the right carotid artery and right subclavian artery.\n\nAnticoagulants were prescribed for two months (enoxaparin 20 mg bid subcutaneously). Five months after surgery, the patient remains asymptomatic, with no new bleeding episodes or infectious, thrombotic, or ischemic complications related to the stents.\n",
    "summary": "A 3-year-old child with encephalopathy, bedridden and tracheostomized for two years, was admitted for treatment of a tracheitis episode. The child was using a plastic balloon cannula continuously inflated with low pressure. The patient presented two self-limited episodes of bleeding from the tracheostomy in a 48-hour interval. A new episode was suggestive of arterial bleeding and the provisional diagnosis of TIF was assumed, confirmed through angiotomography, reaching the bifurcation of the innominate artery and the right wall of the trachea. The patient was immediately treated by endovascular insertion of a polytetrafluoroethylene (PTFE)/nitinol in “Y”. In the follow-up, no recurrence of TIF, neurological sequelae or ischemia of the right arm were found.\n"
  },
  {
    "id": "multiclinsum_gs_en_171.txt",
    "fulltext": "43-year-old male with a history of smoking; HIV diagnosis in 2021 (without treatment), with a last viral load of 183,000 copies and a CD4 count of 124/mm3. He consulted for a clinical picture of a one-month evolution characterized by subfebrile evening readings associated with involuntary weight loss (approximately 10 kilograms) and non-specific abdominal pain; with multiple previous outpatient care without improvement of the symptoms. A tomography of the abdomen was performed that showed a collection at the level of the tail of the pancreas of 38x17 mm with 20 Hounsfield Units (HU), which is why admission to the inpatient department was decided, in the context of an immunocompromised patient. On admission, he presented deep palpation pain in epigastrium and laboratory findings with mild normocytic normochromic anaemia. A thoracic tomography and a magnetic resonance of the brain were performed to determine other sites of probable dissemination, which were negative. Serologies for syphilis, cytomegalovirus, herpes simplex and Epstein Barr virus were requested, and immunoglobulin G for toxoplasmosis was positive 1/64. A tomographically guided puncture of the pancreatic collection was performed, which showed a low number of leukocytes, with acid alcohol-resistant bacillus positive (BAAR +) and a culture with rescue of Mycobacterium tuberculosis. Material was sent for pathological anatomy. A highly active antiretroviral treatment was initiated with emtricitabine, tenofovir and dolutegravir and anti-tuberculosis treatment with isoniazid, rifampicin, pyrazinamide and ethambutol was extended for atypical mycobacteria with good response, since the treatment is similar for any form of extrapulmonary tuberculosis, with at least four anti-tuberculosis drugs being the cornerstone. Hospital discharge was granted with follow-up by the infectious disease service on an outpatient basis, continuing with the treatment established until the twelve months were completed. A control tomography was performed where a decrease in the size of the pancreatic lesion (30x19 mm) with 20 UH was observed.\n",
    "summary": "43-year-old HIV positive male with low CD4 count and high viral load, without antiretroviral treatment, consulted for a one-month evolution characterized by subfebrile records associated with weight loss and non-specific abdominal pain. An abdominal tomography was performed which showed a collection in the tail of the pancreas, and subsequently a puncture of the material with rescue in culture of M. tuberculosis. Antifimic and antiretroviral treatment was initiated with a good response to it.\n"
  },
  {
    "id": "multiclinsum_gs_en_185.txt",
    "fulltext": "A thorough neurologic examination revealed a characteristic facial appearance: staring with wide-open eyes, frown with a scowl (procerus sign), and a fixed expression of the lower face. The patient had a symmetrical, axial-predominant hypokinesia-rigidity with a back-rocking posture of the trunk and neck. The gait examination revealed a high-level gait pattern characterized by a striking initial hesitation requiring the help of nearby objects/people. Once walking began, steps improved relatively, but ineffective gait reappeared when she tried to turn. She exhibited short steps, freezing, wide base of support, imbalance, slow lower limb movement, dragging of feet, and loss of normal trunk and limb fluidity. Postural reflexes were altered. There was also a severe difficulty in standing up after sitting and difficulty in turning over in bed. However, frontal signs such as paratonic rigidity, grasp reflexes, urinary incontinence, and characteristics of frontal cognitive deficits (e.g., disexecutive changes and personality changes and impulsivity) were absent, except for a progressive apathy state. Vertical saccadic eye movements were altered with relatively normal amplitudes and horizontal saccadic eye movements. Square wave nystagmus and a supranuclear ophthalmoplegia were evident. The brain MRI revealed a midline mesencephalic atrophy, dilation of the aqueduct of Sylvius and the third ventricle, and atrophy of the frontal lobes, and the typical signs of the hummingbird and morning glory. Finally, the patient was diagnosed with probable PSP.\n",
    "summary": "58-year-old healthy woman presented with a gait disorder with falls. Neurologic examination revealed a characteristic facial appearance (staring, wide-open eyes, frown, and lower hemifacial fixed expression), and symmetrical hypokinesia-rigidity with axial dominance (retrocollis of trunk and neck). Gait examination revealed a gait disorder of the upper level, characterized by significant initial hesitation, requiring help from objects/people nearby. When initiating gait, steps improved relatively, but ineffective ambulation reappeared when turning. She had short steps, freezing, wide base of support, imbalance, slow leg movement, dragging of feet, and loss of normal cadence of trunk and extremities. Postural reflexes were altered. Brain MRI revealed mesencephalic atrophy, dilation of aqueduct of Sylvius and III ventricle, bilateral frontal atrophy, and the typical hummingbird sign. Finally, the patient was diagnosed with probable PSP.\n"
  },
  {
    "id": "multiclinsum_gs_en_342.txt",
    "fulltext": "16-year-old female patient with a history of situs inversus with dextrocardia, single ventricle due to tricuspid atresia, double left ventricular outflow tract and hypoplasia of the pulmonary artery ring. At the age of 7 years she underwent Glenn surgery with preservation of the anterograde ventriculo-pulmonary flow. At the age of 16 years she underwent fenestrated extracardiac Fontan surgery (inferior vena cava to left pulmonary artery anastomosis) and change of the systemic atrioventricular valve to a mechanical prosthesis due to severe insufficiency. She was discharged without complications, with oxygen saturation between 85-91%, and on treatment with acetylsalicylic acid and warfarin. One month after discharge she presented persistent cough associated with haemoptysis that increased in frequency progressing to frank haemoptysis within 3 days, for which she was admitted to emergency. On admission she was hemodynamically stable, afebrile, and with intermittent dyspnoea and cough. On physical examination, heart rate 90 bpm, blood pressure 110/60 mmHg, respiratory rate 22 bpm, oxygen saturation of 86% with ambient oxygen, decreased vesicular murmurs in the lower third of the left hemithorax, non-crepitant. Laboratory tests demonstrated haemoglobin of 13 g/dL, INR 2.5. Fresh frozen plasma anticoagulation was reversed and tranexamic acid was administered. Chest X-ray showed velamentous clouding of the lower half of the left hemithorax compatible with pleural effusion. A drainage tube was placed and 800 ml of serous fluid was obtained. Microbiological studies of sputum for Mycobacterium tuberculosis were negative.\n\nTransthoracic echocardiography showed that the mechanical prosthetic valve was functioning normally; the systolic function of the single ventricle was preserved, as was the anterograde flow through the pulmonary artery. Cardiac angiotomography showed patency of the extracardiac Fontan conduit, hypoplasia of the pulmonary annulus, pulmonary anterograde flow with dilated pulmonary branches and multiple aortopulmonary collaterals, the largest of which was 2.5 mm in diameter. During the second day of observation, the patient presented new episodes of haemoptysis of up to 500 ml, so she was transferred to the cardiological intensive care unit. In a patient with severe haemoptysis requiring anticoagulation because of a mechanical prosthetic valve, percutaneous closure of the aortopulmonary collaterals and occlusion of the anterograde flow of the pulmonary artery trunk were decided.\n\nCardiac catheterization was performed under general anesthesia, the pressure of the Fontan system was found to be increased (19 mmHg) compared to the preoperative study of the Fontan in AP (pulmonary artery pressure 15 mmHg). Antero-grade flow from the pulmonary artery trunk to the pulmonary branches was found and multiple aortopulmonary collaterals were identified, the largest originating from the subclavian arteries. A 4.5 cm covered stent was implanted at the bifurcation of the pulmonary artery branches with the aim of eliminating the antero-grade flow from the pulmonary artery trunk, and a significant decrease in this flow was observed in the angiographic control. The occlusion of the most important aortopulmonary collaterals of the left and right subclavian arteries was performed with coils. Subsequently, the patient remained stable, did not present new episodes of hemoptysis, allowing the restart of anticoagulation. She was discharged 10 days later. In the follow-up at 6 months, the cardiac angiotomography found the presence of the covered stent at the bifurcation of the pulmonary arteries, the permeability of the Fontan system and the occluded aortopulmonary collaterals with coils. One year later, the control echocardiography showed preserved ventricular systolic function, a normal-functioning systemic mechanical prosthesis, a permeable Fontan system, and minimal pulmonary antero-grade flow. The patient remains in functional class II, with arterial saturation between 89-93%, and there was no recurrence of hemoptysis reported.\n",
    "summary": "A patient with a history of single ventricle due to tricuspid atresia, double left ventricular outflow tract and pulmonary artery ring hypoplasia was presented. The patient was treated with Glenn surgery at 7 years of age and, at 16, underwent Fontan surgery with fenestration. One month after the surgery, she presented severe hemoptysis without adequate response to medical management. Percutaneous closure of the aortopulmonary fistulae was performed with coils, with favorable evolution, without recurrence of hemoptysis.\n"
  },
  {
    "id": "multiclinsum_gs_en_534.txt",
    "fulltext": "25-year-old male who consulted for vomiting, hypogastric pain and equivalent febrile symptoms. As background: hypothyroidism, chronic colitis under study in treatment with mesalazine, multiple consultations during 4 years with gastrointestinal symptoms. In the last year, he had a high-grade digestive tract hemorrhage, in which the video-endoscopy of the upper digestive tract (VEDA) reported a hiatal hernia and normal rest, a rectosigmoidoscopy was performed: without endoluminal lesions, with normal mucosal coloration, painful soft abdomen, with positive hydroaerolic noises. Laboratory was performed: 38% hematocrit, increased erythro-sedimentation, normal amylase and lipase, anti-transglutaminase antibodies, anti-gliadin negative, normal IgA, HIV, hepatitis B, VDRL, cytomegalovirus and Epstein-Barr negative. Non-inflammatory coproculture, with habitual flora. Abdominal radiography: hydroaerolic levels in the splenic colon frame and dilatation of intestinal loops. Together with the Surgery and Gastroenterology Services, it was initially interpreted as a flare-up of inflammatory intestinal disease, and corticosteroid therapy was initiated with hydrocortisone. It progressed with abdominal pain, haemodynamic instability and respiratory insufficiency secondary to distress. He was admitted to the Intensive Care Unit and, due to respiratory insufficiency, an orotracheal intubation was performed. The chest radiography showed an alveolo-interstitial pattern in 4 quadrants. He presented a drop in haemocrit, coagulopathy, metabolic acidosis and respiratory insufficiency. With suspicion of surgical acute abdomen, he was admitted to the operating theatre, where intestinal loops were dilated, with a cartilaginous appearance in the terminal third of the ileum, adenomegaly and mesenteric petechiae. He presented haemoptysis, vasculitis was suspected, so methylprednisolone pulse was initiated. Refractory to treatment, he died 24 hours after admission to the ICU due to multi-organ failure. The biopsy result was: Strongyloides stercoralis. Informed consent was obtained from the patient's direct family member for the publication of the case.\n",
    "summary": "As a result of a frequent disease with atypical presentation, the evolution of a 25-year-old patient with chronic diarrhea who consulted for vomiting, hypogastric pain and equivalent fever was described. Background: hypothyroidism, chronic colitis under study. Laboratory: anaemia and increased erythro-sedimentation. It was interpreted as inflammatory intestinal disease. It evolved with haemodynamic instability, respiratory insufficiency, drop in haematocrit, coagulopathy and metabolic acidosis. Exploratory laparoscopy: intestinal loops were observed dilated, a cartilaginous appearance in the ileum, adenomegaly and mesenteric petechiae. He presented haemoptysis, vasculitis was suspected. He died 24 hours after admission to intensive care. Biopsy: Strongyloides stercoralis. Chronic use of corticosteroids may have been deleterious to the patient.\n"
  },
  {
    "id": "multiclinsum_gs_en_353.txt",
    "fulltext": "A 35-year-old man injured in a motor vehicle accident was transferred to our hospital, which is equipped with a hybrid ER. He had sustained a life-threatening injury, with his right leg shortened and rotated. The patient's vital signs on arrival were follows; respiratory rate of 24 breaths/min, oxygen saturation of 99 % with 12 L oxygen administration, heart rate of 143 beats/min, blood pressure of 80/40 mmHg, and Glasgow Coma Scale score of E4V4M6. We tried to perform a CT scan and resuscitate the patient. Scout CT revealed a left hemothorax, widening of the mediastinum, and pelvic fracture. Since the patient's blood pressure dropped rapidly before the CT scan, life-saving procedures such as emergent intubation, preperitoneal pelvic packing, and massive transfusion were administered with being carefully monitoring blood pressure in the hybrid ER. After stabilization of vital signs with these procedures, contrast enhanced CT revealed a grade IV BTAI rupturing into the left thoracic cavity . Transcatheter arterial embolization (TAE)for the pelvic fracture and external skeletal fixation of the right femoral shaft fracture were performed first since radiologist and cardiovascular surgeon, who perform TEVAR in our medical center, were not available at the moment. Subsequently, TEVAR was performed using a stent graft (GORE C-TAG 26 × 150 mm; WL Gore & Associates, Flagstaff, Arizona, USA) in the hybrid ER without transferring the patient. A stent graft was deployed just distal of the left common carotid artery (zone II) and the distal end of the stent graft was positioned at Th 8 level. We decided to sacrifice LSCA since blood flow from left vertebral artery was sufficient assessed by angiography. The patient had no symptom suggesting ischemia after TEVER. During the surgery, 50 units/kg (3000 units) heparin were administered. The patient was transferred to a rehabilitation hospital on postoperative day 41.",
    "summary": "A 35-year-old man sustained multiple injuries after a motor vehicle accident and was transferred to our hospital in shock status. CT revealed a grade IV BTAI rupturing into the thoracic cavity and pelvic fracture. Soon after preperitoneal pelvic packing and transcatheter arterial embolization for pelvic fracture, TEVAR was performed in the hybrid ER without transporting the patient. The patient was transferred to a rehabilitation hospital on postoperative day 41."
  },
  {
    "id": "multiclinsum_gs_en_142.txt",
    "fulltext": "A 30-year-old woman presented to the emergency department on 10 September 2020 with chief complaint of worsening shortness of breath for the past 2 months.\n\nPatient also had dry cough and fatigue. She had lost around 20 kg weight in the past 5 months. She denied any symptoms of fever, angina, changes in bowels habit, and tremor. The patient denied any contact with positive COVID-19 patient, history of diabetes, heart failure, kidney disease, and liver disease. The patient was tested negative for COVID-19 PCR on 29 Augustus 2020. No similar symptoms were observed in her family.\n\nShe previously visited another hospital because she had right pleural effusion and then suspected of abdominal cancer. Pleural puncture was conducted 1 week before for cytology examination at the previous hospital but the procedure failed to gain adequate sample. The patient also denied family history of malignancies.\n\nPhysical examination on 10 September 2020 showed normal vital signs with blood pressure 132/90 mmHg, respiratory rate 23x per minute, heart rate 119 beats per minute, and temperature of 36.3 Celsius. Additionally, oxygen saturation was 93%. There was no altered mental status. Lung auscultation revealed decreased vesicular sound on the right pulmonary area. Rales and wheezing were not present during auscultation. Cardiac auscultation revealed distant heart sound. Abdominal examination showed presence of minimal ascites. No peripheral edema was observed. The rest of the physical examinations were normal.\n\nComplete blood count and other laboratory examinations were performed on 10 September 2020. The patient’s lab revealed that she had anemia with 8.1 g/dL of hemoglobin, slightly elevated Aspartate transaminase (AST), normal alanine transaminase (ALT), and reduced albumin level. SARS‐CoV‐2 PCR swab test was negative and other laboratory tests were normal. The cancer biomarker results which was available 2 days later showed elevated CA-125 (121.07 U/mL). Due to the presence of severe anemia, the patient received packed red cell transfusion of 600 mL.\n\nHer initial chest radiograph (CXR) on 10 September 2020 showed bilateral pleural effusion, mild right lung infiltrate/pneumonia, and cardiomegaly due to pericardial effusion.\n\nHer non-contrast chest CT scan taken on the same day also showed bilateral pleural effusion and pericardial effusion. Lymph node enlargement on anterior mediastinum, paratracheal, tracheobronchial, and right hilum were observed. The lymph node enlargement was initially suspected due to metastasis. Further information obtained from the chest CT scan was the presence of lytic lesion on sternal bone, head of right humerus, and thoracal vertebrae. Finally, the CT scan indicated presence of pneumonia on left lower lung. Due to the presence of non-COVID-19 pneumonia, the patient was then treated with Cefixime 200 mg 2x1, Ceftriaxone 2g injection, Omeprazole 20 mg 2x1, and supportive therapies.\n\nOn 11 September 2020, a cardiac echocardiography was taken showing normal ventricles volumes, systolic function, diastolic function, and valves, tricuspid annular plane systolic excursion (TAPSE) of 2 cm, ejection fraction (EF) of 75%, inferior vena cava collapsibility of more than 50%, and pericardial effusion of 3.8 cm on plax view.\n\nArterial blood gas analysis was performed on 11 September 2020. Based on the results, the patient had acute uncompensated respiratory alkalosis with high likelihood caused by pneumonia.\n\nOn 12 September 2020, further laboratory examinations were conducted. Results showed bleeding time 2.5 seconds; clotting time 4 seconds; prothrombin time 12.2 seconds (control 10.6 seconds); partial thromboplastin time 33.9s seconds (control 35.2 seconds); and CA 15–3 level 14.7 U/mL.\n\nPositron emission tomography (PET) scan was conducted on 14 September 2020. The PET scan was conducted 50 minutes after injection of F-18 Fluorodeoxyglucose (FDG). The PET scan showed non-metabolic (non FDG avid) thickening on the region of bilateral adnexa. The radiologist suspected primary malignancy originating from thickening of bilateral adnexa which could be in the form of ovarian cancer. Scan also revealed multiple osteolytic hypermetabolic metastases located in bone marrow of right humerus head, sternal bone region, several bilateral ribs, pelvic bone, and most of cervical/sacral vertebra bone. There were also multiple hypermetabolic metastases at lymph nodes of cervical, right mediastinal, and right axilla. Cardiomegaly was observed with hypermetabolic pericardial effusion which suggested pericarditis or pericardial metastasis. Hypermetabolic pleural effusion with suspicion of pleural metastasis was also visible. Finally, there was presence of non-metabolic bleakness at the area of upper omentum with suspicion of metastatic seeding in the form of carcinomatosis omental and there was presence of non-metabolic asymmetrical thickening of ascending colon suggestive of inflammation or cancer mass.\n\nCXR on 15 September 2020 showed no improvement in pericardial effusion. However, pigtail catheter was implemented. Similarly, there was no improvement in pleural effusion. The lung infiltrate was no longer present. In concordance to the resolution of lung infiltrate on CXR, the patient’s dyspnea was improved. The cefixime antibiotic was still continued based on pneumonia guideline.\n\nOn 16 September 2020, obstetrician gynecologist was consulted for evaluation of possible ovarian cancer based on the elevated CA-125 and results from PET-scan. The obstetrician gynecologist reported that there were no signs of abnormalities such as cancer or cysts on gynecological organs based on the USG. These findings were in contrast with the PET-scan.\n\nOn 17 September 2020, the patient had improved hemoglobin level to 10.6 mg/dL. Cyfra 21–1, a biomarker for lung cancer was tested with result of 0.68 (reference <3.3).\n\nAnalysis of pleural and pericardial effusion were completed by pathologist on 18 September 2020. A total of 450 mL of xerohemorrhagic fluid was taken from pleural aspiration. Cytologic examination of pleural fluid showed lymphocytes, leukocytes, and mesothelial cells with no presence of malignant cells. Pericardial effusion aspiration showed color of xerohemorrhagic with a total of 200 mL aspirated. Samples of pericardial fluid were sent for cytologic examination which showed presence of leukocytes and no presence of malignant cells.\n\nOn 18 September 2020, lymph nodes biopsy was taken with results came on 21 September 2020. Based on the pathological anatomy examination, the biopsy showed tubercles surrounded by lymphocytes. The tubercles contained epithelioid cells, datia Langhans (giant multinucleated) cells, and necrosis. No malignant cells were observed. Based on these findings, the pathological anatomy report concluded the diagnosis as tuberculous lymphadenitis. A meeting with attending physicians at that time concluded that the patient’s symptoms did not match pathology report and thus further differential diagnosis should be considered.\n\nDue to improvement of the patient’s dyspnea, on 19 September 2020 the patient was discharged and scheduled for outpatient visit for further examinations.\n\nOn 30 September 2020, another pleurocentesis was conducted. A total of 400 mL of xerohemorrhagic fluid was aspirated from the pleura. Microscopic examination showed no presence of malignant cells. The pleural fluid was then examined for ADA (Adenosine Deaminase) and the result was 31.6 (Tuberculosis if ADA > 40), which indicated that the cause of pleural effusion was other than TB. However, due to lack of specific etiologies found other than possible ovarian cancer, it was decided that the patient should receive anti-tuberculosis drug starting on 1 October 2020 with monitoring of symptoms.\n\nOn 2 October 2020, another CXR was taken. When compared with CXR on 15 September 2020, no change in volume of pleural effusion and pericardial effusion was observed. Patient was given bondronate 6 mg through normal saline infusion for 90 minutes.\n\nColonoscopy on 6 October 2020 revealed no abnormal findings other than Peyer's patches hyperplasia at the terminal ileum. A total of 3 biopsies of the Peyer's patches was taken and examined for pathology. Microscopic examination by the pathologist on 8 October 2020 showed mild to moderate infiltration of lamina propria by inflammatory cells, indicating chronic ileitis. No malignant cells were found during microscopic examination.\n\nDespite receiving tuberculosis drugs, initially the patient had worsening ascites and increasing level of CA-125. Another consultation was made to obstetrician gynecologist on 10 November 2020. Based on examinations and ultrasound by the obstetrician gynecologist, it was concluded that both left and right ovarium was normal with no signs of malignancy. Transvaginal ultrasonography conducted by the obstetrician gynecologist showed normal size uterus retroflexion, normal size of both ovarium, and ascites on pouch of Douglas. The obstetrician gynecologist also recommended diagnostic laparoscopy and biopsy to differentiate between peritoneal cancer and peritoneal tuberculosis. Furthermore, the obstetrician gynecologist revealed that the patient told her that the patient’s IGRA test was positive previously on 5 September 2020. This IGRA test was not previously told to other physicians.\n\nOn 24 November 2020 the patient came to the outpatient clinic due to bloating and abdominal enlargement for the last 7 days. The patient was then suggested to be hospitalized. Abdominal paracentesis was then conducted. Result of paracentesis showed that neither malignant cell or tuberculosis cells were detected. A chest radiograph and non-contrast chest CT scan were also performed. Her CXR showed pleural effusion higher than last month and pericardial effusion with same size compared to 2 October 2020. No lung infiltrates and metastatic nodes were observed on CXR. The non-contrast chest CT scan revealed slightly elevated bilateral pleural effusion, decreased pericardial effusion, and bone metastasis compared with 1 month before.\n\nOn 25 November 2020, pleural puncture was conducted and 1.320 mL of yellow fluid was taken. No malignant cells were observed. Ascites fluid had ADA of < 5. Analysis of CA-125 laboratory test on 26 November 2020 showed the highest level which was 769.18 units per mL.\n\nDiagnostic laparoscopy was conducted on 28 November 2020. The liver appeared very large and the surface is full of white patches. Omentum looked thickened. Biopsies were taken from liver and omentum to be analyzed by pathologist.\n\nBiopsies results were obtained on 30 November 2020. Liver biopsy revealed fatty infiltration of liver and granuloma containing inflammatory cells. Omentum biopsy revealed granuloma containing epithelioid cells and Langhans-type cells. These results suggested tuberculosis infection of omentum and liver.\n\nPatient reported improvement after approximately two months of anti-TB treatment. Furthermore, CA-125 level decreased to 244.57 units per mL. No side effects of tuberculosis drugs such as jaundice, liver enzymes elevation, peripheral neuropathy, and vision changes were found during the intensive phase of tuberculosis treatment regiment. CA-125 level decreased further into 13.81 units per mL after approximately 3 months of antituberculosis treatment, and 4.45 units per mL after approximately 9 months of treatment.\n\nThe patient was still alive and well on August 24th 2021. She did not feel any clinical symptoms and felt much better compared to last year. She underwent thoracic CT-scan and whole abdomen CT-scan on the same day.\n\nThoracic CT scan revealed lessened pleural effusion when compared with previous CT-scan with minimal right pleural effusion observed. There was fibrosis on lower region of both lungs. Lymph nodes of axillary region, anterior region, and paratracheal region were no longer enlarged. Pericardial effusion was no longer observed but there was thickening of pericardium. Lytic sclerotic lesions were observed on right humerus head, several thoracal vertebrae body, several lumbar vertebrae body, several ribs, and sternal bone.\n\nWhole abdominal CT scan showed lytic sclerotic lesions on whole lumbar vertebral body and several sacral vertebrae. CT scan also revealed lumbar spondyloarthrosis with mild narrowing of intervertebral disc of lumbar vertebra 4–5 and bulging disk on lumbar vertebra 3–4 and lumbar vertebra 4–5. No enlargement of paraaortic and pelvic lymph nodes was observed. Thickening of colon was no longer observed. Liver showed regular surface, normal left lobe size, slightly enlarged right lobe size, and homogeneous parenchymal density. After contrast injection, no pathological lesions were observed. Liver vascularization was within normal range. Biliary system was normal. Gynecological organs also showed no pathologies other than Nabothian cyst on cervix and follicular cyst on both ovarium after contrast injection.",
    "summary": "A 30-year-old woman admitted to the emergency department with chief complaint of fatigue and shortness of breath since 3 months ago. She had lost around 20 kg weight in the past 5 months. She was previously suspected with ovarian cancer because of the characteristic features of malignancy, high levels of CA-125, and positive PET scan. She was later diagnosed with abdominal TB. Subsequently, the patient was given anti-TB drugs, and the patient showed clinical improvement."
  },
  {
    "id": "multiclinsum_gs_en_469.txt",
    "fulltext": "20-year-old female with a history of malnutrition, diabetes mellitus type 1 and admission 1 month prior to consultation for candidemia (Candida albicans) sensitive to fluconazole and intrahospital pneumonia as an intercurrent. In this admission, septic emboli were ruled out with an abdominal ultrasound, fundus of the eye, abdominal ultrasound and infammatory bowel disease with transesophageal and transthoracic echocardiogram. She received treatment with 400 mg intravenous fluconazole daily for 23 days and 4.5 g piperacillin tazobactam (PTZ) every 6 hours intravenous for 10 days, with negative blood cultures. The patient consulted 18 days after the admission described, with a clinical picture of a week of evolution characterised by pain in both flanks of a dull type, intermittent, intensity 4 in 10, associated with asthenia, adynamia, hyporexia, unquantified weight loss, dysuria, polyuria and inflammatory bowel disease. On physical examination, the patient was found emaciated, dehydrated, with blood pressure of 110/70 mmHg, heart rate of 100 beats per minute, respiratory rate of 18 cycles per minute and axillary temperature of 36.7 °C, abdomen with positive hydroaerolic sounds, deep pain in the hypogastrium without signs of peritoneal irritation, with mid-ureteral stones and positive right hand percussion. Blood tests reported: haematocrit 31.1%, haemoglobin 10.1 g/dL, white blood cells 13.2 x 109/L, platelets 392 x109/L, creatinine 0.9 mg/dL, blood glucose: 357 mg/L, sodium 129 mEq/L, potassium 5.4 mEq/L, chloride 86.5 mEq/L, albumin 3 g/dL, Quick time 115%, partial thromboplastin time 13.2 seconds, acid-base state with metabolic acidosis, serologies for human immunodeficiency virus (HIV), VDRL, hepatitis B and C negative and inflammatory urinary sediment. The picture was interpreted as pyelonephritis in a patient with recent admission, paired blood and urine cultures were taken. Empirical treatment with 4.5 g PTZ every 6 hours intravenous was initiated, fluconazole 400 mg daily intravenous for isolation of Candida in the previous admission, parenteral hydration and basal insulin in bolus. The abdominal and pelvic ultrasound with EV contrast showed slightly enlarged kidneys, without signs of uronefrosis or lithasis, multiple bilateral cortical images suggestive of abscesses with left-sided predominance, the largest of 33 x 26 mm located in the anterior and posterior leaflets of the right side. A puncture guided by ultrasound of one of the abscesses of the right kidney was performed with isolation of Candida albicans sensitive to fluconazole.\n\nThe image was interpreted as bilateral multifocal renal abscesses caused by Candida albicans. Fundus examination ruled out fungal infections and transthoracic echocardiography did not show vegetations. She completed 6 weeks of treatment with fluconazole IV and an additional 2 weeks of oral treatment. She required continuous insulin infusion to control blood glucose and her nutritional status was optimised. She had a favourable evolution with clinical and imaging improvement and continued ambulatory clinical follow-up.\n",
    "summary": "A 20-year-old woman with type 1 diabetes mellitus diagnosed at 8 years of age, multiple hospitalizations for diabetic ketoacidosis and recent admission for candidemia (Candida albicans) completing treatment with fluconazole for 23 days is presented. 18 days after her discharge, she consulted for dull-type flank pain and general symptoms; an abdominal tomography with contrast was performed that showed bilateral multifocal abscesses. Candida albicans was isolated in one of the samples obtained from the lesions; she received treatment with fluconazole 400 mg intravenous for 6 weeks and 2 weeks via enteral, evolving favorably with clinical and imaging improvement and continuing ambulatory clinical follow-up.\n"
  },
  {
    "id": "multiclinsum_gs_en_189.txt",
    "fulltext": "57-year-old male, salesman by profession, married to a woman and with a history of hypertension and structural focal epilepsy (due to trauma in his youth), on treatment with enalapril and carbamazepine. He presented an anxious-depressive picture of one year of evolution, attributed to confinement due to COVID-19, treated with escitalopram.\n\nInitially, it did not affect his functioning, but he went to the emergency room because in the last two months he had started to have inappropriate social behavior with subsequent loss of learned skills and self-care, as well as a decrease in work performance, which led to his dismissal despite antidepressive treatment.\n\nExamination was limited by marked inattention, restlessness and motor impairment; spontaneous speech was limited but with correct grammar; he had difficulty in naming and understanding complex orders as well as in performing bimanual praxis; he did not show frontal release reflexes or other focal signs. He was admitted to the neurology department for rapid progressive dementia.\n\nA head MRI showed diffuse white matter changes. Screening for treatable causes of dementia revealed HIV positive with 90,600 copies/mL in blood and 462,000 in cerebrospinal fluid (CSF), as well as 31 CD4/mm3 and CD4/CD8 ratio of 0.05; 5 leukocytes/µL in CSF with normal proteinorraquia. In parallel, JC virus (John Cunningham) negative, protein 14.3.3 below the cut points and biomarkers of Alzheimer's disease in CSF (total tau protein = 1800 pg/mL, elevated, and normal phospho-tau and beta-amyloid-42 proteins) compatible with non-specific neuronal death were received.\n\nOther etiologies were ruled out and HAD was diagnosed as a presentation of category C3 HIV infection due to the defining clinical presentation of AIDS (dementia) and severe cellular immunodepression (<200 CD4), and antiretroviral therapy was initiated with bictegravir/emtricitabine/tenofovir alafenamide 50/200/25 mg. During admission, the patient presented a torpid evolution with infectious complications (Staphylococcus aureus bacteremia, pneumonia and oral candidiasis) and decompensation of his epilepsy with acute symptomatic onset of focal seizures with bilateral tonic-clonic evolution; carbamazepine 200 mg/12h was replaced with eslicarbazepine 800 mg/day due to its lower risk of interaction. The patient was stabilised after the resolution of intercurrent infections but the neuropsychological evaluation was hampered by persistent inattention. After two weeks of antiretroviral therapy, a decrease in the viral load in blood (638 copies/mL) was observed but an increase in the CSF (1,180,000 copies/mL). At discharge, the Montreal cognitive assessment (MoCA) score was 9/30, with greater impairment of delayed recall, attention and language; 8/18 in the frontal assessment battery (FAB), with an intact ability to abstract, but a lexical fluency of 0 and significant impairment of inhibitory control, motor series execution and conflicting instructions; the trail making test (TMT) was impossible due to the attention deficit.\n\nAt the three-month follow-up, both the patient and his family reported subjective improvement in function. To monitor this improvement, the plasma and CSF viral load was repeatedly measured, and a reduction in both was observed (136 and 75,263 copies/mL, respectively), which confirmed adequate penetration into the CNS. A better performance in the neuropsychological evaluation was also observed: MoCA 23/30 (failures in visual-spatial domain, attention and lexical fluency), FAB 16/18 (deficit in inhibitory control), TMT-A without failures in 40 seconds and TMT-B with 3 failures not self-corrected in 3 minutes 53 seconds.\n",
    "summary": "We present the case of a patient who debuted with anxious-depressive symptoms and a rapid cognitive deterioration with early repercussions in his daily functioning. In the study, HIV was detected with a higher viral load in cerebrospinal fluid than in plasma. Antiretroviral therapy achieved, despite the torpid initial evolution, a progressive improvement in the cognitive sphere, consistent with the decrease in the viral load.\n"
  },
  {
    "id": "multiclinsum_gs_en_110.txt",
    "fulltext": "A 35-year-old, Japanese, 42.7-kg (dry weight, 41.1 kg before pregnancy), 147-cm-tall woman was scheduled for cesarean section. She had renal failure due to chronic glomerulonephritis. Before she became pregnant, she had been undergoing hemodialysis three times per week. The hemodialysis access (arteriovenous fistula) was in her left upper arm. The symptoms and course of treatment up to cesarean section are described in Table 1. When the pregnancy was identified, she received hemodialysis five times per week. Although she had not shown any symptoms before the pregnancy, she reported dyspnea at 12 weeks of gestation and subsequently developed severe cough. Transthoracic echocardiography (TTE) showed a cardiac left ventricular ejection fraction (LVEF) of 40% and mild pulmonary hypertension. After hospitalization, hemodialysis was increased to six times per week to prevent heart failure. LVEF improved to almost 50% and symptoms also improved, so the plan was to postpone delivery as long as possible. However, she again developed cough and dyspnea at 22 weeks of gestation.\n\nChest X-ray showed significant congestion. TTE showed an LVEF of 20%, mild to moderate mitral regurgitation, and left ventricular dilatation. She was therefore admitted to the intensive care unit (ICU). Percutaneous oxygen saturation (SpO2) was 92% on room air, so supplemental oxygen was provided at 1 l/minute through nasal cannula. After oxygen administration, SpO2 was 98%. In addition, water volume was removed using extracorporeal ultrafiltration. Although respiratory status and cardiac function improved slightly with intensive care, a clinical conference of obstetricians, pediatricians, urologists, cardiologists, and anesthesiologists decided that cesarean section should be performed at 24 weeks 0 days of gestation. The anticoagulant used for dialysis was changed from heparin to nafamostat mesylate (nafamostat) at 23 weeks of gestation for the cesarean section. Blood tests showed hemoglobin 10.1 g/dl and platelets 12.1 × 104/μl. The prothrombin time international normalized ratio was 0.85, and the activated partial thromboplastin time was 25.6 seconds.\n\nWhen the patient arrived in the operation room, two intravenous peripheral vein lines were inserted with a 22-gauge cannula and an 18-gauge cannula in the right forearm to use for fluid resuscitation. An arterial line was inserted via the right radial artery with a 22-gauge cannula. Central venous lines were inserted via the jugular vein. We inserted the central venous lines, using the echography while carefully monitoring the arterial line blood pressure. The echography showed the jugular vein clear, and we made sure that putting her in the mild Trendelenburg position did not affect circulatory dynamics. Overall, the procedure was completed without any significant changes in hemodynamics. Spinal and epidural anesthetic agents were administered in the right lateral position at the L3–L4 and Th10–Th11 interspaces, respectively. After local infiltration of 1% mepivacaine, an epidural catheter was placed with an 18-gauge Tuohy needle. The epidural space was confirmed using the conventional loss-off-resistance method. After aspiration testing confirmed a negative result, a test dose of 1% mepivacaine (3 ml) was administered via the catheter. Lumbar puncture was successfully performed, and 5 mg of 0.5% hyperbaric bupivacaine and 10 μg of fentanyl were administered intrathecally with a 25-gauge Quincke spinal needle. The amount and the type of anesthetic agents were decided by the anesthesiologists and the surgeons. Continuous administration of phenylephrine was immediately started at 1 mg/hour to avoid hypotension due to anesthesia. Five milliliters of 0.25% ropivacaine was administered via the epidural catheter.\n\nAfter confirming sensory block at the Th4 level, the operation was started. Before delivery, 0.1 mg of nitroglycerin was administered to relax the uterus. The neonate was delivered 4 minutes after starting the cesarean section. Central venous and peripheral blood pressures were maintained during cesarean delivery. The patient did not report any nausea, pain, or dyspnea intraoperatively. After the delivery, 600 mg of acetaminophen was administered. Once the operation was finished without complications, 2 mg of morphine was administered via the epidural catheter, which was then removed. Operation and anesthesia times were 49 minutes and 88 minutes, respectively. Total infusion and blood loss volumes were 1050 ml and 1029 ml, respectively. Postoperatively, the patient was transferred to the ICU and hemodialysis was performed. She was transferred to the gynecology ward on postoperative day (POD) 5 and discharged on POD 10. Cardiac function improved after the cesarean section. As of the time of writing, both mother and child were doing well.",
    "summary": "We encountered a case in which cesarean section was performed using combined spinal and epidural anesthesia for a pregnant woman with chronic renal and heart failure. The 35-year-old Japanese woman had been undergoing hemodialysis for several years. Heart failure symptoms that appeared during pregnancy initially improved with treatments such as increasing hemodialysis, but recurred. She was admitted to the intensive care unit. The initial plan was to deliver the baby after a few weeks, but further progression of heart failure became a concern. After a clinical conference among staff, a cesarean section with combined spinal and epidural anesthesia was scheduled for 24 weeks, 0 days of gestation. The anticoagulant for dialysis was also changed from heparin to nafamostat in preparation for cesarean section. Monitoring was started with central venous and radial artery pressures before induction of anesthesia. Combined spinal and epidural anesthesia was induced and the cesarean section was completed without complications. Surgery was initiated under continuous administration of phenylephrine, which was intended to avoid hypotension due to anesthesia. The hemodynamic and respiratory status of the patient remained stable postoperatively. After the cesarean section, morphine was administered epidurally and the epidural catheter was removed."
  },
  {
    "id": "multiclinsum_gs_en_292.txt",
    "fulltext": "A 29-year-old woman came to the Oral Medicine Clinic at Padjadjaran University Dental Hospital with canker sores throughout her mouth, swollen lips, and hemorrhagic crusts that bleed easily two months prior. The complaint started with a small canker sore on the lateral of the tongue, which the patient attempted to treat with “Natural Green Tea” alcohol-containing mouthwash, but the canker sore was felt to have worsened. The patient admitted to recurrent mouth ulcers but had never experienced such a severe condition before. Previous history of allergy or fever was refused by the patient.\n\nExtra-oral examination revealed upper and lower lip edema with hemorrhagic crusts that bled easily. No lesions were found in other parts of the body. Intra-oral examination showed a macerated appearance on the upper and lower labial mucosa accompanied by multiple ulcers with erythema edges. Several ulcer lesions with irregular margins were also identified on the right and left buccal mucosa, ventral tongue, and floor of the mouth. The gingiva region of teeth 21–24 showed painless erythema with diffuse borders.\n\nBased on the history and clinical findings, the suspected diagnosis on the first visit was herpes-associated erythema multiforme, with the differential diagnosis being contact stomatitis and stomatitis medicamentosa. Investigations were carried out to determine the etiology and rule out the possibility of a differential diagnosis. Results of a complete blood count, IgE, and anti-HSV-1 IgG titer. Based on the examination, a diagnosis of recurrent oral erythema multiforme was made.\n\nFollowing the initial visit, the patient was advised to discontinue using alcohol-containing mouthwash. Prednisone was used at a dose of 20 mg per day, divided equally during morning and night. In addition, the patient was instructed to take multivitamins in the morning, rinse her mouth with benzydamine HCl mouthwash before meals, and 0.025% hyaluronic acid mouthwash after meals, 10 mL each three times a day. Furthermore, apply hydrocortisone cream to the lips three times per day. Improvement of lesions in the lips and oral cavity.\n\nThe complaint of swollen lips that bleed easily disappeared on the second visit (twelfth day), but there was a little stinging in her mouth. The patient still felt redness and pain in the upper labial and buccal mucosa. Multivitamins, hydrocortisone cream, and benzydamine HCl mouthwash were discontinued at this visit. The patient was instructed to continue to use 0.025% hyaluronic acid mouthwash, take prednisone at a dose of 15 mg per day, and do scaling. Total serum IgE levels were re-evaluated to screen for allergic conditions.\n\nOn the third visit, the pain in the mouth was no longer felt and the patient had done scaling. The patient used the medication according to the instructions given. Instructions to continue taking prednisone at a dose of 5mg per day, education to maintain oral hygiene, and a well-balanced lifestyle were given to the patient.",
    "summary": "A 29-year-old woman came to the Oral Medicine clinic complaining of canker sores all over her mouth and swollen lips accompanied by crusts that had been bleeding easily two months prior. Complaints worsened after the patient used alcohol-containing mouthwash without a history of fever or other symptoms. Extra-oral examination showed upper and lower lip edema with hemorrhagic crusts that bleed easily. No lesions were found in other parts of the body. Intra-oral examination showed ulcers, multiple, irregular in almost the entire oral mucosa. Laboratory examination revealed non-reactive anti-HSV-1 IgG and a total IgE serum level of 612.00 IU/mL. The diagnosis based on the examination results is recurrent oral erythema multiforme."
  },
  {
    "id": "multiclinsum_gs_en_9.txt",
    "fulltext": "38-year-old patient, diagnosed with asthma (07/2021) and anxiety (04/2023), clinical conditions for which he is prescribed salbutamol 100 mcg inhaler (2 puffs every 6 hours) and diazepam 5 mg (0-0-1), respectively, comes to a medical appointment (24/05/2023) concerned about a worsening of the episodes of anxiety and low mood that he presents, and cannot be attended to on this occasion by his usual Primary Care Physician (MAP).\n\nAfter a medical evaluation, an anxious-depressive condition was diagnosed, for which a pharmacological treatment was prescribed that combined the use of desvenlafaxine 50 mg (1 tablet with breakfast) and mirtazapine 30 mg (1 tablet before bedtime). In addition, the suspension of use of diazepam 5 mg was recommended, in order to avoid a future problem of addiction.\n\nEVALUATION AND STUDY\nTo carry out the Dispensing Service (SD), the scheme of the methodology proposed by the Forum of Pharmaceutical Care in Community Pharmacy (Forum AF-FC) in its Practical Guide for the Professional Pharmaceutical Care Services in Community Pharmacy was followed. During the provision of the SD and after an evaluation of the pharmacotherapy, the following Problems Related to Medication (PRM) and Negative Results associated with the Medication (RNM) were detected:\n\nPRM of potentially serious drug interaction between mirtazapine and desvenlafaxine that could lead to a non-quantitative safety concern given the high risk of serotonergic syndrome (SS), a potentially fatal condition resulting from increased activity of the central nervous system that usually presents itself suddenly within the first 24 hours of initiating treatment with a serotonergic product, dose modification, or the addition of a new drug to an established treatment (2,4). Therefore, it became vital to intervene preventively to avoid its occurrence.\n\nPRM of Health problem insufficiently treated by sudden discontinuation of treatment with diazepam that could lead to a RNM of Need for Treatment the risk of worsening of episodes of anxiety.\n\nThe clinical case was registered in the SEFAC e_XPERT platform, obtaining the initial status.\n\nINTERVENTION\nTo avoid possible risks that could derive from the direct use of the prescribed pharmacological combination and with the aim of optimising the safety of the patient, only the usual medication (salbutamol and diazepam) was dispensed, and written information was provided to the patient, which allowed the intervention performed to be validated.\n\nIn addition, a referral report was prepared for the MAP through the SEFAC e_XPERT platform, which was delivered by the patient at the face-to-face medical appointment, where the intervention proposals shown below were collected and the risks detected were warned:\n\nConsider discontinuing one of the two antidepressive drugs prescribed (mirtazapine and/or desvenlafaxine) or prescribing an alternative medication to both.\n\nUse of diazepam should be continued for at least 2 to 3 weeks after the start of optimal antidepressive treatment, as this is the average time required for antidepressive treatment to exert a significant effect. After this period, the need for use and gradual withdrawal of diazepam should be assessed.\n\nIn addition, a record of the potential safety error detected was made through the online form of the portal of the Institute of the Safe Use of Medication (ISMP), for its evaluation and the implementation of measures that allow its occurrence to be avoided in future.\n\nRESULTS\nThe patient comes in for an appointment with their usual MAP (5/31/23) to hand over the referral report.\n\nConsidering the potential risk of the reported interaction, the MAP suspended the treatment with mirtazapine and desvenlafaxine, and prescribed paroxetine 20 mg (1 tablet with breakfast). Given the similarity of clinical criteria with the pharmacist, the patient is advised not to suspend the treatment with diazepam until further evaluation.\n\nIntervention was achieved from the FC by carrying out a preventive measure, which allowed the appearance of a PRM and RNM to be avoided, which could have compromised the safety of the patient, receiving thanks from both the doctor and the patient.\n\nIn addition, a brief telephone interview was conducted from the CF on 30/06/23 with the patient, which allowed us to verify that through the use of paroxetine and diazepam, he experienced an improvement in mood, as well as a better control of the episodes of anxiety, and the proposal made from the CF for the gradual suspension of use of diazepam was declined momentarily by the MAP, but considered as an intervention to be carried out in the short term.\n",
    "summary": "38-year-old patient, diagnosed with asthma and anxiety who used 2 medicines (salbutamol 100 mcg inhaler (2 puffs every 6 hours) and diazepam 5 mg (0-0-1)), went to the Community Pharmacy (FC) to withdraw a treatment prescribed by the Primary Care Physician (MAP) after diagnosis of an anxious-depressive condition.\n\nA Problem Related to the Medication (PRM) of a potential error in the prescription was detected by the Dispensary Service (SD), which could have an associated Negative Result associated with the Medication (RNM) in the case of concomitant use of desvenlafaxine and mirtazapine, as well as a PRM of Insufficiently Treated Health Problem (PS) in the case of a proposal to suspend the use of diazepam, which could lead to an RNM of Need for Treatment in the case of the risk of worsening of episodes of anxiety.\n\nThe FC prepared a referral report with recommendations that were accepted by the MAP. A follow-up of the case was carried out that allowed a better control of the PS presented by the patient, as well as the resolution of the PRM and RNM detected, thus guaranteeing a rational, safe and effective use of the medicine.\n"
  },
  {
    "id": "multiclinsum_gs_en_149.txt",
    "fulltext": "A 40-day old male infant was admitted to the Emergency Department (ED) with bronchiolitis and dyspnea. He showed no comorbidities during pregnancy, he was born at full-term and normal.\n\nAt the time of admission, the patient was reported to be coughing for a week, worsening with a vomiting episode in the previous two days and reduction of feeding. Diuresis was regular. At the same time, he was treated with nasal and aerobic salbutamol administration. Patient’s parents also reported an older sister with phlogosis of upper respiratory tract.\n\nThe physical examination highlighted persistent dry cough, globus abdomen, marbled skin with thoracic rush, respiratory rate of 52 breaths/minute, heart rate of 160 beats/minute and arterial oxygen saturation (SaO2) of 93%. No sign of neuropathological damage was evident. A nasopharyngeal swab performed with molecular assay Xpert® Xpress Flu/RSV (Cepheid, USA) tested positive for RSV. No Flu A and B were detected. During observation, SaO2 remained 93% until one hour and half from admission in ED when, due to hypoxaemia (SaO2 89%) and respiratory acidosis (pH 7.347; pCO2 56.6 mmHg) (BG1), the patient was given low-flow oxygen therapy (1 l/minute). After an initial improvement in clinical parameters (respiratory rate: 40 breaths/minute; SaO2 96%), flow oxygen therapy was reduced and stabilized to 0.5 l/minute until 12 h from admission in ED. Within this time frame, SaO2 was observed to be settled on 96–97%. Subsequently, a sudden worsening of respiratory dynamics happened (respiratory rate: 60 breaths/minute; SaO2 92%) and the therapy was changed to high-flow oxygen administration (8 l/minute). The subsequently BG2 performed after oxygen administration showed a correction in the parameters (pH 7.447; pCO2 45.5 mmHg) (BG2). Nevertheless, three hours after BG2, despite an improvement in the respiratory dynamics (respiratory rate: 48 breaths/minute; SaO2 96%), a re-evaluation of the patient’s parameters was performed showing again hypercapnia and respiratory acidosis (pH 7.336; pCO2 59.2 mmHg) (BG3).\n\nMoreover, the chest Xrays performed at time of BG3 and two hours apart highlighted how fast was the clinical worsening: the first one showed normo expanded lungs with no opacification, while the second Xray showed diffuse bilateral pulmonary opacification with marked ectasia of the stomach.\n\nBecause of the persistent respiratory failure, the patient was treated with nebulized epinephrine and prepared for endotracheal intubation, however he died before this could be done.\n\nPostmortem examination was carried out on the infant’s body.\n\nLung’s microscopic examination revealed severe vascular congestion with massive bleeding, peribronchiolitis due to lymphocytic infiltrates and sporadic foci of pneumonia with reactive interstitial infiltrates and alveolar atelectasis.\n\nAlso, extensive injury was present in the brain, characterized by white matter degradation in the left hemisphere, basal ganglia, hippocampus, bulbar region and pons with edema.\n\nA detailed microscopic analysis showed hypertrophic astrocytes, acutely damaged glia and focal necrosis at the bulbar level, features reported to be associated with viral infection. Basal ganglia were affected by neuronal necrosis with perineuronal halo and white matter strongly damaged. The brain’s histological examination didn’t exclude injuries in the cardiovascular center, probably due to viral infection.\n\nNo narcotic or psychotropic drugs were detected in the blood.\n\nMicrobiological analysis performed on autoptic samples confirmed the viral etiology of brain damage and death. In fact, using molecular assay BioFire® FilmArray® RP2 Panel Plus (BioMérieux, France), RSV was detected in tracheobronchial aspirate, meningeal swabs, pericardic and abdominal fluids, lung and brain biopsies. On the contrary, the samples tested negative for Adenovirus, Coronavirus, Human Metapneumovirus, Human Rhinovirus/Enterovirus, Influenza A and B, Human parainfluenza virus, Bordetella pertussis, Bordetella parapertussis, Chlamydophila pneumoniae and Mycoplasma pneumoniae. Moreover, the microbiological cultures found neither fungal nor specific pathogenic bacteria.\n\nTherefore, post-mortem examination revealed a severe bronchiolitis resulting in a fatal cerebral involvement due to RSV and its neurotropic behaviour.",
    "summary": "A 40-day old male infant was admitted to the Emergency Department with severe bronchiolitis and dyspnea. The patient was reported to be coughing for a week with a vomiting episode in the previous two days. The nasopharyngeal swab confirmed the diagnosis of RSV infection and blood gas test showed hypoxemia and respiratory acidosis. For these reasons, the patient was provided with oxygen therapy. A few hours later, after an initial improvement in clinical parameters, a worsening of respiratory dynamics occurred and the patient was prepared for endotracheal intubation, but in the meantime death occurred. During all the observation period in the Emergency Room, no signs of neuropathological damage were evident. Post mortem examination showed lungs congestion with alveolar atelectasis and white matter degradation with severe edema at brain level. Microbiological analysis performed on autoptic samples confirmed the presence of RSV genome in tracheobronchial aspirate, meningeal swabs, pericardic and abdominal fluids, lung and brain biopsies."
  },
  {
    "id": "multiclinsum_gs_en_253.txt",
    "fulltext": "24-year-old woman with no relevant medical history. She has a history of 6 months of intermittent episodes of syncope, with no obvious trigger. She has repeatedly consulted the emergency department of the hospital where she is based, where low capillary blood glucose levels have been detected, and she has been treated with oral glucose. Given the recurrence of symptomatic hypoglycaemia, a possible insulinoma was suspected, and an imaging study was requested. In an abdominal and pelvic magnetic resonance (MR) scan, an 8.5 × 4.2 cm tumour and another lesion smaller than 2 cm in the junction of the body and tail of the pancreas are observed.\n\nShe is transferred to the San Borja Arriarán Clinical Hospital for surgical resolution. Remote anamnesis is performed, where the presence of multiple tumours in relatives by paternal line is highlighted (pancreatic insulinoma, pituitary and parathyroid tumours in father, pituitary macroadenoma and parathyroid tumours in aunt and adrenal and pituitary tumours in uncle), with this background the possibility of NEM1 is raised. A directed study is performed, highlighting:\n\nFasted state test compatible with endogenous hyperinsulinism (Glucose: 35 mg/dl, Cortisol: 15.9 µg/dl, Insulin: 55.6 µ Ul/ml at 4 hours)\n\nCalcemia: 11.8 mg/dl; Phosphemia: 2.3 mg/dl; Creatininemia: 1.05 mg/dl; PTH: 205 pg/ml; Gastrin: 14.4 pg/ml\n\nCervical ultrasound and Tc-99m MIBI SPECT parathyroid scintigram suggestive of lower right parathyroid adenoma\n\nTurkey-cock's-eye MRI with finding of a pituitary macroadenoma. PRL: 7.5 ng/ml; IGF-1: 346 ng/ml; TSH: 1.49 µUI/L; FSH: 3.5 mUI/ml.\n\nA total pancreatectomy was performed, with the presence of three tumour lesions: in the head and tail, without locoregional lymph node involvement. In the postoperative period, pancreatic enzyme, insulin glargine and insulin aspart boosting were initiated. The histological study showed:\n\nImmunohistochemistry: Synaptophysin: intense and diffuse positive in cytoplasm of tumour cells; Chromogranin A: Mild positive in cytoplasm of some tumour cells.\n\nCell proliferation index KI67: 5%\n\nFindings consistent with G2 neuroendocrine tumour (WHO 2010). Given the strong family history, a genetic study was requested that demonstrated a c.375_376delAT (p.lle 125 Metfs*54) mutation in exon 2 of the MEN1 gene, consistent with the diagnosis of NEM1. The surgical resolution of primary hyperparathyroidism (subtotal parathyroidectomy) was deferred.\n",
    "summary": "A 24-year-old woman with recurrent episodes of symptomatic hypoglycemia and a first-degree family history of insulinoma presented. Initial study was compatible with endogenous hyperinsulinism secondary to two pancreatic tumors, the main one 8.5 × 4.2 cm, and PTH-dependent hypercalcemia secondary to a parathyroid adenoma. Subsequent studies with magnetic resonance imaging of the sella revealed a macroadenoma of the pituitary gland. Genetic study revealed deletion in the IAT gene, compatible with MEN1. She was managed with pancreatic and parathyroid tumor resection, with subsequent replacement management.\n"
  },
  {
    "id": "multiclinsum_gs_en_433.txt",
    "fulltext": "A 34-year-old female patient presented to the outpatient clinic complaining of difficulty in swallowing due to an enlarging mass on the left side of her neck for the past few months. The swelling was also associated with pain radiating to her left shoulder and mild shortness of breath.\n\nShe had no significant past medical history except for cervical spinal surgery due to a herniated disc 3 years ago with implant seen in situ at C5-C6 level. She has no significant family history or history of smoking or alcohol intake.\n\nOn examination, the patient was vitally stable. Chest was clear and abdomen was soft. Neurological examination was normal. An immobile, non-tender, and non-pulsatile swelling was noted on the left side of the neck.\n\nBlood work-up showed normal blood cell count, electrolytes, renal, liver, and thyroid function tests. C-reactive protein was high measuring approximately 21.9 mg/L (normal value less than 5 mg/L). AFP-tumour marker was within normal limits.\n\nCervical spine radiographs were obtained and showed a maintained vertebral alignment with radio-opaque metallic disc spacer in situ at level C5-C6. The trachea appeared slightly displaced to the right side.\n\nNeck ultrasound showed normal appearance of the thyroid gland and no evidence of cervical lymphadenopathy. Nevertheless, upon scanning the left carotid region, a hypoechoic tubular and lobulated left paraspinal soft tissue mass centred between the left common carotid artery anteriorly and the cervical vertebra posteriorly measuring approximately 30 × 34 × 80 mm in diameter was seen, and it appeared to be displacing the left common carotid artery anteriorly and the trachea laterally. The mass showed a heterogeneous echotexture with minimal vascularity on colour Doppler images.\n\nA contrast-enhanced CT scan of the neck showed a well-defined iso-to-hypo-dense mass compared to the surrounding musculature centred on the left carotid space extending from the bifurcation of the common carotid artery down to the thoracic inlet with minimal extension to the mid-line measuring approximately 85 × 32 × 26 mm in diameter. The mass was located between the common carotid artery and the internal jugular vein with displacement of the common carotid artery anteromedially. It showed homogeneous faint delayed enhancement at the late arterial/early venous phase exerting mass effect by displacing the trachea and oesophagus to the right side with no signs of local invasion. No calcifications were noted.\n\nContrast-enhanced MRI of the neck showed a well-defined hyperintense lesion on T2WI centred in the left carotid space extending from the bifurcation of the common carotid artery downward to the thoracic inlet with minimal extension across the mid-line. It was centred between the left common carotid artery and the internal jugular vein displacing the common carotid artery anteromedially and showed enhancement upon contrast administration. It was seen exerting a mass effect and displacing the trachea and the oesophagus to the right side. A C5-C6 disc spacer was also noted showing a metallic artefact minimally indenting the thecal sac.\n\nThe differential diagnosis included neurogenic tumours such as schwannomas, conglomerated lymphadenopathy, carotid body tumours (paraganglioma), and other soft tissue tumours.\n\nThe patient underwent a core needle biopsy of the lesion, and histopathology found interlacing bundles of elongated spindle cells with wavy nuclei interspersed with collagen bundles; no atypia, pleomorphism, mitosis, or necrosis were seen. Immunochemistry was diffuse and strong for Beta-Catenin and Vimentin. Focal scattered positive for Smooth Muscle Actin (SMA), SOX 10, and S100 was observed. Findings were suggestive of fibromatosis.\n\nThe patient underwent mass excisional surgery in her home country, and the histopathology of the lesion also showed findings denoting aggressive fibromatosis. Unfortunately, after several months, the patient returned with recurrence of the lesion with the same symptoms of pain and neck swelling.\n\nThe C5-C6 intervertebral disc cage was removed with vertebral bodies osseous fusion done. The patient underwent another excisional surgery, which resulted in a complication of chronic hoarseness of voice likely due to the involvement of the recurrent laryngeal nerve.\n\nFortunately, she improved after the surgery with no recurrence of the lesion up to the current date.",
    "summary": "We report a case of a 34-year-old Asian female who presented to our hospital with a history of difficulty in swallowing due to an enlarging lump on the left side of her neck. Patient had a past medical history of previous cervical spinal disc surgery due to a herniated disc. Diagnostic imaging showed a large soft tissue mass centred between the left common carotid artery and the cervical vertebrae displacing the trachea and oesophagus to the right side. A biopsy was obtained, and histopathological examination was suggestive of a desmoid tumour. The patient underwent surgical resection of the tumour but returned later with recurrence and had to undergo the surgery again to achieve full cure."
  },
  {
    "id": "multiclinsum_gs_en_424.txt",
    "fulltext": "On 12 March 2022, a 10-year-old boy of Arab-Asian ethnicity from Mosul, Iraq, fell from the stairs and got a nosebleed. His condition deteriorated, with headache, dizziness, nausea, vomiting, and altered consciousness. He was seen at the emergency department of a general hospital in Erbil with the suspicion of a head injury. Providing that the patient’s family gave a history of fever, headache, vomiting, and diarrhea for 2 days before admission, another pathology was considered, and dizziness could be the cause of falling. Upon admission, the boy was looking toxic with impaired consciousness, his oxygen saturation (SPO2) was 92%, he was febrile (38.3 °C), had tachycardia (130 beats/min), tachypnea (36 breaths/min), and hypotension as his blood pressure was less than the 5th percentile (<90/50 mmHg). In addition, his face was edematous, with bruises over the nose and bleeding from the nose. He was unconscious with flexion to pain, and his Glasgow coma scale (GCS) scored 8/15 (Eye, 3; Verbal, 2; and Motor, 3). Supportive care was given to maintain oxygenation, ventilation, and circulation, with head elevation to 15 degrees, and cardiorespiratory monitoring was set. However, the ventilator was not required. Crystalloid intravenous (iv) fluid, antipyretics, and empiric antibiotics (vancomycin and ceftriaxone) were given while obtaining samples for laboratory tests. Urgent computed tomography (CT) of the head was arranged to exclude the fracture at the base of the skull and to determine if there is bleeding inside or around the brain or other serious brain injuries. A neurosurgeon was consulted, and the patient was referred to the intensive care unit (ICU). The CT was normal. The baseline investigations were conducted, including random blood sugar, blood gas analysis and electrolytes, c-reactive protein (CRP), complete blood count (CBC), blood culture, renal function test, and liver function test (LFT). LFT included lactate dehydrogenase (LDH) and gamma-glutamyl transferase (GGT), in addition to alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Also, coagulation markers were evaluated to assess prothrombin time, international normalization ratio, activated thromboplastin time, and D-dimer.\n\nFurther investigations, such as troponin T and procalcitonin, were conducted later. Ultrasound (US) of the abdomen, portable chest X-ray (CXR), electrocardiography (ECG), and echocardiography were also performed.\n\nThe patient also had bilateral non-purulent conjunctivitis, and his pupils were dilated, reacting to light with normal fundoscopy. He had inflamed oral mucosa with swollen, dried, cracked lips, a strawberry tongue, and a skin rash. He also had red edematous hands and feet. His abdomen was tender, and there was a soft palpable liver. The patient developed seizure and apnea on the second day of admission; however, neck stiffness and Kernig’s sign were challenging to be assessed. After excluding the contraindications, a lumbar puncture was performed with a normal cerebrospinal fluid examination (CSF) and negative culture. The chest examination was shown to be normal, with normal CXR, and the ECG showed sinus tachycardia. The patient weighed 25 kg (on the 5th percentile), and his height was 140 cm (above the 50th percentile). He was kept in an isolated room with consideration of the possible diagnosis of SARS-CoV-2. Likewise, MIS-C was among the differential diagnosis. Therefore, SARS-CoV-2 IgG, and reverse transcription polymerase chain reaction (RT-PCR) COVID-19 were also performed.\n\nSince the patient had a skin rash, vancomycin was rapidly switched to meropenem to avoid confusion with vancomycin-related rash, which is still common in our practice, in addition to ceftriaxone (50 mg/kg/dose) iv, every 12 h. Dexamethasone (0.15 mg/kg/dose) iv, every 6 h, and acyclovir (60 mg/kg/day) were started from the first day concerning the suspicion of meningitis or encephalitis. Diazepam and phenobarbital were administered due to the occurrence of seizures. A nasogastric tube was inserted for oral feeding to be resumed by the next day. Thus, he was kept on iv fluid, dexamethasone, antibiotics, acyclovir, and anticonvulsants. On the third day, with close monitoring, the multidisciplinary team concluded that MIS-C criteria were fulfilled according to the CDC/WHO definitions. Therefore, iv methylprednisolone (M-PRD) was given in a dose of 25 mg twice a day (1 mg/kg/12 h) for 5 days, along with intravenous immunoglobulin (IVIG) infusion using (2 g/kg/day) given over 12 h for 2 days. Subsequently, the patient showed striking improvement. The next day he regained consciousness, vital signs started to be stabilized, and the edema and redness were decreasing. Esomeprazole (10 mg once daily) was added on day three to avoid steroid-induced stomach irritation. Sinus tachycardia was detected since admission, and on the third day, mild dilation of the left ventricle and mild pericardial effusion were noticed through sequential ECG and echocardiography monitoring. Antithrombotic treatment with aspirin 81 mg orally was added on day six, and he carried on with oral prednisolone. Significant improvement was noticed after ambulation within a few days. Physiotherapy was part of his management. We continued alternate-day oral prednisolone for four weeks and aspirin for eight weeks with continuous monitoring until a normal quality of life was regained.\n\nIn summary, during the 10-day period of the patient’s stay in the hospital, he was deteriorating over the first three days in terms of fever, impaired level of consciousness, and the occurrence of seizure and apnea. Similarly, the laboratory data related to liver and renal function were deteriorating.\n\nHe was treated empirically as a case of toxic shock syndrome with antibiotics, and a glucocorticoid was given with consideration of central nervous system infection. But soon after receiving IVIG and M-PRD, he showed a substantial response. His consciousness improved by day 4, and GCS became (13/15), with less edema and good oral intake. Rising levels of (CRP, LDH, D-dimer, GGT, ALT, AST, s. ferritin, troponin T, and procalcitonin) were observed until the fifth day of admission. However, D-dimer and GGT did not stop increasing until the eight day. Meanwhile, according to the CBC, the blood parameters were gradually improving. Serial echocardiography revealed mild left-ventricular dysfunction. On day 9, he was back to normal clinically, and his liver enzymes, including GGT, were starting to decrease. By day 10, he had normal heart rates and echocardiography. D-dimer returned to normal in 1 month.\n\nOf note, and perhaps from a social point of view, the parents hid the information that COVID-19 was confirmed in more than one family member four weeks before the onset of symptoms in the patient. Additionally, no one in the family, including the child, had received COVID-19 vaccination.",
    "summary": "A 10-year-old boy presented with blunt trauma in a shock-like status, and a head injury was suspected. Since he was febrile two days before the trauma, another pathology was assumed. Imaging and laboratory evaluations were performed, and after excluding gross neurosurgical etiology, he was initially treated as a toxic shock syndrome. Meanwhile, he was deteriorating with continuous fever, impaired consciousness, and seizure on the following day. Although not considered initially, close monitoring with a multidisciplinary approach and serial investigations revealed that the child met the criteria of MIS-C. SARS-CoV-2 IgG was shown to be high, while the RT-PCR of COVID-19 was negative. Once he received immunoglobulin and methylprednisolone, he improved dramatically."
  },
  {
    "id": "multiclinsum_gs_en_182.txt",
    "fulltext": "A 25 year old male was discovered recumbent by relatives after a night of partying, presenting with emesis, aggression and localised pain in the right lower limb and gluteal region. Initial evaluation in the emergency department revealed no traumatic injury, however, worsening symptoms led to re-evaluation the following day. Laboratory findings revealed unremarkable complete blood count, elevated levels of serum CPK (42 527 IU/l), serum creatinine (735 µmol/l), urea (44.3 mmol/l) and potassium (5.7 mmol/l). Urinalysis revealed red-brown coloured urine without red blood cells, proteinuria (+1), glucosuria (+1) and WBCs (9–10/hpf). These results confirmed RM and AKI. Toxicology established heroin administration 1796 μg/l (> 5× the baseline) without detection of any other substances. Although he initially denied taking medication, after the toxicology analysis, the patient admitted that he administered heroin once intramuscularly in the right gluteal region on the night of the incident.\n\nA CT scan demonstrated gluteal muscle oedema and myositis located in the right gluteal region. Upon commencement of conventional treatment with intravenous (IV) fluid resuscitation, AKI management failed, necessitating RRT with haemodialysis due to progression of azotaemia with serum creatinine rising to 1052 µmol/l. Renal function improved post-RRT cessation with a total length of stay (LOS) of 9 days. Subsequent patient follow-up was incomplete due to failure of attendance.",
    "summary": "This case report describes a 25-year-old male who developed severe RM and Acute Kidney Injury (AKI) after intramuscular (IM) heroin administration as a first time user. IM heroin use can induce higher CPK levels due to direct myocyte toxicity and mechanical trauma. The highly vascularised gluteal muscles with type 1 fibres at the injection site likely exacerbated the severity. Additional factors included lower mitochondrial density in males and alcohol exposure. Despite aggressive fluid resuscitation, renal replacement therapy (RRT) was required, and the patient responded well to haemodialysis."
  },
  {
    "id": "multiclinsum_gs_en_29.txt",
    "fulltext": "Our patient was an 83-year-old Japanese woman with chronic heart failure (ejection fraction: approximately 30%) who was initiated on empagliflozin 10 mg daily about 8 months before admission. She had never been diagnosed with diabetes mellitus (HbA1c 5.9% before starting empagliflozin). About 6 months before hospitalization, her treatment was changed to dapagliflozin 5 mg. Her diuretics and other cardiac medications were not adjusted during that time. Two weeks before admission, she tripped and fell, sustaining vertebral and rib fractures. The patient became significantly debilitated from the pain from the fractures, which caused difficulty walking and anorexia. She could eat only 50-70% of her usual dietary intake. This got worse in the following week when she also developed nausea and vomiting and further reduced her food intake to only 10-20% of the usual amount. During this period, she continued to take dapagliflozin. She was admitted to the hospital.\nOn admission, she was conscious with a body temperature of 37.4°C, blood pressure of 124/68 mmHg, heart rate of 91 bpm, and oxygen saturation of 98% breathing room air. Blood tests revealed a blood glucose level of 124 mg/dL, pH of 7.3, HCO3–concentration of 14 mmol/L, base excess of -10 mEq/L, anion gap of 20 mEq/L, and b-hydroxybutyrate concentration of 5150 μmol/L (Table 1). These findings were consistent with the diagnosis of normoglycemic ketoacidosis. The patient had no history of alcohol consumption, smoking, or drug use.\nOther causes of high anion gap acidosis were ruled out. Her C-peptide level was consistent with the blood glucose levels on admission, indicating that she had adequate insulin secretion; therefore, insulin was not initiated. SGLT2 inhibitor use was discontinued, and the patient was initially treated with isotonic saline and a maintenance infusion of approximately 170 g glucose daily.\nDespite not starting insulin, her pH (7.418), HCO3– concentration (20.7 mmol/L), and anion gap (13.3 mEq/L) improved on the day after admission. The Carb 60 diet was initiated, but intravenous glucose infusions were continued because the patient’s food intake was poor. The amount of glucose infusion administered was adjusted according to her food intake. On the fourth day of hospitalization, urinary ketones disappeared.\nThe glucose infusion was terminated on the 12th day of hospitalization once the patient could eat full meals. Although the patient’s blood glucose level was within the normal range, the urinary glucose excretion was 3+ (>500 mg/dL) for 8 days after the last dose of dapagliflozin.\nOn admission, the patient was unable to walk due to pain from the fracture, general fatigue, and disuse syndrome, but after rehabilitation, she was able to walk independently. She was discharged on day 19 of hospitalization after undergoing rehabilitation.\nThe SGLT2 inhibitors were not restarted.",
    "summary": "Herein, we describe a case of ketoacidosis in an 83-year-old Japanese woman without diabetes who was administered SGLT2 inhibitors for heart failure (ejection fraction: approximately 30%). Two weeks prior to admission, she had suffered a vertebral fracture and rib fracture due to a fall, which was followed by anorexia, but she continued to take SGLT2 inhibitors. On admission, blood test results revealed a blood glucose level of 124 mg/dL, hemoglobin A1C level of 5.9%, pH of 7.329, HCO₃⁻ concentration of 14.3 mmol/L, and a β-hydroxybutyrate concentration of 5150 μmol/L, leading to a diagnosis of euglycemic ketoacidosis. The patient’s C-peptide level was consistent with the blood glucose levels on admission, indicating that she had adequate insulin secretion. The patient was treated only with glucose administration without insulin and was discharged after discontinuation of the SGLT2 inhibitor."
  },
  {
    "id": "multiclinsum_gs_en_533.txt",
    "fulltext": "A 56-year-old male patient diagnosed with COVID-19 was referred to the Oral Medicine Department with the chief complaint of an uncomfortable burning sensation in the mouth along with whitish plaque covering the tongue. The complaint appeared a year ago, at first it was just a thin spot, which sometimes arise and disappear. For the last three months, the condition was getting worse parallel to the hospitalization of the patient because infected by COVID-19. Furthermore, in the last five months, he experienced a massive weight loss of 25 kg.\n\nThe patient was diagnosed with HIV for the last six years and stopped taking ARV medication during the mid-COVID-19 pandemic. In addition, the patient was diagnosed positive for COVID-19, for 8 months since this examination was carried out and had not come back negative. The symptoms that patient got during COVID-19 infection are coughing, fever, and shortness of breath. The symptoms are getting worse from month to month.\n\nOn the first visit when the examination was carried out, the general condition of the patient was compos mentis but looked weak and suffered. The patient was wearing nasal cannula oxygen with a saturation of 94%. The intraoral examination is inadequate, but there was visible a white plaque that covers almost the entire surface of the tongue and intraoral mucosa.\n\nThe patient underwent various supporting examinations including complete blood count, examination of CD4+ count, and HIV viral load. Based on the results of the investigations carried out, the patient has anemia, lymphopenia, also HIV positive with high viral load results, and COVID-19 infection for 8 months. In conclusion, based on the history, clinical examination, and supporting examinations, it was found that the patient was diagnosed with HIV stage IV with wasting syndrome, confirmed COVID-19 severe case, and intraoral diagnosis as pseudomembranous oral candidiasis.\n\nThe management for this case from Department of Internal Medicine were given Co-Trimoxazole (Trimetropin/Sulfamethoxazole), Efavirenz/Emtricitabine, Tenofovir, Lovenox, Enoxaparin Sodium, Anticoagulant, Remdesivir, and Vitamin D 5000 IU. While the management provided by the Department of Oral Medicine were in form of education and oral hygiene instruction, including brushing the teeth and tongue at least two times a day and administering nystatin oral suspension 4 times 2 mL per day by swishing for a minute before spit.\n\nAt the first medical control, showing that the general condition of the patient still looked breathless, with thick white plaques that covered almost the entire intra-oral mucosa conditions still showed in the mouth even worse, oral candidiasis conditions spread to the oropharynx. The patient still had difficulty following the instructions given, such as brushing his teeth and tongue regularly because of the general condition of the patient.\n\nThe patient was instructed to continue maintaining oral hygiene, discontinue the usage of nystatin oral suspension, and replaced it with systemic antifungal administration of fluconazole. Because the patient is struggling in cleaning his teeth and tongue mechanically, we administered chlorhexidine gluconate mouthwash 0.2% of 10 mL swish and spit three times a day to prevent secondary infection.\n\nDuring the second medical control, the patient’s general condition improved, less shortness of breath was visible and the patient was able to follow the instructions from the previous visit. In the intraoral examination, it was found that the white plaque on the surface of the tongue had thinned.\n\nThe patient was instructed to maintain the cleanliness of his oral cavity by brushing his teeth and tongue twice a day, continue to use chlorhexidine gluconate three times a day and additional therapy was given to apply a thin layer of Vaseline album on the upper and lower lips, because chapped lips were visible.\n\nDuring the third medical control, the general condition of the patient was getting better compared to the previous visit, without any shortness of breath, but the patient’s lip was still dry and exfoliation was visible. While the white plaque covering the tongue disappeared completely. The instructions given to the patient are still the same as the previous visit.\n\nTreatment and monitoring that is carried out periodically give the expected results. Chief complaints of pain and discomfort experienced by the patient and the white plaque that covers the patient’s tongue were resolved completely. The good general condition of the patient makes the patient cooperative and supports the patient in carrying out the instructions given.",
    "summary": "A 56-year-old male patient was consulted from the COVID-19 isolation unit to the Department of Oral Medicine with complaints of sore and uncomfortable mouth related to white plaque covering the surface of the tongue. The patient was diagnosed with HIV/AIDS and had a COVID-19 infection. The management instructions were to maintain oral hygiene, administration of antifungal drugs such as nystatin oral suspension and fluconazole, chlorhexidine gluconate 0.2% mouthwash, and vaseline album."
  },
  {
    "id": "multiclinsum_gs_en_303.txt",
    "fulltext": "A 2-year-old female patient was admitted to Shenzhen Children’s Hospital in July 2021 because of a cough, fever for 5 days, and worsening shortness of breath for 1 day. Five days before admission, the child presented with paroxysmal productive cough, cyanosis, and fever. The highest temperature was 40.0 ℃. Four days later, the child had a worse cough and significant shortness of breath, then she was admitted to the hospital with presumptive pneumonia.\n\nShe was previously diagnosed with acute myeloid leukemia (M5, CR1) and was in the induction phase of chemotherapy, The chemotherapy regimen was cytarabine (Ara-c) 100 mg/m2 d1-7, etoposide (VP-16) 150 mg/m2 d3, cladribine (Cla) 5 mg/m2 d1-5, and granulocyte colony-stimulating factor (G-CSF) 200 µg/m2 d1-7. The patient had no history of eczema or wheezing. There was no special birth history, personal history, or family history.\n\nThe physical examination on admission was as follows: temperature 38.9 °C, heart rate 138 beats/min, respiratory rate 50 beats/min, blood pressure 104/60 mmHg, weight 12 kg, and 94% arterial oxygen saturation (with supplemental oxygen concentration 65%). The patient had poor mental status, dysphoria, shortness of breath, cyanosis, nasal flaring, retraction, wheezing, and rales on auscultation. Examinations on the heart, abdomen, and nervous system were unremarkable. The capillary refill time was 2 s.\n\nLaboratory tests were as follows: The white blood cell counts 0.83*109/L, neutrophils 0.21*109/L, lymphocytes 0.62*109/L, hemoglobin 105 g/L, platelet 50*109/L, hypersensitive C-reactive protein 22.71 mg/L; procalcitonin 2.95 ng/ml; blood gas analysis: pH 7.403, carbon dioxide partial pressure 43.5 mmHg, oxygen partial pressure 87.4 mmHg, and standard bicarbonate 26.3 mmol/L. The standard residual base was 2.2 mmol/L. The liver and kidney function, creatinase, Brain Natriuretic Peptide, electrolyte, and coagulation function were normal; The blood culture and sputum culture were negative. The throat swab and alveolar lavage fluid PCR for respiratory pathogens (including metapneumovirus, influenza B virus, influenza A virus H3N2, Chlamydia, Mycoplasma pneumonia, bocavirus, coronavirus, respiratory syncytial virus (RSV), influenza A virus H1N1, adenovirus, rhinovirus, parainfluenza virus) indicated positive only for RSV only. A Chest CT suggested consolidation of both lungs with segmental atelectasis.\n\nTreatment and follow-up: During hospitalization, the child was in the induction phase of M5 chemotherapy with neutropenia and fever. Therefore, the intravenous meropenem (20 mg/kg q8 h) was given, with high-flow nasal catheter oxygen (HFNC), nebulization (with budesonide 2 ml ipratropium 2 ml salbutamol aerosol 1.25 ml once/8 h), rehydration and antipyretic. On the 6th day of hospitalization, the difficulty breathing, and retraction were worsening, and the oxygen saturation was 88% on HFNC, then she was transferred to the Pediatric Intensive Care Unit (PICU). By intubation and mechanical ventilation, the oxygen saturation was still lower than 90%, and mechanical ventilation-related lung injuries such as subcutaneous emphysema and mediastinal pneumatosis occurred. On the 9th day of hospitalization, extracorporeal membrane oxygenation (ECMO) was given, by which the tidal volume was still low, and manual lung recruitment was ineffective. Repeated chest radiographs indicated signs of “white lung”. Airway obstruction was considered, the bronchoscopy was performed on the 10th, 13th, 15th, and 19th days of ECMO operation, respectively, and many plastic plugs were aspirated during the first two procedures. After that, the tidal volume increased. The alveolar lavage fluid was sent for a high-throughput etiology test by next-generation sequencing, which was only positive for RSV. The pathology of the plastic plugs indicated fibrinous secretions, as well as red blood cells, lymphocytes, and neutrophils. The ECMO was withdrawn 35 days later. At discharge, she was on HFNC (FiO2 34%, flow 13 L/min) with, an oxygen saturation maintained above 95%.\n\nAfter discharge, the child had a cough, exercise intolerance, and persistent moist rales on lung auscultation. A chest CT scan performed six months post-discharge (February 2022) revealed uneven inflation, hyperinflation, ground-glass opacity, atelectasis, and interlobular septal thickening in both lungs. Consequently, bronchiolitis obliterans (BO) was diagnosed. oral montelukast sodium and low-dose azithromycin, as well as budesonide nebulization, were given. A follow-up CT scan performed 19 months post-discharge (March 2023)still indicated a mosaic attenuation pattern, atelectasis, and interlobular septal thickening. In October 2022, oral pirfenidone was initiated for the treatment of pulmonary fibrosis. Currently, during more than two years of monitoring, no exacerbation of BO has been observed.",
    "summary": "A 2-year-old immunocompromised girl was admitted to the hospital with cough, fever for 5 days, and aggravated with shortness of breath for 1 day. With mechanical ventilation, her respiratory failure was not relieved, and subcutaneous emphysema and mediastinal pneumatosis appeared. Extracorporeal membrane oxygenation (ECMO) was administrated, but the tidal volume was low. Therefore, a bronchoscopy was performed, by which plastic secretions were found and removed. Pathology of the plastic secretions confirmed the diagnosis of type I PB. RSV was the only positive pathogen in the alveolar lavage fluid by the next-generation sequencing test. After the bronchoscopic procedure, her dyspnea improved. The patient was discharged with a high-flow nasal cannula, with a pulse oxygen saturation above 95%. Half a year after discharge, she developed sequelae of bronchitis obliterans."
  },
  {
    "id": "multiclinsum_gs_en_162.txt",
    "fulltext": "A 66-year-old hypertensive, hypothyroid woman with a history of intermittent alcohol consumption presents with progressive abdominal distension of 6 months' duration and diffuse tenderness to percussion. She undergoes a paracentesis with the equivocal support of an ultrasound examination that reports a large amount of intra-abdominal free fluid. A CT scan of the abdomen and pelvis reveals a cystic expansion of 295 mm x 208 mm x 250 mm. Left ovariectomy is scheduled with a pathologic report of a mucinous cystadenoma of the ovary. The case report refers to the possibility of a giant ovarian cyst as a differential diagnosis of ascites. If there are no obvious signs or symptoms of liver, renal, cardiac or malignant disease and ultrasound does not reveal typical signs of intra-abdominal free fluid (fluid in the Douglas or Morrison pouch, free floating intestinal loops), a CT scan and/or MRI should be performed prior to a paracentesis, which could have potentially serious consequences.\n",
    "summary": "A 66-year-old hypertensive and hypothyroid woman with occasional consumption of alcohol presents with progressive abdominal distension of 6 months' evolution and diffuse mateness to percussion. A paracentesis is performed with the equivocal support of an ultrasound examination that reports abundant intrabdominal free liquid, and a CT scan of the abdomen and pelvis is performed that shows a cystic expansion of 295 mm x 208 mm x 250 mm. Left ovariectomy is scheduled with an anatomopathological report of mucinous cystadenoma of the ovary.\n"
  },
  {
    "id": "multiclinsum_gs_en_558.txt",
    "fulltext": "She is a 2-year-old girl weighing 14.2 kg with a diagnosis of ventricular septal defect and a history of pulmonary artery banding surgery performed at 1 year of age through a mid-sternal approach.\n\nThe patient underwent elective cardiac surgery for defect repair in our institution. A mid-sternal approach, aortobicaval central cannulation, mild hypothermia, and closure of the ventricular septal defect with a bovine pericardium patch, debanding, and pulmonary artery plasty were performed with a prolonged extracorporeal circulation (EC) time. The sternal closure was performed with Robicsek type left sternal edge reinforcement and the patient was transferred to the pediatric intensive care unit (ICU).\n\nOn the third postoperative day, the patient was reoperated due to severe stenosis at the origin of both pulmonary branches. Artery and pulmonary branches were reconstructed with a patch of bovine pericardium.\n\nSeven days later, the patient was readmitted to the operating room for sternal dehiscence and surgical site infection and high suspicion of mediastinitis. The intraoperative findings included: infection and dehiscence of the surgical wound; dehiscence of the sternal suture in its entirety; total loss of the sternum due to multiple fractures in areas of previous osteosynthesis and significant involvement of chondrocostal cartilages with necrosis and infection; there was also abundant purulent secretion in the mediastinum. Different samples were taken for culture and pathological anatomy and surgical cleaning was performed with extensive debridement of necrotic tissues; extensive opening of both pleurae; placement of pleural drains; mediastinal drain; placement of a catheter for mediastinal irrigation and total skin closure.\n\nMediastinal infection was confirmed in the operating room due to the finding of purulent discharge, while the pathological anatomy demonstrated acute osteomyelitis. In the ICU the patient evolved with stable hemodynamics, respiratory support was provided due to thoracic instability and mediastinal irrigation with physiological solution was left for 5 days.\n\n3 weeks after the last surgery and with the infection controlled, a multidisciplinary medical team decided to perform thoracoplasty with titanium bars for the stabilisation of the thorax, after performing thoracic TEM with reconstruction of the thoracic wall.\n\n\nSurgical technique\nSkin reopening was performed at the level of the previous incision, dissection by planes until reaching the costal cartilages, curettage of the cartilage edges, cavity washing, release of the muscle flap (bilateral pectoral major, anterior sheath of the rectus abdominis muscle and part of the aponeurosis of the external oblique).\n\nSternal ribs were faced with 1/0 nylon suture; 04 mini-titanium plates 2.0 in the form of C (CONMET; LLC 24/1 Onezhskaya str. Moscow) adapted to the curves of the ribs in both hemithoraxes are placed, the plates are fixed to the ribs 1, 2, 4 and 5 with 1/0 surgical wire suture (TAGUM) and 02 mini-titanium screws 5 mm (CONMET; LLC 24/1 Onezhskaya str. Moscow) per side.\n\n01 mediastinal drain 20 Fr and 14 Fr subpectoral Hemovac were placed bilaterally. Muscle flaps were approximated to the midline with 2/0 polyglactin suture, covering the entire titanium bars. The skin and subcutaneous tissue was closed with 2/0 Nylon total stitches.\n\nPostoperative evolution\nAfter thoracic plastic surgery, the patient was kept on mechanical ventilation, with sedoanalgesia, without inotropic vasopressor support, and continued parenteral antibiotic therapy. After 6 days of mechanical ventilation, with therapy for the management of withdrawal syndrome, and having received prophylactic corticosteroids, a scheduled extubation was performed; respiratory support was continued post-extubation with nasal CPAP for 6 days, and then a binasal cannula was used. Respiratory physiotherapy was provided throughout the pre- and post-extubation process. The patient completed 6 weeks of parenteral antibiotic therapy and was discharged after 2 months of hospital stay. At the 8-month follow-up, she was asymptomatic and was not taking medication.\n",
    "summary": "A 2-year-old girl with a history of pulmonary banding surgery was presented with a thoracic wall stabilisation technique with titanium bars and coverage with muscle flaps for presenting post-surgical mediastinitis associated with total sternal loss, after a surgery of closure of the interventricular communication, debanding and pulmonary artery plastic surgery. The patient presented a favourable post-surgical evolution.\n"
  },
  {
    "id": "multiclinsum_gs_en_15.txt",
    "fulltext": "A newborn girl was evaluated in the neonatal nursery shortly after delivery due to the presence of extensive, scar-like lesions on her flanks and upper thighs. Born to a 28-year-old Asian mother at 39 weeks of gestation, the baby was part of a spontaneous twin pregnancy. Her mother, a fifth gravida, had a history of one spontaneous first-trimester abortion during her second pregnancy.\n\nThe parents were the first cousins and reported no health issues in their three living children. Ultrasound at 13 weeks confirmed dichorionic diamniotic pregnancy and absence of cardiac activity in one of the twins. Subsequent scans showed a normally developing fetus alongside a nonviable twin.\n\nDuring pregnancy, the mother reported no medication use or symptoms such as fever and rash. She tested negative for Group B streptococcus and was admitted to the obstetric emergency department with labor pain. The baby girl was delivered vaginally, weighing 2.83 kg, and was vigorous at birth. Attached to the placenta was a compressed, nonviable fetal remnant measuring 6 × 2 cm. The placenta weighed 460 g and appeared normal on examination.\n\nThe infant presented with extensive and irregular skin lesions, characterized by a star-like appearance on both flanks, extending laterally over the gluteal area and upper thigh. The lesions were symmetrical across the flanks. However, lesions on the thighs were notably milder on the left side. Her vital signs were stable, and she showed no other external abnormalities. Clinical examination of her respiratory, cardiovascular, gastrointestinal, and neurological systems revealed normal results, and no other skin abnormalities were noted, including the absence of bullous lesions.\n\nGiven the symmetrical nature of cutaneous abnormalities and the context of twin pregnancy with FP, a diagnosis of aplasia cutis congenita group-V was made. Laboratory tests, including complete blood counts, electrolytes, and kidney and liver function tests, returned normal results. Screening for toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and HIV (TORCH) yielded negative results. Ultrasonography of the brain, abdomen, and heart revealed no abnormalities.\n\nSince the lesions healed in utero, only local emollients were prescribed. After 48 h of observation, the baby was discharged home, with referrals to pediatric dermatology and plastic surgery clinics. At the 2-week follow-up, no changes in the skin lesions or no new symptoms were observed. Her chromosomal microarray analysis was reported normal.",
    "summary": "We report a neonate diagnosed with Group G-V ACC associated with fetus papyraceus from a dichorionic diamniotic twin pregnancy. Born to a 28-year-old Asian mother, this female infant presented with extensive, healed, scar-like lesions on her flanks and upper thighs. These lesions were consistent with the \"H\"-shaped distribution commonly described in ACC linked to fetus papyraceus. Despite significant dermatological manifestations, the infant showed no other external abnormalities or systemic involvement, and comprehensive screenings, including ultrasounds and chromosomal microarray, were normal."
  },
  {
    "id": "multiclinsum_gs_en_369.txt",
    "fulltext": "We present a case of CAF between the proximal LAD and the PA trunk, causing a “steal phenomenon” to distal LAD territory. Given the rare occurrence of this fistulae type, the clinical presentation is exceptional in this variant, causing a significant shunt from the LAD territory, which resulted in daily cardiac ischemic chest pain.\n\nA 57 years old female, with Type 2 DM, presented to consultation complaining of typical anginal chest pain for 2 years. Anginal episodes were related to physical activity and occasionally at rest, had variable duration and were associated with dyspnea and dizziness. During the last 6 months, symptoms progressed to become daily despite optimal medical treatment. Physical examination was unremarkable. Electrocardiogram showed normal sinus rhythm and no ST changes, Trans-thoracic echocardiogram, on Doppler analysis, revealed a small jet flow in the main pulmonary trunk without definite identification of its source. We decided to proceed to a nuclear stress test to confirm ischemic heart disease. The test revealed an antero-apical wall defect, along with normal left systolic function. Coronary Angiogram demonstrated the tortuous and dilated LAD to PA CAF, and of notice, a significant decrease in the caliber of the LAD distal to fistula take off, as an indirect sign of an ongoing “steal phenomenon”. LAD proximal to fistulae take off, was dilated. According to Sakakibara fistulae classification, this patient had a Type A fistulae.\n\nThese types of fistulae are typically complex and large, and may have a high flow. 3-D CCTA was performed, which confirmed the isolated aberrant branch (fistula), taking off from the LAD at 0.4 cm distal to first diagonal branch, which communicated with the left anterior surface of the pulmonary trunk. The fistula was very tortuous and measured 9.96 cm in length.\n\nBecause of the anatomical location and characteristics, the tortuosity of the trajectory, the caliber of the fistula, and the severity of the symptoms, surgical closure was decided.\n\nThe operation was performed through a standard median sternotomy, on a beating heart, OFF-PUMP.\n\nThe fistula was clearly identified on the surface of the right ventricle reaching the proximal portion of the main pulmonary trunk above the pulmonary valve. The aspect of the fistula vessel wall, although of good caliber, looked very friable and easy to be ruptured on a beating heart. So, dissection and surgical clip closure was discarded. Instead, the fistula was closed using several stitches of 5/0 polypropylene with pledgets. Additional 5/0 stiches were placed on small branches running on surface of the main PA, suspicious of being branches or collaterals from the main fistula trunk. One fine branch running over RVOT was left intact, believed to be a branch of the RCA supplying the RVOT, visualized in the Coronary angiography.\n\nLAD was not identified at the level of the sutures, due to its intramuscular location, but close observation of the monitor for the presence of transient ECG changes, and the anterior/septal wall motion during the procedure, precluded any accidental inclusion of LAD in the stitches. Postoperative outcome was uneventful, with no perioperative MI or other complications. The patient was discharged on the fourth post-operative day. She is currently pain free and with no dyspnea after 5 months of follow up.",
    "summary": "We present a 57 years old female with a large LAD to PA fistulae. Given the rare occurrence and the predominance of low shunt of LAD to PA CAF, this case is functionally exceptional in this fistulae variant, causing a significant shunt which resulted in daily cardiac ischemic chest pain. Diagnosis work up included a nuclear stress test, Coronary Angiography and 3-D Coronary Computed Tomography Angiogram (CCTA). Traditionally, surgery has been the main therapy for symptomatic CAF, but transcatheter closure has emerged as a less invasive strategy and is a valuable alternative or even preferable if no associated cardiac conditions are present, provided the anatomical characteristics of the fistulae are appropriate. The surgical approach includes off pump epicardial interruption of the fistula or closure through a cardiac chamber (trans-cameral) or transpulmonary, or epicardial closure using Cardiopulmonary bypass. Caution must be taken in cases of CAF with Coronary Artery (CA) aneurysm in dominant CA, or drainage into the Coronary Sinus, as the possibility of ischemic complications are higher. Due to anatomical considerations and tortuosity of the fistulae, our patient was considered not amenable for percutaneous closure and surgery was opted. Epicardial closure of the fistula was performed on a beating heart, off pump. Outcome was favorable with complete resolution of ischemic symptoms."
  },
  {
    "id": "multiclinsum_gs_en_475.txt",
    "fulltext": "The patient was a 75-year-old Chinese woman who was a farmer from Yongzhou City, Hunan Province, China. A total of 2 months prior, the patient presented with symptoms of dizziness, poor appetite, poor sleep, and weakness in the limbs without any obvious cause. The patient gradually worsened and was diagnosed with chronic atrophic gastritis with Helicobacter pylori (Hp) positivity, hypoproteinemia, and IDA. Moreover, left atrial enlargement and left ventricular diastolic dysfunction were diagnosed via echocardiography.\n\nThe results of routine blood tests were as follows: a red blood cell (RBC) count of 1.84 × 1012/L, hematocrit level of 13%, platelet count of 500 × 109/L, hemoglobin level of 35 g/L (critical value), mean corpuscular volume of 70.7 fL, total protein level of 44.6 g/L, eosinophil ratio of 5.3%, erythrocyte sedimentation rate of 25 mm/h, immunoglobulin (Ig)E level of 1282.2 IU/ml, serum Fe level of 3.85 μmol/L, and positive fecal occult blood test result. Her bone marrow cytomorphologic examination revealed active proliferation of the granulocyte, megakaryocyte, and myeloid cell series. A flow cytometry examination did not indicate the abnormal immunophenotypes indicative of acute leukemia, MDS, lymphoma, or myeloid tumors. Gastrointestinal endoscopy showed live nematodes in the descending portion of the patient’s duodenum. The patient was treated with leukocyte-reduced red blood cells to correct severe anemia and the antihelminthic albendazole. After treatment, her hemoglobin level was confirmed to be 77 g/L. During follow-up visits, the patient successfully underwent antihelminthic treatment, and her anemia was cured.\n\nImaging and morphological examination\nTo rule out gastrointestinal disease, the patient underwent gastrointestinal endoscopy. Live nematodes were discovered feeding on the mucosa of the descending portion of the patient’s duodenum. Hookworm eggs were found in the stool via saturated brine flotation. Therefore, the patient ultimately was diagnosed with severe IDA caused by hookworm infection.",
    "summary": "A 75-year-old Chinese woman who presented with dizziness, poor appetite, poor sleep, and weakness in her limbs was diagnosed with chronic atrophic gastritis and was positive for Helicobacter pylori, iron deficiency anemia with a hemoglobin concentration of 35 g/L, and left atrial enlargement. However, after symptomatic treatment, the patient did not improve. Upper gastrointestinal endoscopy revealed the presence of live nematodes in the descending portion of the patient’s duodenum. Fecal examination via saturated brine flotation revealed hookworm eggs. Further verification via semi-nested reverse transcription-polymerase chain reaction assay confirmed provided confirmation that the hookworm species was Necator americanus. Albendazole was used for antihelminthic treatment. Through follow-up visits, we found that the antihelminthic treatment was successful and that her anemia was cured."
  },
  {
    "id": "multiclinsum_gs_en_169.txt",
    "fulltext": "A 15-year-old male patient (height = 161 cm; weight = 66 kg; body surface area = 1.70, blood group = B positive) with dilated cardiomyopathy was referred to Ankara University with loss of consciousness and cardiogenic shock in July 2016. Venoarterial extracorporeal membrane oxygenation support was conducted about 1 week later. His left ventricular ejection fraction was 22%. Eight days later, the patient received SynCardia total artificial heart implant (50 mL; SynCardia Systems, Inc., Tucson, AZ, USA). On postoperative day 131 after TAH surgery, the patient complained of bilateral hearing loss and was referred to the ear, nose, and throat department.\n\nPrevious medical history revealed no evidence of hearing loss, family history of deafness, or any additional anomaly in his childhood. His medical records revealed no evidence of meningitis. However, he had received amikacin (15 mg/kg), an ototoxic antibiotic, against major gram-negative pathogens during his intensive care unit stay. The patient was listed on the high urgent heart transplant wait list and was mobile on the portable Freedom Driver (SynCardia).\n\nThe patient’s otoscopic examination was unre­markable. Pure tone audiometry and auditory brainstem response revealed bilateral profound hearing loss. Tympanometry revealed normal type A tympanograms bilaterally. Both computed tomo­graphy and magnetic resonance imaging confirmed normal morphology of the labyrinth and intact cochlear nerves.\n\nHe was reviewed by a multidisciplinary team (cardiovascular surgery, pediatric intensive care, pediatric cardiology, consultation-liaison psychiatry, physical therapy and rehabilitation, infectious diseases and clinical microbiology, anesthesiology, audiology, and otorhinolaryngology) to perform a cochlear implant. After possible options were discussed with both the patient and his parents, it was then decided that he would benefit from a cochlear implantation because of hearing loss and reduction in cognitive function and adaptation needed for heart transplant. After a discussion of his case with the multidisciplinary team, a right-sided cochlear implant (Nucleus CI24RE with Contour Advance Electrode; Cochlear, Macquarie University, Australia) was decided.\n\nThe patient was on warfarin (10 mg/day), which was stopped 3 days before the surgery, and heparinization (loading dose of 50 U/kg and maintenance dose of 20 U/kg/h) was commenced when prothrombin time (international normalized ratio [INR]) was under 1.5. Two hours before surgery, heparinization was stopped. In the operating room, a spare device was available for a possible TAH device malfunction. Flow results for the TAH were closely monitored by the anesthesiology team and the perfusionist. Nonpulsatile blood flow unfavorably affects the monitoring of vital signs, and noninvasive blood pressure was not sufficient in our patient. Under local anesthesia, invasive radial arterial catheterization was performed. In addition, the left internal jugular vein catheter was left in place, which allowed monitoring of central venous pressure and use as large fluid replacement when needed. After monitoring was started, propofol 2 mg/kg, rocuronium bromide 1 mg/kg, and fentanyl 1 μg/kg were administered cautiously, and the patient was intubated orally. Sevoflurane 1 to 1.5 minimum alveolar concentration in 40% oxygen was used for maintenance. Inhaled nitric oxide was also ready to use in case of possible pulmonary hypertensive crisis.\n\nOn postoperative day 250 after TAH implant, cochlear implant surgery with round window approach was performed without any perioperative complications; the patient had minimal blood loss (only 50 mL). The duration of the operation was 120 minutes. The patient was extubated in the operating room without any circulatory and respiratory problems. Heparinization was commenced at posto­perative hour 6. We started warfarin on postoperative day 1, and heparinization was stopped after achieving INR of 2.0. No complications (infections, hematoma) were observed at postoperative follow-up.\n\nThe cochlear implant was switched on at week 4 postoperatively. The audiology team reviewed him 4 and 8 weeks later; he showed continuous impro­vement in his hearing, with normal impedances. His speech perception results were significantly impro­ved at 3 months after cochlear implant.",
    "summary": "We report a case of 15-year-old boy with postlingual bilateral total hearing loss following ototoxic medication during his pediatric intensive care unit stay. The patient received the SynCardia total artificial heart implant (50 mL; SynCardia Systems, Inc., Tucson, AZ, USA) for end-stage biventricular heart failure as a bridge to heart transplant. During his time on the urgent heart transplant wait list, he underwent successful cochlear implantation following optimized coagulation and hemostasis status and appropriate anesthetic preparation. "
  },
  {
    "id": "multiclinsum_gs_en_516.txt",
    "fulltext": "A 20-year-old male working as a farmer, free of past medical and surgical history was admitted to the emergency department complaining of severe colic pain in nature in the right flank region, radiating to the surrounding area and groin. The pain is associated with high-grade fever and recurrent vomiting. He reported painless hematuria, fever, and flu-like symptoms 2 weeks before admission to the hospital. Fever and flu-like symptoms had been treated with the use of analgesia. He had no previous history of urinary stone disease or urinary tract infections. Physical examination showed tenderness in the right groin and positive right costovertebral angle tenderness, otherwise, it was normal. A complete blood count test, urinalysis, stool analysis, and abdominal ultrasound were performed. Laboratory analysis showed moderate leucocytosis of 20 000/mm3 (normal range: 4.5-11 × 103/mm3), relative neutrophilia, and relative lymphopenia. The serum creatinine was normal. Urinalysis showed +3 hematuria and calcium oxalate crystals. The stool analysis showed Entamoeba histolytica present, with no ova or worms detected, and the rest of the stool analysis was normal. Abdominal ultrasound showed a hyperechoic cylindrical structure measuring 6 mm in diameter and 6 cm in length in the distal part of the right ureter involving the ureterovesical junction (UVJ) associated with minimal right-sided hydronephrosis and a mild increase in the echogenicity of the right kidney. There is no definite renal stone; otherwise, both kidneys are normal in size, site, and shape. Doppler imaging was not performed.\n\nHe was hospitalized in the urology department; conservative treatment was initially pursued. A contrast CT scan was done, which showed a 6-cm tubular-shaped structure (a foreign body) located at the distal ureter about 2.5 cm inside the bladder. The structure shows soft tissue density in the wall and fluid density in the inner aspect, causing minimal right-sided hydroureteronephrosis. An axial image at the level of the distal part of the right ureter shows a dilated ureter and rounded filling defect representing the obstructing parasite. Axial CT image at the level of UVJ at 10 min delay phase showing the parasite partially passing through the vesicoureteral junction. Otherwise, the right kidney is normal in size, echotexture, and cortical thickness with no stones or masses. There is no evidence of a fistula between the gastrointestinal and urinary tract.\n\nA ureteroscopy was performed at the hospital. During the procedure, a 6-mm wax-like structure was discovered in the distal third of the right ureter, accompanied by a significant amount of pus. Additionally, a polyp-like projection was observed within the ureteroscope view. The extracted object measured 6 cm in length, had a brown colouration, was not moving structure, and displayed a tight elastic consistency. To facilitate pus drainage, a Double J (ureteral stenting) was inserted. Subsequently, the dead specimen underwent pathological review, identifying it as A lumbricoides. The patient received a 400 mg albendazole tablet once daily for 3 days and experienced an uneventful recovery.",
    "summary": "In this report, we present a case of a 20-year-old male who arrived at the emergency room with severe right flank pain, high-grade fever, and recurrent vomiting. Diagnostic evaluations were conducted, including a complete blood count test, urinalysis, stool analysis, abdominal ultrasound, and CT scan. The final diagnosis was A lumbricoides found in the distal part of the ureter. A ureteroscopy procedure confirmed the diagnosis and extracted the worm, which measured 6 cm in length, had a brown colour, and exhibited a tight elastic consistency."
  },
  {
    "id": "multiclinsum_gs_en_183.txt",
    "fulltext": "A 90-year-old female with hepatitis C and a 60-year smoking history from a rural area presented with swelling on the posteromedial aspect of the left thigh just above the knee. The swelling was first noticed 3 years ago and gradually increased in size over this period. She felt mild discomfort but denies any associated symptoms of pain, itching, discharge, fever, or joint immobility. As she was from a rural area she also had a history of animal exposure.\nOn physical examination, the swelling was 14 × 10 spherical in shape, firm, fixed, and nontender with well-defined margins seen on the posteromedial aspect of the left thigh just above the knee. The overlying skin was pinchable and showed prominent veins, and the temperature was comparable to the surrounding skin.\nUltrasound revealed a large cystic lesion with several small cysts inside it measuring 13.2 × 11 × 13.6 cm and a volume of 1046 ml. It was arising from the left knee joint and was extending into mid-thigh. Color Doppler showed no vascularity inside it. MRI was done and showed a large cystic lesion (21 × 9.9 × 8.1 cm) with multiple small scattered lesions with both intramuscular and intermuscular extension involving adductor longus and gracilis medially and bicep femoris posteriorly. All these features were suggestive of a hydatid cyst. The diagnosis was confirmed by a hemagglutination test for Echinococcus. X-ray chest and ultrasound of the abdomen were normal.\nSurgical excision of the cystic swelling was planned, and an S-shaped incision was made on the skin, followed by careful dissection through the subcutaneous tissue to access the cyst. The lesion was well-defined within the inter- and intramuscular planes. Meticulous dissection was performed to isolate and remove the cyst intact, ensuring no spillage of its contents. To minimize the risk of contamination, the surgical site was thoroughly irrigated with normal saline following excision.\nIntraoperative findings revealed a large intermuscular cystic swelling measuring 22 × 14 cm, involving the posterior and medial compartments of the left thigh. The cyst demonstrated intramuscular extension into the adductor longus and gracilis medially and the biceps femoris posteriorly, extending up to the popliteal fossa. Notably, there was no communication between the cyst and the knee joint. A biopsy sent to the lab further confirmed the diagnosis. Histopathological examination of the excised specimen revealed a fibrocollagenous cyst wall lined by attenuated epithelium with inflammatory infiltration. The presence of focal keratinous material further characterized the lesion. These findings, along with gross features, favored the diagnosis of a hydatid cyst. The postoperative course was uncomplicated and the patient was discharged with anthelminthic therapy for six weeks. Follow-up visits were scheduled at one week, three weeks, six weeks, nine weeks, and twelve weeks. During these visits, the patient showed no signs of recurrence or complications.",
    "summary": "A 90-year-old female from a rural area presented with a slow-growing swelling on the posteromedial thigh for three years. She had no history of trauma or systemic symptoms. Clinical examination revealed a firm, non-tender mass. Imaging suggested a cystic lesion, and serology confirmed Echinococcus infection. Surgical excision was performed, and histopathology confirmed a hydatid cyst. The patient received a six-week course of albendazole postoperatively. Her recovery was uneventful, with no recurrence at follow-up."
  },
  {
    "id": "multiclinsum_gs_en_67.txt",
    "fulltext": "A 5-year-old girl was admitted to the paediatric emergency room (ER) of our hospital due to a reported episode of vomiting during her sleep, followed by central cyanosis perorally of short duration (<5′). She also experienced a sudden rightward turn of her head and gaze fixation with right eye deviation. Additionally, urinary and faecal incontinence were observed. After the episode, the patient appeared drowsy. It was noted that she had a similar episode approximately one year prior.\n\nOur patient was admitted to the paediatric department for further investigation. Laboratory screening (haematological and general biochemical examinations), electrocardiogram (ECG) monitoring, and ophthalmological assessment with fundoscopy took place.\n\nConsidering the patient’s medical history, the suspicion of SeLEAS arose as a potential diagnosis for her episodes. After a one-day hospitalization without any recurrence of symptoms, the patient was discharged, with the recommendation of neurological assessment by a paediatric neurologist and EEG evaluation.\n\nAbout a month later, the patient experienced a similar episode and was subsequently readmitted to the paediatric ER, this time at a tertiary health unit. Further investigations, including an EEG, were carried out.\n\nThe EEG revealed pathologic paroxysmal abnormalities of high-amplitude sharp waves and spike-wave complexes in temporal-occipital areas of the left hemisphere, followed by enhancement of focal abnormalities in temporal-occipital areas of the left hemisphere during sleep.\n\nBased on the EEG findings, our first hypothesis was confirmed, and the patient was diagnosed with SeLEAS and started levetiracetam as prophylactic therapy.",
    "summary": "A 5-year-old girl was admitted to the paediatric emergency room (ER) of our hospital due to a reported episode of vomiting during her sleep, followed by central cyanosis perorally of sort duration (<5'), a right turn of her head, and gaze fixation with right eye deviation. She was dismissed after a one-day hospitalization free of symptoms. A month later, the patient was admitted to the paediatric ER of a tertiary health unit due to a similar episode. The patient underwent EEG, which revealed pathologic paroxysmal abnormalities of high-amplitude sharp waves and spike-wave complexes in temporal-occipital areas of the left hemisphere, followed by enhancement of focal abnormalities in temporal-occipital areas of the left hemisphere during sleep. The patient was diagnosed with SeLEAS and started levetiracetam."
  },
  {
    "id": "multiclinsum_gs_en_427.txt",
    "fulltext": "A 4-year-old male diagnosed with juvenile myelomonocytic leukemia is undergoing chemotherapy with vincristine, cytarabine, and etoposide. He presented to the emergency room with a 2-day history of fever, hypotension, and pruritic lesions on his inner thighs, which progressively spread to cover his entire body surface. Physical examination revealed multiple erythematous papules, some non-responsive to acupressure. On the elbows and knees, they formed large purple plaques, with few papules on the soles and palms and no oral mucosal involvement. Additionally, facial edema was noted. The patient was hospitalized 15 days prior for severe thrombocytopenia (platelets <6,000) and received a platelet transfusion. He was subsequently diagnosed with juvenile myelomonocytic leukemia and started chemotherapy 10 days before admission.\n\nThe patient's diagnostic tests revealed significant abnormalities in the blood count: white blood cell count of 1,100, with an absolute neutrophil count of 50, absolute lymphocyte count of 840, absolute monocyte count of 150, and absolute eosinophil count of 50. Hemoglobin level was measured at 7.6 g/dL, hematocrit at 22.8%, and platelet count at 23,000 per microliter. Additionally, the C-reactive protein level was elevated at 2.67 mg/L. Liver function tests returned within normal ranges, as did the lactate dehydrogenase test, which showed a value of 245 U/L.\n\nBased on the low-output clinical symptoms, it was decided to start volume expansion with crystalloids and to initiate intravenous immunoglobulin support. In addition, albumin replacement associated with diuretic infusion was started, in search of physiological dialysis. With worsening symptoms and suspicion of a hypersensitivity reaction, a biopsy of the skin lesions was taken for histopathological study. The dermatopathological changes observed were hyperkeratosis, focal parakeratosis, acanthosis with slight spongiosis, and frequent intraepithelial dyskeratotic cells, and there was involvement of the dermis by perivascular lymphoid infiltrates with abundant eosinophils. In addition, eosinophils permeated the acrosyringium, eccrine ducts, and epithelium. This skin biopsy report was compatible with drug-induced toxicoderma. According to the RegiSCAR scale for DRESS, the total score is 5, which classifies it as a probable case.\n\nWith the definitive diagnosis and given the continued progression of the lesions and lack of response to immunoglobulin, bolus methylprednisolone (30 mg/kg per day) was started. Five doses were administered without clinical relapses. After 2 days, the patient showed a better hemodynamic evolution, though with initial progress of the extension and intensity of cutaneous erythematous involvement, which resolved during the week. Given the patient's progression, a modification of the chemotherapeutic regimen is undertaken, with mercaptopurine being administered.\n\nFinally, the management of this syndrome involves early elimination of the causative agent and treatment with antihistamines in their mild form, corticosteroids in their moderate form, and plasmapheresis in the more severe forms. Healthcare professionals should be more attentive to the early manifestations of this syndrome, as early diagnosis and treatment improve outcomes significantly.",
    "summary": "We present a case of a 4-year-old male patient who started chemotherapy with vincristine, cytarabine, and etoposide. The first clinical signs were fever, hemodynamic in-stability, and maculopapular erythema. Biopsies of skin lesions were taken, and hyperkeratosis, focal parakeratosis, acanthosis with slight spongiosis, and intraepithelial dyskeratotic cells were observed. There was a perivascular lymphoid infiltrate with abundant eosinophils in the dermis, and eosinophil permeations to the acrosyringium and epithelium were found."
  },
  {
    "id": "multiclinsum_gs_en_323.txt",
    "fulltext": "Here, we report on a 57-year-old patient who presented with pruritic erythematous plaques on the sides of the fingers and toes in 2008. From 2010, skin-colored papules emerged on the entire integument, including the face.\n\nConcurrently, the patient was diagnosed with MGUS, specifically IgG kappa type, in 2011. He developed renal insufficiency necessitating hemodialysis in January 2012, attributed to histologically evident nephrosclerosis. Since then, the patient underwent hemodialysis three times per week and has unfortunately required multiple shunt revisions due to decreased flow. His renal condition further led to poorly controlled hypertension and consecutive loss of visual function due to hypertensive retinopathy.\n\nUpon initial assessment at our dermatology department in August 2012, significant skin induration with a notable restriction of mouth and eye opening, eyelash loss, and ectropion was observed. Based on clinical and histological findings, diagnosis of scleromyxedema was confirmed. The patient’s skin condition failed to respond to topical steroids and PUVA treatment. Consequently, immunosuppressive therapy with prednisolone 100 mg/day was initiated, but turned out to be ineffective.\n\nGiven the limited options for additional immunosuppression in the context of dialysis-dependent renal insufficiency, high-dose IVIg was the treatment of choice. Due to preexisting renal insufficiency, a sugar-free IVIg preparation (Intratect® 100 g/L with a dose of 2 g/kgbw distributed over 2 days every 4 weeks) was chosen and initiated in February 2013. Concerning further treatment, several factors had to be considered. Since high-dose IVIg therapy is associated with a relative increase in blood viscosity, frequently leading to headaches and other adverse effects, both the daily dose (distribution of the dose over 3–5 consecutive days) and the infusion rate should be reduced to the lowest feasible level in patients with renal impairment or those prone to thromboembolic adverse reactions. Notably, in the herein presented case, the scheduling of IVIg intervals was particularly restricted due to the fixed dialysis intervals and the psychological strain of continuous hospitalization endured by the patient. Administering IVIg doses over more than 2 days was not possible due to the 3-days-a-week dialysis regimen and was also refused by the patient. Nonetheless, the infusion rate was reduced to the practical minimum of 1.6 mL/kgbwh. Fortunately, IVIg quickly resulted in a notable improvement of the patient’s skin and overall well-being.\n\nFurther on, the patient experienced syncopal episodes and was diagnosed with AV-block III, subsequently undergoing pacemaker implantation. The development of multiple basal cell carcinomas and other rare skin tumors such as trichoepitheliomas required multiple surgical interventions. Hence, kidney transplantation due to renal insufficiency was precluded. Due to persistent disease activity, progression of skin lesions and elevated intraocular pressure IVIg Intratect® intervals were reduced to 2 g/kgbw over 2 days every 3 weeks in March 2020, resulting in disease stabilization.\n\nNevertheless, the patient reported headaches, lethargy, and fatigue following Intratect® administration lasting up to 1 week. Experiencing fever, chills, and malaise for 3 days following each cycle of Intratect® had the most pronounced impact on quality of life. Hence, in September 2023, the patient was transitioned to the novel sugar-free IVIg preparation Yimmugo® (Yimmugo 100 g/L; Biotest AG; 2 g/kgbw distributed over 2 days every 3 weeks). After the first infusions, the patient reported fewer side effects with Yimmugo® compared to Intratect®, experiencing reduced fatigue and fewer headaches, resulting in increased productivity following IVIg administration. This was accompanied by ongoing clinical remission of scleromyxedema lesions. In November 2023, shunt thrombosis was detected during dialysis, which led to the initiation of anticoagulation therapy without the necessity of surgical intervention thus far.",
    "summary": "We present the case of a 57-year-old patient with scleromyxedema and monoclonal gammopathy with end-stage renal failure on hemodialysis (3 times a week). Stabilization of skin symptoms was finally achieved by high-dose IVIg therapy administered at 2 g per kg bodyweight distributed over 2 days every 3 weeks. However, disease stabilization came at the expense of flu-like side effects that significantly affected daily life. After transitioning to Yimmugo®, the patient reported an improved quality of life."
  },
  {
    "id": "multiclinsum_gs_en_165.txt",
    "fulltext": "A 7-year-old girl was found to have decreased visual acuity in her left eye during a school checkup. Subsequently, she visited her local clinic, where an ERM was observed in her left eye, leading to a referral to our department for further investigation and treatment. Her medical and family histories were unremarkable. She was born weighing 3,710 g, with a gestational age of 40 weeks and 1 day. At her initial visit, the best-corrected visual acuity was recorded as 20/16 in the right eye and 20/32 in the left eye. The anterior segment and optic media were normal, and intraocular pressure was measured at 12 mm Hg in both eyes. Fundus examination of both eyes revealed straight vessels and an avascular field on the temporal side. Additionally, the left eye exhibited exudative changes and hemorrhage in the temporal peripheral retina, along with membranous tissue extending from the optic disc to the macula and around the periphery. Fluorescein angiography indicated an avascular field temporally in both eyes and fluorescein leakage in the left eye’s avascular field during the late phase, suggesting the presence of an active fibrovascular proliferation in these area. Examination of the mother’s fundus showed straight vessels in the temporal retina and avascular areas in the peripheral retina of both eyes. Based on these clinical findings, the patient was diagnosed with FEVR. Fundus examinations of the father and brother showed no abnormalities. A comprehensive examination by a pediatrician revealed no general abnormalities. At her first visit to our hospital, the FT was found to be strongly adhered to the macula, forming an ERM, with an abnormal layered vitreous cortex observed between the FT and the retina. OCT examination revealed ectopic inner foveal layers, absence of the foveal depression, a wrinkled macula, and thickening of the outer nuclear layer (ONL). Six months before symptom onset, the visual acuity of the left eye was 20/20, as recorded by a local doctor. Retrospective OCT analysis showed no ERM but identified foveal hypoplasia (extrusion of plexiform layers) in the left eye.\n\nEncircling scleral buckling and retinal photocoagulation were performed to alleviate macular traction. Photocoagulation was performed as close as possible to the areas that were hyperfluorescent on fluorescein angiography. However, OCT revealed that the FT on the macula was adhering vertically and afferently and further rose from the retina. This resulted in increased retinal traction and thickening of the ONL, resulting in a decrease in visual acuity to 20/50.\n\nOne year and six months later, a vitrectomy was performed to excise the FT from the macula. During the procedure, multiple layers of the hyaloid membrane were noted, along with the extension of FT along these layers. Strong adhesions were present on the macula and optic disc. Given the absence of posterior vitreous detachment (PVD) and the strong adhesion of the posterior hyaline membrane to the surrounding retina, a PVD was initiated from the optic disc toward the equator. Within the FT, a single blood vessel was identified, but the majority of the FT, which was fibrous, adhered firmly to the retina. The FT was carefully detached using forceps from areas outside the vascular arcade where the retinal adhesion was less intense. A fundus examination post-surgery revealed the alleviation of macular traction without surgical complications and the visual acuity reached 20/20 at 6 months postoperatively. On OCT, the FT was removed, and the appearance of a foveal depression and normalization of the ONL were observed; however, an ectopic inner foveal layer was still present 3 months after the surgery.",
    "summary": "A 7-year-old girl presented with the chief complaint of decreased visual acuity in the left eye during a school examination. Fundus examination revealed retinal folds with FT extending from the peripheral retina to the posterior pole of the left eye. Despite interventions such as retinal photocoagulation and encircling buckling aimed at reducing the traction on the macula, OCT revealed persistent deep retinal folds and a thickened outer nuclear layer (ONL), indicating gradually increasing macular traction, which contributed to vision loss. A subsequent vitrectomy alleviated the macular traction, enhanced the retinal morphology, and reduced ONL thickening regardless of persistent ectopic inner foveal layers."
  },
  {
    "id": "multiclinsum_gs_en_113.txt",
    "fulltext": "A 71-year-old man hospitalized at another hospital for heart failure with a history of heart failure admission several times was transferred to our hospital for the further evaluation and treatment of refractory heart failure. Although he was suspected of having cardiac amyloidosis in the previous hospital, a diagnosis was not made.\n\nAt admission to our hospital, he received oral medications including many types of diuretics, but he still had dyspnea with an NYHA functional class IV. His blood pressure was 106/70 mmHg, and the third heart sound was audible at the apex. Congested jugular veins were observed, but no peripheral edema was found. Chest X-ray showed a high cardiothoracic ratio of 61% with bilateral pleural effusion. Electrocardiographic findings were a heart rate of 65/min with atrial fibrillation, intraventricular conduction delay and left-axis deviation. Transthoracic echocardiography revealed diffuse left ventricular (LV) hypertrophy with increased wall thickness of 12 mm, mild hypokinetic LV wall motion (ejection fraction=43%), increased right ventricular (RV) wall thickness of 7 mm with a reduced RV systolic function, and biatrial dilatation. Speckle-tracking echocardiography showed an ‘apical sparing’ pattern of longitudinal strain. He had abnormal laboratory test results showing a high brain natriuretic peptide (BNP) level (1,186 pg/mL) and elevated high-sensitivity cardiac troponin T level (0.057 ng/mL). 99mTechnetium pyrophosphate (99mTc-PYP) scintigraphy revealed a grade 3 cardiac uptake on SPECT/CT fusion imaging. Bence-Jones protein was not detectable, and the ratio of free light chain κ/λ was normal. Later, we performed an endomyocardial biopsy and genetic analysis, and we finally made a diagnosis of ATTRwt.\n\nWith regard to the management of heart failure, we tried to control his heart failure with oxygen therapy and medical management including intravenous injection of furosemide, but he still had dyspnea with persistent general fatigue, and his level of bilirubin increased. Right-heart catheterization (RHC) showed a high pulmonary artery wedge pressure and pulmonary hypertension and a low cardiac index of 1.37 L/min/m2 (thermodilution) with a right atrial mean pressure of 8 mmHg.\n\nBased on these results, we started dobutamine infusion at 2 μg/kg/min for his low cardiac output. His symptoms improved significantly with improvement of creatinine and bilirubin levels. Six days later, we administered pimobendan in order to taper off the dobutamine infusion. During the treatment course, he was basically stable except for temporary deterioration of heart failure due to influenza. After one month of medical therapy and cardiac rehabilitation while admitted, dobutamine infusion was terminated, and RHC showed a dramatic improvement in his hemodynamic status. Since his hospital discharge, his condition has remained stable without deterioration of heart failure or arrhythmias for six months.",
    "summary": "We treated a 71-year-old man with refractory heart failure due to ATTRwt. He was expected to be dependent on dobutamine infusion. We administered pimobendan and successfully improved his symptoms and hemodynamic status to allow his discharge from the hospital. An additional retrospective investigation observed that there were eight patients with ATTR amyloidosis who were administered pimobendan. Although all of the patients at the time of administration of pimobendan were NYHA class III or IV with repeated hospitalization for heart failure, pimobendan seemed to be effective for improving symptoms and enabling patients to be discharged and receive outpatient medical care. Furthermore, focusing on the changes in some biomarkers, we found that the brain natriuretic peptide and estimated glomerular filtration rate values improved after the administration of pimobendan in 5 consecutive patients for whom data were available without additional treatment (p=0.018 and 0.051, respectively)."
  },
  {
    "id": "multiclinsum_gs_en_421.txt",
    "fulltext": "A four-day old male infant born at 39 4/7 weeks’ gestation presents to an emergency department (ED) with worsening respiratory distress and stridor exacerbated by feeding and supine positioning.\n\nHe was born to a 31-year-old G2P2 mother with serologies significant for positive indirect Coomb’s test via an uncomplicated vaginal delivery with APGARs of eight and nine at one and 5 min, respectively. His birth weight was 3,050 g. Fetal ultrasound demonstrated concern for intracardiac focus, with an otherwise uncomplicated pregnancy. Nursery course was significant only for a failed hearing screen bilaterally and normal echocardiogram. The infant was discharged home on day of life two. He was noted to have nasal congestion at time of discharge. Family was instructed to suction his nose and use saline drops as needed.\n\nOn day of life four, the infant’s mother noted stridor associated with difficulty feeding and is directed to the ED by the pediatrician. Examination in the ED is significant for high-pitched, inspiratory stridor with tracheal tugging and subcostal retractions. Additionally, he is noted to have pectus excavatum. The stridor and increased work of breathing improve with prone or side lying positioning. Laboratory evaluation is significant for respiratory acidosis on venous blood gas [pH 7.18 and CO2 73 mmHg (9,732 Pa)] and urinalysis that reveals moderate bacteria and 11–20 white blood cells without the presence of urine nitrite or leukocyte esterase. A complete blood count is reassuring. He is placed on high flow nasal cannula and initiated on ampicillin and gentamicin after obtaining blood cultures.\n\nHe is escalated to continuous positive airway pressure (CPAP) and transferred to a level III neonatal intensive care unit (NICU) for further management and otolaryngology evaluation. A nasogastric tube was passed through bilateral nares without difficulty. Flexible laryngoscopy showed an immobile left vocal cord and narrow nasal cavities with edema of nasal turbinates, bilateral arytenoids, and vocal cords. Bronchoscopy did not reveal any further abnormalities. Further physical exam was notable for subtle dysmorphic features including low set ears, retromicrognathia, microphthalmia, and clinodactyly of toes. Empiric antibiotics were discontinued following reassuring infectious work-up. A multidisciplinary team was consulted.\n\nThe patient eventually required intubation at two weeks of life due to worsening respiratory failure. Nasal Ciprofloxacin and Dexamethasone were administered for upper airway edema. An MRI of the brain, neck, and chest showed a normal course of the recurrent laryngeal nerves. Genetics evaluation included a normal chromosomal microarray analysis (CMA). Further gene panel testing was positive for pathogenic variant in CHD7 gene, consistent with CHARGE syndrome. In this case, VFP was attributed to known association with CHARGE syndrome. Continued evaluation revealed further features consistent with CHARGE syndrome including bilateral colobomas, glaucoma, confirmed hearing loss, and genital abnormalities.\n\nRepeat bronchoscopy on day of life 42 demonstrated improvement in overall laryngeal edema but continued mild edema of bilateral vocal cords. The patient was extubated post-bronchoscopy in the setting of improved airway edema. However, he was subsequently reintubated on day of life 46 due to worsening respiratory failure. Repeat laryngoscopy that day had shown continued edema. At this point, the patient had already received multiple short courses of Dexamethasone in an attempt to decrease the airway edema. Due to the need for reintubation, he was treated with topical Tobramycin and Dexamethasone applied directly to vocal cords via direct laryngoscopy for five days. Following this treatment, he was successfully extubated at two months old and underwent gastrostomy tube placement at three months.\n\nAt the time of gastrotomy tube placement, he underwent an additional bronchoscopy and microlaryngoscopy which demonstrated the originally affected left vocal cord was fully mobile but showed new immobility of right cord; the etiology of this is unclear. Both vocal folds were mildly edematous still but much improved from prior evaluation. Patient was discharged in room air at age four months and continues to follow closely with otolaryngology. On repeat outpatient laryngoscopy at four months of age, both cords appeared mobile with continued airway edema.\n\n",
    "summary": "A four-day old, full-term, male infant born via uncomplicated vaginal delivery with a nursery course significant for failed hearing screen presented to an emergency department (ED) with respiratory distress and worsening stridor. He was transferred to a level III neonatal intensive care unit (NICU) for further evaluation and required intubation due to progressive hypercarbia. Laryngoscopy revealed left-sided unilateral vocal fold paralysis (VFP). He underwent further evaluation that included a normal MRI brain, neck and chest. Genetics was consulted with concern for dysmorphic features on physical exam. Following gene panel testing, VFP was attributed to known association with CHARGE syndrome. Airway edema was noted on laryngoscopy that prevented extubation until two months of age. Further features of CHARGE syndrome identified included colobomas, glaucoma, sensorineural hearing loss, and genital abnormalities. He was discharged in room air and following gastrostomy tube placement with otolaryngology follow up."
  },
  {
    "id": "multiclinsum_gs_en_14.txt",
    "fulltext": "A 40-year-old Iranian woman presented to a primary care office complaining of electric shock-like sensations in her head that had started 2 days earlier. These sensations were exacerbated by neck flexion. The patient described previous self-resolving episodes of similar, though less severe, symptoms. She reported no other symptoms. Her physical exam, including neurological assessments such as visual field, position sense, vibration, and Romberg’s sign, was normal. Her medical history included hypothyroidism, fibromyalgia, and iron deficiency anemia. She was taking levothyroxine 100 µg orally once daily, duloxetine 30 mg orally once daily, and ferrous glycine sulfate 400 mg daily [equivalent to 80 mg Fe(II)] orally.\n\nWhile investigating her current complaints, a review of the patient’s medical history revealed a longstanding pattern of symptoms dating back to 2014. During the initial visit, a series of targeted questions were asked to rule out potential causes. These included assessing consistent use of duloxetine (to evaluate for serotonin–norepinephrine reuptake inhibitor withdrawal), a history of cervical disc disease, and the presence of numbness or tingling sensations in the limbs. The patient denied all these factors. Given that paresthesia is a common symptom in fibromyalgia, reassurance was provided regarding the likelihood of spontaneous improvement.\n\nOn the basis of the patient’s history and medical records, it appears that she began experiencing symptoms and signs in 2014, which led to her subsequent diagnoses. According to the patient, the initial manifestations included multiple chronic oral ulcers and widespread musculoskeletal pain, prompting a thorough evaluation by a rheumatologist. On the basis of positive initial test results—currently unavailable—the patient was prescribed prednisolone, azathioprine, and hydroxychloroquine. However, according to the patient, the results of subsequent tests were negative, and the rheumatologist discontinued the medications. Although the patient’s oral ulcers improved after a few months, the widespread musculoskeletal pain persisted. Moreover, because the rheumatological tests were normal, a rheumatological diagnosis was not made. During this time, the patient also received psychiatric treatment for major depressive disorder (MDD), with sertraline prescribed for mood stabilization.\n\nBy 2021, the patient’s symptoms evolved further, culminating in a significant episode of optic neuritis in the left eye. This presented as an acute unilateral decreased vision and severe eye pain, particularly with eye movement. The condition responded well to methylprednisolone treatment. Magnetic resonance imaging (MRI) scans of the brain, orbits, cervical spine, and brain magnetic resonance venography (MRV) imaging showed no significant findings; however, scattered tiny unidentified bright objects (UBOs) (n = 4–5) were noted in the subcortical white matter on T2-weighted fluid-attenuated inversion recovery (FLAIR) images. Visual field tests revealed significant abnormalities, with the left eye showing field defects in the upper and lower quadrants, and moderate-to-severe MD (mean deviation) loss, while the right eye exhibited peripheral vision loss and an abnormal pattern deviation. Despite these findings, high-definition optical coherence tomography (OCT) scans demonstrated intact retinal layers, normal macular thickness, and no structural optic nerve damage. Laboratory tests revealed a positive antinuclear antibody (ANA, 1:160, fine speckled pattern) but negative extractable nuclear antigen (ENA), anti-dsDNA, neuromyelitis optica (NMO), and myelin oligodendrocyte glycoprotein (MOG) antibodies; effectively ruling out systemic autoimmune or demyelinating diseases such as neuromyelitis optica. Notably, a low-normal vitamin B12 level (232 pg/mL) was identified, which could have contributed to the patient’s neurological symptoms but was overlooked at the time.\n\nThe findings strongly suggest optic neuritis, likely as part of a clinically isolated syndrome (CIS), raising concern for a future risk of multiple sclerosis (MS). The episode’s clinical presentation and nonspecific UBOs in the brain align with early demyelinating disease, although progression to MS is not definitive at this stage. Recommendations included close neurological monitoring with repeat brain and spinal MRIs in 6–12 months, and cerebrospinal fluid (CSF) analysis if new symptoms occurred. However, the patient did not follow through with these recommendations, and no follow-up imaging or tests were conducted to monitor for disease progression.\n\nThroughout all these years, the patient’s chief complaints were persistent; widespread musculoskeletal pain and fatigue, which had never been attributed to a specific diagnosis by any physician. Finally, in 2022, the patient was referred to a psychiatrist for these complaints. The psychiatrist diagnosed fibromyalgia and prescribed duloxetine 30 mg daily, which significantly alleviated her symptoms.\n\nApproximately 1 week later, the patient returned for a follow-up visit, reporting a worsening of her initial symptoms. She also described new complaints, including increased widespread musculoskeletal pain and cognitive disturbances such as forgetfulness, decreased attention, and slowed thinking. A mini-mental state examination (MMSE) was performed, which yielded normal results. Laboratory tests were ordered to investigate potential causes. Gabapentin 300 mg at night was prescribed to alleviate paresthesia. The evaluation focused on possible thyroid hormone imbalances, worsening anemia, and vitamin B12 deficiency as potential contributors to the neurological symptoms.\n\nFour days later, at the third follow-up visit, the patient reported improvement in the electric shock-like sensations but continued to struggle with persistent mental slowness and forgetfulness. Laboratory testing revealed normocytic normochromic anemia, with a hemoglobin level of 10.9 g/dL, a mean corpuscular volume (MCV) of 81.2 fL, and a mean corpuscular hemoglobin concentration (MCHC) of 33 g/dL, both near the lower limit of normal. Ferritin levels were adequate at 57 ng/mL; however, the patient’s vitamin B12 level was critically low at < 150 pg/mL, well below the normal range. Thyroid function was assessed, and thyroid-stimulating hormone (TSH) level was normal at 1.4 mIU/L, ruling out thyroid dysfunction as a contributing factor.\n\nA review of medical records revealed that the patient underwent an upper endoscopy in 2016 for chronic dyspepsia, which confirmed the presence of severe chronic gastritis with intestinal and pancreatic metaplasia. The patient’s previous records also showed the following laboratory findings: positive anti-thyroid peroxidase (TPO) and normocytic normochromic anemia, and a ferritin level below 15 ng/mL.\n\nThe patient was prescribed parenteral vitamin B12 (hydroxocobalamin) at 1000 µg intramuscularly three times per week for the first week, followed by 1000 µg once weekly for 4 weeks. She was also referred to a hematologist, neurologist, and gastroenterologist for further evaluation.\n\nThe gastroenterologist confirmed diagnoses of pernicious anemia and atrophic gastritis. To rule out Crohn’s disease and celiac disease, laboratory tests were ordered, all of which returned normal. An upper endoscopy was performed to assess the patient’s condition and exclude potential malignancies, with histopathological analysis confirming atrophic metaplastic gastritis. The gastroenterologist recommended repeating an upper endoscopy every 3 years and referred the patient to a hematologist for further management.\n\nThe hematologist supported the diagnosis and proposed a treatment plan of weekly intramuscular injections of parenteral vitamin B12 (hydroxocobalamin) at 1000 µg for 3 months, followed by injections every 2 months, depending on the patient’s symptoms and laboratory results. A complete blood count and vitamin B12 level test were scheduled 4 weeks after starting treatment. At the follow-up, the patient’s vitamin B12 level had increased to 587 pg/mL, and hemoglobin improved to 11.1 g/dL. The hematologist emphasized that, owing to the irreversible nature of atrophic gastritis, lifelong treatment is necessary, which may include injections or oral supplementation, along with iron supplementation. The next follow-up was scheduled for 6 months later to reassess symptoms and laboratory results.\n\nThe neurologist requested a follow-up MRI of the brain and cervical spine. The brain MRI showed a few stable unidentified bright objects (UBOs) in the frontal subcortical and deep white matter, consistent with the previous MRI, with no interval changes or new abnormalities. Their nonspecific nature and lack of progression reduced the likelihood of an active demyelinating disease. The cervical spine MRI revealed cervical hypolordosis, with no significant abnormalities in the vertebrae, intervertebral discs, spinal cord, or surrounding soft tissues. On the basis of these findings, physical therapy was recommended to address the cervical spine condition. In addition, a referral to a rheumatologist was suggested for further evaluation and management on the basis of the patient’s clinical presentation.\n\nAfter reviewing the patient’s test results, the rheumatologist determined that systemic lupus erythematosus (SLE) was unlikely and attributed the positive ANA test to coexisting Hashimoto’s thyroiditis. They concluded that vitamin B12 deficiency alone could not account for the full spectrum of the patient’s symptoms. A diagnosis of fibromyalgia was made, and treatment with duloxetine 60 mg once daily and pregabalin 50 mg once daily was recommended. Furthermore, a referral to a psychiatrist specializing in psychosomatic medicine was advised to ensure comprehensive care.\n\nhe patient’s condition approximately 4 months after diagnosis and the initiation of treatment\nThe patient has not yet consulted a psychiatrist. While there has been a noticeable improvement in symptoms, particularly cognitive disturbances and fatigue, the patient continues to experience widespread musculoskeletal pain and intermittent electric shock-like sensations in the head. However, the frequency of these sensations has significantly decreased. As previously noted, the patient’s vitamin B12 level increased to 587 pg/mL, and their hemoglobin level improved to 11.1 g/dL.",
    "summary": "This case describes a 40-year-old Iranian woman with a decade-long history of nonspecific symptoms, including fatigue, widespread musculoskeletal pain, paresthesia, cognitive disturbances, and optic neuritis; misattributed to conditions such as fibromyalgia, hypothyroidism, and autoimmune diseases. Despite annual monitoring for normocytic anemia, her critically low vitamin B12 levels (< 150 pg/mL) and a diagnosis of pernicious anemia were identified only after persistent symptoms prompted further evaluation, revealing atrophic gastritis as the underlying cause. Neurologic improvement with parenteral B12 therapy, alongside management of fibromyalgia, emphasizes the importance of considering vitamin B12 deficiency even in the absence of classic hematologic findings."
  },
  {
    "id": "multiclinsum_gs_en_572.txt",
    "fulltext": "An 85-year-old man living alone was referred to our department for the management of his DM treatment, which had become complicated by dietary issues. He had a history of gastroesophageal reflux disease (GERD) in his 30s and angina pectoris requiring stent placement in his 70s. The patient was diagnosed with DM in his 40s and commenced insulin therapy in his 60s. He had been treated with multiple daily insulin injections and oral glucose-lowering agents, including empagliflozin, which had maintained his glycated haemoglobin in the 7% range over the past year until three months before his initial visit to our department. There was no history of gastroesophageal surgery or radiation therapy. He had abstained from alcohol and cigarettes throughout his life.\n\nTwo months earlier, the patient underwent craniotomy for a meningioma in the parasphenoid region. Postoperatively, he developed moderate cognitive impairment (the revised Hasegawa dementia scale: 15/30 points) and was admitted to a nursing home. According to his patient’s caregiver, he was dissatisfied with life in the facility, refused meals, and left to return home of his own volition two days prior to his initial consultation. A representative from the comprehensive community support centre urged him to seek medical attention as he had not eaten anything and suspended all DM treatment regimens since leaving the nursing home.\n\nUpon arrival, his vital signs were as follows: blood pressure 116/50 mmHg, pulse rate 90 beats/min, and respiratory rate 20 breaths/min. Laboratory tests revealed hypoalbuminaemia and elevated serum urea nitrogen, creatinine, and uric acid levels. The anion gap, serum β-hydroxybutyric acid, and glucose levels imply euglycaemic ketoacidosis. A compensatory mechanism by respiratory alkalosis prevented the development of acidaemia despite the underlying metabolic acidosis. Anti-glutamic acid decarboxylase antibody titre and serum C-peptide level indicated a non-insulin-dependent state of type 2 DM.\n\nThe patient experienced several days of dietary deficit, leading to a diagnosis of SKA rather than DKA. After admission, SKA and dehydration were corrected with an infusion of dextrose-containing balanced crystalloid solutions, resolving the acid–base imbalance by the second hospital day. Oral intake was then attempted; however, food-refluxing noises came from the throat during food ingestion. A barium meal study revealed that a tapered narrowing in the mid-oesophagus prevented solid objects from passing despite excellent swallowing function. A computed tomography scan showed circumferential oesophageal wall thickening at the site of the stricture and a hiatus hernia. Neither mediastinal mass lesion nor lymph node enlargement was observed. The gastroesophageal endoscopy confirmed the stricture 30 cm from the incisors. Oesophageal biopsy specimens revealed a non-specific chronic oesophagitis. Mucosal cultures showed no evidence of aerobic bacteria or fungi.\n\nOral intake was restricted, and a high-calorie infusion was implemented to calm oesophageal inflammation and restore nutritional status. The patient subsequently underwent endoscopic bougienage, which enabled the resumption of oral intake. His DM was managed with metformin, sitagliptin, repaglinide, and voglibose, achieving adequate glycaemic control without the need for insulin therapy.",
    "summary": "An 85-year-old man with dementia was referred to our department because of problematic eating habits, which made it difficult to manage his diabetes mellitus. The patient exhibited euglycaemic ketoacidosis, with a clinical course and biochemical parameters more indicative of starvation ketoacidosis rather than diabetic ketoacidosis. After correcting the acid-base imbalance with dextrose-containing fluids, he attempted to resume oral intake; however, throat noises consistent with reflux were noted during food ingestion. Imaging and pathological studies revealed a stricture with wall thickening in the mid-oesophagus attributed to non-specific chronic oesophagitis. After receiving hypercaloric fluids to calm oesophageal inflammation, an endoscopic bougienage was performed, enabling oral intake and achieving appropriate glycaemic control with oral glucose-lowering agents."
  },
  {
    "id": "multiclinsum_gs_en_493.txt",
    "fulltext": "A 13-year-old female patient with a history of trichotillomania presented with a weight loss of 10 kg in less than two months, chronic constipation, night vomiting and abdominal pain of seven days duration. Initially she was treated with pinaver bromide and, as she did not improve, she was admitted to the emergency department for exacerbation of the symptoms and intolerance to oral treatment.\n\nOn physical examination, he had decreased peristalsis, a solid, fixed, deep-seated mass 5 x 5 cm in diameter in the epigastrium.\n\nLaboratory: hemoglobin: 14.2 g/dL; platelets: 155 10^3/μL; leukocytes: 8.60 10^3/μL; neutrophils: 2.78 10^3/; creatinine: 0.95 mg/dL; urea: 32.6 mg/dL; urea nitrogen (BUN): 15.2 mg/dL; aspartate aminotransferase (TGO/AST): 22 U/L; alanine aminotransferase (TGP/ALT): 28 U/L; gamma glutamyl transpeptidase (GGT): 36 U/L. The results were within normal ranges for the patient.\n\nA plain abdominal X-ray showed radiopacity in the epigastrium, an abdominal ultrasound showed a hyperechoic line with posterior acoustic shadow projection, and an abdominal computed tomography with a water-soluble contrast agent showed a defect in the filling of the fundus to the pylorus.\n\nA laparotomy was performed and a tricobezoar was found in the stomach extending into the duodenum and part of the jejunum. It was removed without complications.\n\nThe patient was stable.\n",
    "summary": "13-year-old female patient presenting with weight loss of 10 kg in two months, chronic constipation, predominantly nocturnal vomiting and abdominal pain of seven days' evolution. On physical examination, decreased peristalsis and a palpable mass in the epigastrium were found. Laboratory tests taken on admission: normal haematological biometrics, renal and hepatic function tests. The abdominal radiograph showed opacities in the fundus, corpus and antrum of the stomach, the abdominal ultrasound showed non-specific findings in the epigastrium, and an abdominal tomography with swallowing of a water-soluble contrast agent showed occupation of the gastric lumen. The patient underwent exploratory laparotomy and the finding was a trichocephalic triceratops in the stomach with extension to the duodenum and part of the jejunum, which was removed without complications. The patient's evolution was favourable.\n"
  },
  {
    "id": "multiclinsum_gs_en_336.txt",
    "fulltext": "Patient information: A 64-year-old patient with no particular medical history presented with progressive generalised abdominal pain associated with intermittent vomiting and low-grade rectal bleeding in the context of feverlessness and general malaise.\n\nClinical findings: vital signs were normal. Abdominal examination and rectal examination were normal.\n\nDiagnostic approach: a colonoscopy performed showed a bulging and hard process of Bauhin's valve. The anatomopathological examination of this process showed the presence of a chronic inflammatory lesion in acute ulcerated outbreak, containing rare dense cellular clusters, whose rarity did not allow to specify with certainty their nature. An abdominal-pelvic scan was performed and objectified a significant circumferential thickening bulging of the caecum extending from the ileo-caecal junction of 21 mm maximum thickness, extending over 8 cm in height. This thickening is accompanied by infiltration of the neighbouring fat with the presence of neighbouring peritoneal nodules and a magma of mesenteric adenoiditis reaching 24 mm of small axis for the largest.\n\nTimeline: Four days later, the patient presented with an occlusive syndrome of food and gas stoppage with incoercible vomiting in the context of fever and altered general condition. The unprepared abdominal radiograph confirmed the diagnosis of intestinal obstruction. The patient was operated and the exploration revealed a low-volume serous effusion with the presence of a 5x4 cm, mobile and narrowing ilio-caecal crossroad tumour and also the presence of right mesocolic lymphadenopathy. The patient underwent a right hemicolectomy with mechanical ileo-colonic anastomosis.\n\nThe anatomopathological examination of the piece of the hemicolectomy revealed the presence of a round cell pan-parietal malignant tumour proliferation of moderate to high cell density. The lymph node dissection brought back 16 lymph nodes of which seven were tumoural. An immunohistochemical complement confirmed the diagnosis of a diffuse large cell non-Hodgkin's B-cell lymphoma of germinal centre type with anti-CD20 positive, anti-BCL2 positive, anti-CD 10 positive, anti-CD 3 positive, anti-pan-cytokeratin negative and anti-chromogranin negative antibodies. The anti-Ki 67 antibody was positive on 70% of the labelled cells. A PET scan showed a lymphomatous extension to the supra- and sub-diaphragmatic, hepatic, peritoneal and pancreatic lymph nodes. An oeso-gastroduodenal fibroscopy (EGD) was performed and showed no anomalies.\n\nTherapeutic intervention: the therapeutic decision was to put the patient on six courses of R-CHOP (Rituximab, Cyclophosphamide, Doxorubicine, Vincristine and Prednisone) protocol.\n\nFollow-up and results of therapeutic interventions: the patient presented a good clinical and radiological evolution with the TEP-scan performed at the end of treatment showing a major metabolic remission.\n",
    "summary": "We report a case of a colonic diffuse large B-cell lymphoma revealed by an occlusion, diagnosed on a surgical specimen in a 64-year-old man who was in complete remission after six R-CHOP courses.\n"
  },
  {
    "id": "multiclinsum_gs_en_60.txt",
    "fulltext": "The patient was a 57-year-old female admitted with a history of lumbar spondylolisthesis, discovered over 20 years ago, and presenting with lumbago for the past 7 months. Preoperative CT scans revealed L4 vertebral slippage along with degeneration of the L4/5 and L5/S1 intervertebral disc. After a thorough evaluation upon admission, and with no significant contraindications to surgery, the patient underwent vertebroplasty. Postoperatively, her vital signs remained stable, and her recovery progressed well.\n\nHowever, on the 10th postoperative day during hospitalization, the patient developed acute chest tightness and dyspnea, along with a gradual decrease in hemoglobin levels. She had no prior history of heart disease. To rule out cardiac pathology, an electrocardiogram and cardiac enzyme tests were performed, both of which returned normal results. The patient’s postoperative wound had healed well, with no signs of gastrointestinal bleeding, such as hematemesis or melena. Additionally, blood cell morphology appeared normal, effectively excluding hematologic disorders. As a result, the progressive decline in hemoglobin was suspected to be due to undetermined blood loss, and the patient was promptly transfused with 2 units of concentrated red blood cells.\n\nOn the 11th postoperative day, the patient’s chest tightness and shortness of breath persisted. To rule out any issues at the lumbar surgical site, a full abdominal computed tomography (CT) scan was performed. The results showed no significant abnormalities in the surgical site or abdominal organs but did reveal pericardial and pleural effusion. At this time, the patient’s albumin level was 29.8 g/L, just below the threshold for hypoalbuminemia, although she had normal levels prior to surgery. Given her overall stable condition and the absence of clear signs of acute heart failure or compressive pericardial effusion, conservative treatment was initiated, including diuresis and albumin infusion. However, despite this approach, there was no reduction in pericardial or pleural effusion. A bedside color Doppler ultrasound of the heart was then performed, revealing moderate pericardial effusion and bilateral pleural effusion. Diuresis was continued, and albumin infusions were administered, as the pleural effusion was suspected to be related to decreased plasma osmotic pressure.\n\nOn the 13th postoperative day, the patient’s chest tightness and shortness of breath worsened compared to the previous day, raising concerns about potential cardiac and pulmonary issues. A CT scan of the lungs was performed, revealing a surprising increase in pericardial and bilateral pleural effusion compared to the previous scan, as well as a long, dense shadow at the heart. Given the patient’s elevated pleural effusion and deteriorating oxygenation, she was promptly transferred to the intensive care unit of the thoracic surgery department. A chest tube was inserted on the same day to drain the pleural effusion.\n\nOn the 14th postoperative day, the patient’s chest tightness and shortness of breath persisted, with 800 ml of fluid drained from the chest tube. The drainage fluid was light red and tested positive for the Rivalta test (+). The total cell count exceeded 50,000, with a white blood cell count of 6,480, indicating an exudate with associated inflammation. A chest X-ray confirmed a large volume of pericardial and bilateral pleural effusions, along with a long, high-density shadow resembling blood vessels near the heart. Given the patient’s lack of previous cardiac surgery or thoracic trauma, this finding raised concern. That day, pericardiocentesis was performed to relieve pressure from the accumulating pericardial effusion, yielding 190 ml of dark red fluid.\n\nOn the 15th postoperative day, a multi-disciplinary team (MDT) meeting was held. By integrating findings from the CT scan and chest X-ray with the patient’s clinical symptoms and history, the team hypothesized that the long, high-density shadow represented leaking bone cement. The MDT discussed whether immediate thoracotomy was necesssary to remove the bone cement. However, only 23 ml of pericardial drainage fluid was collected the following day, suggesting that intracardiac bone cement was unlikely to have caused perforation. The pericardial drainage fluid was confirmed to be exudate. Coagulation tests revealed prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT), a slight decrease in platelet count, and reduced fibrinogen levels, indicating significant coagulation dysfunction and increasing the risk of hemorrhagic complications. The MDT concluded that intracardiac bone cement could potentially be removed via percutaneous intervention, but given the patient’s critical condition and coagulation abnormalities, conservative management was prioritized. On the 16th day, the patient received a continuous infusion of 2 units of concentrated red blood cells.\n\nFrom the 17th to the 24th postoperative day, the patient continued closed chest and pericardial drainage. During this period, the volume of pericardial drainage fluid decreased, and by the 23rd day, no fluid was present. However, the patient’s symptoms of chest tightness and shortness of breath persisted, prompting a follow-up echocardiogram, which revealed moderate pericardial effusion. Suspecting possible obstruction of the drainage tube due to fibrinous exudate, a pigtail catheter was deployed as a substitute. On the 24th day, the pericardial drainage fluid volume increased to 200 ml.\n\nOn the 25th postoperative day, the volume of pericardial drainage fluid increased to 570 ml, while the patient’s hemoglobin level continued to decline. Suspecting active bleeding from the heart, the patient underwent comprehensive CT angiography of the entire aorta. The results revealed a high-density shadow in the region of the right atrium, tricuspid valve, and right ventricle, as well as in the posterior segment of the right upper lobe where the pulmonary artery branches travel. A transthoracic echocardiogram also identified a long, floating, hyper-echoic object within the heart.\n\nOn day 26, the patient underwent emergency cardiac foreign body removal in the cardiovascular surgery department. Intraoperative transesophageal echocardiogram revealed a long, hyper-echoic strip in the right heart region. Upon opening the chest, the intraoperative findings confirmed our suspicions. A minor laceration was identified in the inferior vena cava near the side wall of the right atrium, accompanied by extensive local thrombosis. A long, thin piece of bone cement, approximately 8 cm in length, was located in the right atrium. One end of the cement was embedded in the anterior-lateral region of the right atrium near the atrioventricular groove, while the other end extended into the right ventricle through the tricuspid valve orifice. The surgeon successfully removed the foreign body, and the operation was completed without complications.\n\nFrom the 27th to the 39th postoperative day, the patient underwent several follow-up cardiac examinations, including chest CT and chest X-rays, which showed a continued reduction in pericardial and pleural effusions. The patient was discharged on the 45th day, reporting improvement in all symptoms.",
    "summary": "A 57-year-old female was admitted to the hospital with a slipped lumbar vertebra and back pain, for which she underwent percutaneous vertebroplasty. On the 10th postoperative day, the patient suddenly developed chest tightness and shortness of breath, accompanied by a gradual decline in hemoglobin levels. After several imaging studies, a diagnosis of right atrial perforation caused by bone cement was confirmed. The patient subsequently underwent open cardiac foreign body removal and made a full recovery, with no residual cardiac dysfunction."
  },
  {
    "id": "multiclinsum_gs_en_125.txt",
    "fulltext": "An 82-year-old female was admitted to the emergency department due to epigastric pain, nausea and vomiting for 1 day. Abdominal computed tomography (CT) was performed at a local hospital indicating HPVG and for this reason the patient was referred to our hospital for treatment on the day of onset. On the day of admission, her temperature was 38.2°C, respiratory rate was 18 breaths per minute and oxygen saturation was 98% on air, the pulse was 88 beats per minute, lying blood pressure was 122/84 mmHg. The only abnormal physical examination was epigastric tenderness. Laboratory studies showed a white blood cell of 18.81×109/L; neutrophils, 89.2%; hemoglobin (HB), 122g/L; blood platelet count 275 × 109/L, hypersensitive C-reactive protein 87.82mg/L. The arterial blood gas analysis, serum creatinine, blood urea nitrogen, serum amylase, total bilirubin and hepatic enzyme spectrum were normal. Continuous gastrointestinal decompression, anti-infection, rehydration and other treatments were given. Contrast-enhanced abdominal CT was performed 3 hours after the first plain CT scan and revealed a significant reduction of intrahepatic biliary tract gas. Two days later, enhanced abdominal CT showed that intrahepatic biliary tract gas had disappeared. After treatment, abdominal pain, nausea, vomiting and other symptoms gradually relieved. Antibiotics were discontinued after 7 days, and blood cultures were not performed. The patient refused gastroenteroscopy and was discharged after 13 days of hospitalization. After six months of follow-up, the patient recovered well without abdominal pain, fever, vomiting and other symptoms.",
    "summary": "An 82-year-old female was admitted to the emergency department due to epigastric pain, nausea and vomiting for 1 day. Intrahepatic gas was found on computed tomography (CT), which was initially diagnosed as portal venous gas, and contrast-enhanced abdominal CT was performed 3 hours after the first plain CT scan and revealed a significant reduction of intrahepatic gas, then diagnosed as biliary tract gas. Two days later, enhanced abdominal CT showed that biliary tract gas had disappeared. Continuous gastrointestinal decompression, anti-infection, rehydration and other treatments were given. After treatment, abdominal pain, nausea, vomiting and other symptoms of the patient were gradually relieved. The patient refused gastroenteroscopy and was discharged after 13 days of hospitalization."
  },
  {
    "id": "multiclinsum_gs_en_145.txt",
    "fulltext": "The patient was a 66-year-old man who lived in Juan Bautista Alberdi, province of Buenos Aires, with a history of hypertension and obsessive-compulsive disorder. His usual medication included amlodipine, quetiapine, venlafaxine, and valproic acid. He presented with a 4-day history of fever of 39°C with no associated symptoms and was admitted to the general ward for evaluation. On admission, he was found to be lucid with no motoric focal signs, no sensory deficits, and no neck stiffness (GCS 15/15). The rest of the physical examination and general laboratory tests were unremarkable. Cultures of blood and urine were negative, and the computed tomography of the brain, thorax, abdomen, and pelvis showed no abnormalities. After 24 hours, he presented with episodes of disorientation and spatial disorientation alternating with episodes of drowsiness (GCS 13/15). On physical examination, he was found to have a thick distal tremor in all four limbs. The cerebrospinal fluid examination reported: cerebrospinal fluid clear, and post-centrifugal appearance clear. White blood cell count 310/mm3 (mononuclear 54%, polynuclear 46%), red blood cell count < 1000/mm3, protein 0.76 g/l, glucose 54 mg/dl (glucose 120 mg/dl), and lactic acid 21 mg/dl. Empirical treatment with 10 mg/kg intravenous acyclovir every 8 hours was initiated. PCR for herpes simplex virus (HSV) and equine encephalopathy virus (EEO) were requested, but were not reactive. However, IgM (ELISA) for EEO was positive in serum and cerebrospinal fluid at 10 days. MRI of the brain showed an increase in the intensity of FLAIR and T2 sequences in the dorsal trunk, both in the protuberant and bulbar regions, both peduncles and basal ganglia, with bilateral involvement and a slight predominance of the right basal ganglia. There were also multiple focal hyperintense images in the white matter of both cerebral hemispheres. The patient deteriorated in sensory function (GCS 8/15), without airway protection, so he was admitted to the ICU. He required intubation and mechanical ventilation with sedation and analgesia. On admission to the ICU, he presented: arterial acid-base (AAB) status: pH 7.11, pCO2 41 mmHg, pO2 65 mmHg, bicarbonate 28 mEq/l, excess base 0 mEq/l, saturation 93% (with FIO2 21%), lactic acid 11.5 mg/dl. Mechanical ventilation was initiated with a minute volume of 9.8 litres (tidal volume 490 ml corresponding to 6 ml/kg of theoretical weight, respiratory rate 20 per minute, end-expiratory pressure (PEEP) 5 cmH2 O, fraction of inspired oxygen 30%), blood was drawn for arterial AAB status: pH 7.40, pCO2 70 mmHg, pO2 65 mmHg, bicarbonate 28 mEq/l, excess base 0 mEq/l, saturation 93%, PAFI 216. He presented without fever, hemodynamically stable, with adequate oxygenation and rhythm of diuresis. When sedatives were discontinued, he presented a GCS of 3 points out of 10 (corresponding to ocular and motor evaluation of 1 point), with generalized rigidity and adequate osteotendinous reflexes, with rhythmic movements of the tongue and perioral area. The 12-channel electroencephalogram did not show pathological discharges. On the tenth day of the onset of symptoms, he presented with eye opening and less rigidity, but he did not tolerate spontaneous respiratory support due to hypoventilation and hypercapnia, which led to transient hypoxemia. In the arterial AAB status, he presented: pH 7.31, pCO2 70 mmHg, pO2 76 mmHg, bicarbonate 35 mEq/l, excess base 8 mEq/l under spontaneous respiratory support in the form of a pressure support of 5 cmH2 O, respiratory rate 6 per minute, PEEP 5 cmH2 O and tidal volume between 120-150 ml. The following days, the patient was connected, responding to simple and complex orders, and he moved symmetrically with some weakness. Due to intolerance to spontaneous respiratory support, he was tracheostomized. In the functional respiratory evaluation, the pressure was lower than -40 cm H2 O, the end-expiratory pressure was higher than 80 cm H2 O, but he continued to have hypercapnia in the spontaneous respiratory support, so he required mechanical ventilation with controlled mode. A transthoracic echocardiogram was performed, which reported normal right ventricular cavities, without signs of pulmonary hypertension. In the new MRI of the brain, the hyperintense areas in FLAIR and T2 sequences visible previously were reduced.\n\nThe patient progressed with decreasing ventilatory support as this report was being written.\n",
    "summary": "We present the case of a 66-year-old man from Juan Bautista Alberdi, province of Buenos Aires, with a history of arterial hypertension and obsessive-compulsive disorder. He consulted for a sudden fever of four days duration, with the development of encephalopathy during his admission. The lumbar puncture showed a crystalline cerebrospinal fluid, although inflammatory with a predominantly mononuclear predominance. The MRI of the brain reported hyperintensity in FLAIR and T2 sequences in the dorsum of the brain stem. He was admitted to the intensive care unit due to neurological deterioration and severe respiratory acidosis, requiring mechanical ventilation assistance. After 10 days he presented neurological improvement, without motor deficit but with alveolar hypoventilation that made it difficult to wean him off the respirator.\n"
  },
  {
    "id": "multiclinsum_gs_en_98.txt",
    "fulltext": "39-year-old woman with a history of IgA nephropathy that required a renal transplant in 2014. She subsequently remained on immunosuppressive therapy with oral prednisone 5 mg/day, tacrolimus 5 mg every 12 hours orally and mycophenolic acid 360 mg every 12 hours orally. In 2019 she developed a picture of flat warts and verrucose plaques in the inguinal fold, which spread to the perianal, abdominal and hand regions. Initially, this was interpreted as flat warts and was managed with topical imiquimod 5%, but there was no response, and subsequently she was immunised with the HPV vaccine (Gardasyl 9) with partial response. A histopathological study of the inguinal lesions showed mild acanthosis with hypergranulosis, keratinocytes with large cytoplasm, grey blue staining with clear perinuclear halos. The diagnosis of acquired epidermodysplasia verruciformis was made and 0.1% retinoic acid was initiated topically, and immunosuppressive therapy was adjusted to everolimus 0.75 mg every 12 hours orally, which resulted in a marked decrease in the lesions. Initiation of treatment with acitretin was proposed for management of residual lesions, but due to the patient becoming pregnant during follow-up, the initiation of this therapy was postponed. With regard to the renal transplant, the development of the EVA was not associated with changes in renal function. She is currently being monitored periodically by the dermatology and nephrology teams.\n",
    "summary": "We report the case of a 39-year-old woman who received a renal transplant and was treated with prednisone and tacrolimus. After initiation of immunosuppressive therapy, she developed a condition characterized by warty papules and plaques in the inguinal region. A skin biopsy was performed and was consistent with epidermodysplasia verruciformis. It was decided to adjust the immunosuppressive therapy to everolimus, which resulted in a decrease in the lesions.\n"
  },
  {
    "id": "multiclinsum_gs_en_259.txt",
    "fulltext": "A 48-year-old African American woman with past medical history only significant for uncontrolled essential hypertension presented to the Emergency Department with a chief complaint of palpitations. She also reported associated fatigue and shortness of breath. Over the past month, she described an intermittent sensation of an irregular heartbeat without any specific triggers. Her symptoms progressed to left-sided chest discomfort with associated left upper-extremity tingling. Additionally, she reported black spots in her vision, as well as dysphagia primarily to solids, which also had been worsening over the past few weeks. She had no history of similar symptoms in the past. She was not on any medications.\n\nOn admission, vital signs were significant for a blood pressure of 166/92 mmHg and heart rate of 109 beats/minute. A physical exam was significant for conjunctival pallor, without evidence of glossitis or koilonychia. In the Emergency Department, a complete metabolic panel was unremarkable including a serum creatinine of 0.56 mg/dL [0.60–1.20 mg/dL]. An electrocardiogram showed sinus tachycardia with occasional premature ventricular complexes. Troponins were within normal limits. Hemoglobin on admission was 5.7 g/dL [11.9–15.1 g/dL] with a mean corpuscular volume of 65.3 fL [80.0–96.0 fL]. Her serum iron on admission was 12 ug/dL [50–212 ug/dL], iron saturation was 3% [20–50%], and ferritin was 3.1 ng/mL [11.0–306.8 ng/mL]. The fecal immunochemical test (FIT) result was negative. Upon further questioning, the patient stated that she still menstruated, but did not describe menorrhagia. She denied hematemesis, hematochezia, or melena. She was transfused with 2 units of packed red blood cells in the Emergency Department and was started on 1400 mg of intravenous iron dextran complex infusions.\n\nThe patient was unable to sit for an esophagogram to evaluate for dysphagia secondary to nausea and vomiting while attempting to drink the contrast agent. Gastroenterology was consulted, and the patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy on day 6 of her hospitalization. Colonoscopy results were within normal limits. The EGD revealed a few intrinsic stenoses in the upper esophagus, with the narrowest measuring 9 millimeters. Biopsies were obtained from the proximal and distal esophagus with cold forceps for suspected eosinophilic esophagitis versus Plummer-Vinson syndrome, based on gross appearance. A pathology exam of the esophagus showed squamous-only mucosa, with mild chronic inactive inflammation. No eosinophilia was seen. Given the clinical, laboratory, and endoscopic findings, a diagnosis of Plummer-Vinson syndrome was made. Her dysphagia improved over the next 9 days in the hospital after iron infusions and blood transfusions, and she was able to tolerate a regular diet by eating slowly with small bites.\n\nShe underwent a cardiac workup to assess the palpitations, including an echocardiogram, which revealed an ejection fraction of 30–34%, with global hypokinesis and without valvular pathology or pulmonary hypertension. A nuclear stress test was negative for myocardial ischemia. A new diagnosis of congestive heart failure with reduced ejection fraction was made. Cardiology was consulted and she was started on carvedilol, lisinopril, spironolactone, and hydralazine. She was given a Life Vest in the hospital at discharge.\n\nApproximately 6 months after her discharge, a follow-up phone call was made to the patient. She stated that she had been compliant with all of her medications and her dysphagia had resolved. At the time of the phone call, she was tolerating a regular diet without any dietary restrictions.",
    "summary": "Patient: Female, 48\n\nFinal Diagnosis: Plummer-Vinson syndrome\n\nSymptoms: Chest pain • fatigue • palpitation\n\nMedication: —\n\nClinical Procedure: Esophagogastroduodenoscopy (EGD) • colonoscopy\n\nSpecialty: General and Internal Medicine\n\nWe present the case of a 48-year-old African American woman with symptomatic anemia and new-onset congestive heart failure secondary to hypertension, who presented with the classic symptoms of PVS."
  },
  {
    "id": "multiclinsum_gs_en_101.txt",
    "fulltext": "A male, 26 years old, was admitted to our hospital with a fever and altered mental status. He reported a 12-day history of fevers (38–39°C), headaches, photosensitivity, diplopia, and severe fatigue. His relatives stated that he was self-employed, a mild smoker, a non-drinker, and denied drug use. In the emergency department, he was drowsy, febrile (temperature of 38°C), and had a heart rate of 110 beats per minute. He denied having chest discomfort or heart palpitations. The emergency department’s Glasgow coma scale score was 13. There was no evidence of rash, bruising, or petechiae. The examination of the patient’s respiratory, cardiovascular, and abdominal systems was unremarkable. The neurological examination revealed mild neck stiffness but no meningeal sign.\n\nStudies in the laboratory indicated the following: 5.8 x 109/L white blood cells, 11.2 g/L hemoglobin, 243 x 109/L platelets, 89.5% neutrophils, 3.1% lymphocytes, 126 mmol/L sodium, 4 mmol/L potassium, and 134 mg/dL glucose. Blood cultures did not detect any growth. A chest x-ray indicated no pathology or localized consolidation, and his brain’s initial computed tomography (CT) scan was unremarkable. On the third day, the results of his lumbar puncture suggested tuberculous meningitis: clear appearance, increased white cell counts (40/L) with lymphocytes predominating, red blood cells (16/L), high protein (2.09 g/L), and low glucose (40 mg/dL). The cerebral fluid to serum glucose ratio was less than 50%. Both were negative for cytomegalovirus (CMV), toxoplasmosis IgM, and human immunodeficiency virus (HIV) serology.\n\nThe patient was admitted to the hospital ward with meningitis and hyponatremia as his clinical diagnoses. He was initially administered 2 grams per day of ceftriaxone, 10 milligrams per day of dexamethasone injection, hypertonic saline, and paracetamol. The condition improved slightly on the second day. He was treated for tuberculosis meningitis with 10 milligrams per day of dexamethasone injection and a combination of levofloxacin infusion 750 milligrams per day and antitubercular drugs including isoniazid 300 milligrams, rifampin 600 milligrams, ethambutol 1,100 milligrams, pyrazinamide 1,200 milligrams, and pyridoxine 50 milligrams, based on the results of the lumbar puncture. The patient’s condition was slightly improved, he was completely conscious, and he continued to suffer from a terrible headache and third nerve palsy. However, the patient’s condition suddenly worsened considerably on day seven, manifesting as unconsciousness and seizures.\n\nEight days after admission, a repeat contrast CT of the brain showed the development of ventriculomegaly suggestive of obstructive hydrocephalus and basilar enhancement. There was an enlargement of the third, fourth, and lateral ventricles. His serum sodium levels decreased (124 mmol/L) over several days. Based on well-established case definition criteria of tuberculous meningitis research, the patient was diagnosed with probable tuberculous meningitis with a total score of 12, which includes clinical criteria (symptom duration of more than five days (4), cranial nerve palsy (1)), cerebrospinal fluid criteria (clear appearance (1), lymphocytic predominance (1), protein concentration greater than one g/L (1), absolute cerebrospinal fluid glucose concentration less than 2.2 mmol/L (1)), cerebral imaging criteria (hydrocephalus (1), basal meningeal enhancement (2)). The patient was transferred to the intensive care unit (ICU) for the insertion of an emergency ventriculoperitoneal shunt. The possibility of complication after shunt insertion was observed. We did not identify complications such as infection, phlebitis, or an exposed shunt in the patient. The patient’s condition worsened gradually, and he died ten days after hospital admission.\n\n",
    "summary": "A 26-year-old male with no significant past medical history, tuberculosis, or indications of immunological compromise, was admitted to our hospital with a fever and altered mental status. He was drowsy, febrile (temperature of 38°C), had a heart rate of 110 beats per minute, and showed mild neck stiffness but no meningeal sign. A lumbar puncture on the third day of admission suggested tuberculous meningitis. He was treated for tuberculosis meningitis, and his condition slightly improved. However, the patient’s condition suddenly worsened, and a repeat contrast computed tomography (CT) of the brain showed the development of ventriculomegaly and basilar enhancement. Insertion of an emergency ventriculoperitoneal shunt was performed; however, the patient died ten days after hospital admission."
  },
  {
    "id": "multiclinsum_gs_en_304.txt",
    "fulltext": "In December 2020, a 43-year-old man with a 9-year-history of hepatitis B underwent an ultrasound scan during a routine medical examination in Ruian People’s Hospital, which revealed several hypoechoic lesions in his liver.\n\nLaboratory tests showed a slight elevation in alpha-fetoprotein (AFP) levels (AFP: 32.9 ng/ml) while other tumor markers such as carbohydrate antigens 19–9, 125, and 153, and carcinoembryonic antigen were within normal limits. The lesions appeared as low density with unclear margins on plain computed tomography (CT) imaging, and showed centripetal enhancement from the arterial to the portal phase on dynamic contrast-enhanced CT imaging. The sizes of the lesions varied, with the largest being an irregularly shaped lesion measuring 4.1 × 4.3 cm in diameter.\n\nOn dynamic contrast-enhanced magnetic resonance imaging (MRI), the largest lesion exhibited immediate peripheral ring-like enhancement, followed by progressive continuous enhancement and a central enhancing scar. Meanwhile, smaller lesions exhibited ring-like enhancement with gradual centripetal enhancement during the portal venous and delayed phases. For further examination, the patient was referred to Shanghai Huashan Hospital on December 30th, 2020.\n\nThe patient promptly underwent [18F]-FDG positron emission tomography (PET)-CT, which revealed no obvious uptake. However, [11C]-acetate PET/CT indicated slight uptake only for the largest lesion located in lobe VII (maximum standardized uptake value [SUVmax] = 4.21, tumour-to-background ratio (TBR) = 1.45), whereas other smaller ones exhibited no uptake. Interestingly, [68Ga] Ga-FAPI-04 PET/CT scan not only showed strong, high uptake for the largest lesion (SUVmax = 1.94, TBR = 3.08), but also for the smaller intrahepatic lesions (SUVmax = 1.47, TBR = 2.33).\n\nBased on the existing examinations, a preliminary diagnosis of hepatocellular carcinoma (HCC) was made. The patient then received partial hepatectomy in 6 days, and the diagnosis was confirmed by pathological analysis. The largest lesion located in segment VII was identified as a solitary HCC, while the other smaller lesions were diagnosed as hepatic epithelioid hemangioendothelioma (HEHE).\n\nMicroscopically, smaller lesions appeared as nests and cords of epithelioid endothelial cells, with intracytoplasmic lumina spread throughout the myxohyaline stroma. CD31 and ERG1 staining was strongly positive, confirming the diagnosis of HEHE (Fig. 4A–E). The segment VII hepatic lesion exhibited Hep1 positivity on immunohistochemistry, confirming the diagnosis of HCC.\n\nThe patient was discharged on postoperative day 9 and no recurrence has been detected during his follow-up until now.",
    "summary": "We present a case of synchronous hepatocellular carcinoma (HCC) and HEHE in a 43-year-old Chinese male patient. Multiple hypoechoic liver lesions were depicted, but no specific imaging findings were detected on enhanced computed tomography (CT) or contrast-enhanced magnetic resonance imaging (MRI). The patient then underwent [18F]-FDG PET/CT, [11C]-acetate PET/CT, and [68Ga]Ga-FAPI-04 PET/CT. The HEHE lesions demonstrated no uptake on both 18F-FDG and 11C-acetate PET/CT imaging, but presented a clear visualization in [68Ga]Ga-FAPI-04 PET/CT. The largest lesion located in segment VII was finally diagnosed as HCC, while the other smaller ones were diagnosed as HEHE, which was confirmed by immunohistochemical staining for CD31. To the best of our knowledge, only 2 cases have been reported in the worldwide literature, and the first case undertook both 11C-acetate and [68Ga]Ga-FAPI-04 PET/CT instead of 18F-FDG PET/CT."
  },
  {
    "id": "multiclinsum_gs_en_435.txt",
    "fulltext": "31-year-old male with a history of alcohol, tobacco, cocaine inhalation, pulmonary tuberculosis treated, left nephrectomy and post-traumatic splenectomy. He consulted the emergency department for a week-old condition that began immediately after intramuscular administration of penicillin for sexual contact with a partner with syphilis, characterized by pain in the right gluteal region that radiated to the foot, with subsequent appearance of purpuric dermatosis related to the injection site, being a plaque-like lesion configured in a ring-like shape, with irregular borders and a racemose distribution measuring 15 centimeters (cm), with healthy skin inside. He also presented a small scrotal scar and a large right plantar lesion of livedoid appearance from the talar region to the tip of the toes that did not respect a strict margin. An ultrasound of the greater gluteus was performed, which showed loss of the heterogeneous fibril pattern, an increase in the thickness of the fibril at the mid-section of the fibril, which appeared edematous, as well as edema of the subcutaneous cellular tissue (SCT); in the homolateral plantar region and in the scrotum, an SCT edema. In the laboratory, he presented leukocytosis of 13.7 × 109/L, C-reactive protein of 3.2 mg/dL (normal up to 0.5 mg/dL), which was interpreted as acute phase reactants, also increased transaminases with aspartate aminotransferase of 175 IU/L (normal up to 32), alanine aminotransferase of 245 IU/L (normal up to 33), creatine kinase with a value of 2741 IU/L (normal up to 170) and lactate dehydrogenase of 2499 IU/L (normal up to 250) representing muscle involvement. Complete serologies for syphilis were performed, with venereal disease research laboratory (VDRL and treponemal antibodies), human immunodeficiency virus (HIV) hepatitis B, hepatitis C, with negative results. The chronology, clinical manifestations and subsequent biopsy supported the diagnosis of Nicolau syndrome, for which anticoagulation was initiated with 1 mg/kg c/12 hs subcutaneously, cilostazol 100 mg every 12 hours and tramadol, for 10 days. A skin biopsy of the gluteus was performed that evidenced epidermal necrosis and extension to follicular epithelium, with formation of a secondary blister due to reepithelization, without vasculitis or vascular thrombosis, linked to acute cutaneous embolism. There was frank improvement with decrease in transaminases, with aspartate aminotransferase of 39 IU/L, alanine aminotransferase of 77 IU/L and creatine kinase of 167 IU/L. No immunological profile was requested, based on the fact that our presumptive diagnosis did not justify the search for other etiologies. A discharge was granted with cilostazol and analgesics, ambulatory control at 3 months with improvement of pain and lesions, remaining a discromatic scar in the right gluteus with presence of fine desquamation and a discromatic scar in the right foot with thick desquamation in the support area of the tarsometatarsus associated with minimal livedoid lesions in the same foot.\n",
    "summary": "A 31-year-old man developed this syndrome after intramuscular administration of benzathine penicillin. The diagnosis was supported by biopsy. He was treated with enoxaparin and cilostazol with subsequent improvement.\n"
  },
  {
    "id": "multiclinsum_gs_en_265.txt",
    "fulltext": "59-year-old male patient with a history of hemochromatosis, transient ischemic attack, and glaucoma. He had a family history of death at age 60 from an unspecified neurological disease. He presented with dysarthria and facial paresis of sudden onset, with improvement within a few days. After one week he developed involuntary movements of the left upper limb (LUL) associated with dysarthria, mild anomia (difficulty in naming people and objects), and dyscalculia (difficulty in calculating). He did not have fever or other symptoms. On neurological examination, he had no significant change in the higher nervous functions, with mild dysarthria, right central facial paresis, myoclonic movements of the LUL, and left hemiface. The MRI-CE showed changes in T2 and diffusion (DWI) in the right caudate and putamen, without involvement of the contralateral striatum. Due to the worsening, he repeated the MRI-CE after five days, and there was additional hyper signal in the diffusion of the medial fronto-parieto-cingular cortex. The investigation for autoimmune, infectious, and paraneoplastic causes was negative. The CSF showed increased tau protein and normal protein 14.3.3. The EEG revealed slow activity in the right parietal and bilateral frontotemporal regions. In the following two weeks, the dysarthria worsened and gait ataxia appeared. The possibility of autoimmune encephalitis was considered, and intravenous methylprednisolone (1 g for five days) was administered, without improvement. In the following months, neurological deterioration progressed, with the development of anarthria (inability to articulate words) and dysphagia, left hemiparesis, urinary incontinence, and cognitive deterioration with impairment of recent memory, disorientation, and executive dysfunction. A new MRI-CE was performed, which showed bilateral restriction of the diffusion of the basal ganglia and multiple cortical areas, predominantly in the frontal and parietal cortex. The EEG identified periodic generalized spike wave activity with reactivity to stimulation. The patient died four months into the disease. Genetic testing was performed later and was positive for the c.598G > A (E200K) mutation.\n",
    "summary": "We present a case of a 59-year-old patient with a sudden onset of central facial paresis and dysarthria followed by myoclonus in the left hemicorpus. Initial cranioencephalic MRI showed T2 hyper signal and diffusion in the right caudate and putamen and cerebrospinal fluid with hyperproteinorraquia. Investigation for autoimmune, infectious and paraneoplastic causes was negative. There was a progressive worsening in the following months to left hemiplegia, dysphagia, urinary incontinence and posterior acinetic mutism. Cranioencephalic MRI showed evolution to bilateral basal ganglia diffusion restriction and multiple cortical areas; Electroencephalography showed periodic activity and elevated tau protein in the cerebrospinal fluid. Genetic analysis revealed c.598G > A mutation. The patient died after four months of illness.\n"
  },
  {
    "id": "multiclinsum_gs_en_287.txt",
    "fulltext": "28-year-old male patient, a resident of a periurban area of Lima, who works as a motorcycle taxi driver. He has a history of complete individualized treatment five years ago for pulmonary tuberculosis resistant to isoniazid, streptomycin and ethionamide. He comes to the emergency department of the Edgardo Rebagliati Martins National Hospital with a 34-day illness characterized by persistent fever, chills, weight loss, dyspnea and leukocytosis.\n\nThe patient was initially seen by a private doctor with a clinical picture of moderate intensity left rib cage pain, palpitations and high intensity fever. The electrocardiogram was normal and the chest X-ray on day 4 of illness (day 4) was reported as normal, but the high intensity fever (38 °C), chills and leukocytosis with neutrophilia persisted. In addition, the patient had weight loss and abdominal pain. Serology for the immunodeficiency virus (HIV 1-2) and baciloscopy (BK) for the detection of the Koch bacillus were requested in three sputum samples, which were non-reactive and negative, respectively. The abdominal ultrasound and the faecal examinations showed no alterations. Due to the persistence of these symptoms, the patient was hospitalized.\n\nClinical findings\nOn physical examination, the patient was in fair general condition, emaciated, with a heart rate of 110 beats per minute, blood pressure of 100/70 mmHg, oxygen saturation of 96% without oxygen support, moderate dehydration and abolition of the vesicular murmur in the middle and lower third of the left hemithorax.\n\nCalendar\nDuring hospitalization, the patient persisted with fever, chills and marked increase in leukocytes and C-reactive protein (CRP). On day 9 of hospitalization (DH 9) or day 42 of illness (DE 42), thoracocentesis was performed plus placement of a thoracic drainage tube (TDT) in the left hemithorax. Initially, 600 ml of greenish, purulent secretion was drained, from which samples were obtained and sent to the laboratory for analysis. On DH 10 (DE 43), intravenous antibiotic coverage was initiated.\n\nIn DH 12 (DE 45), the patient no longer has a fever and the leukocytosis, neutrophilia and CRP have decreased. The secretion is no longer purulent. The tomography of DH 15 (DE 48) showed a decrease of the volume of the empyema by more than 50% and the chest ultrasound of DH 22 (DE 55) quantified it to only 73 ml.\n\nDiagnosis assessment\nThe initial chest tomography showed the presence of an extensive pleural empyema in the left hemithorax. It was considered a probable case of tuberculosis in an immunosuppressed patient and new serological tests for HIV 1-2 and for human lymphotropic virus of T cells type 1 and 2 or HTLV 1-2 were performed, which were non-reactive. The culture and bacilloscopy tests for Mycobacterium tuberculosis in sputum and urine were also negative.\n\nThe samples of the empyema, obtained by thoracocentesis, were processed for the detection of Mycobacterium tuberculosis and identification of common germs. For the first, the automated system in liquid medium MGIT (Mycobacterium Growth Indicator Tube) and the GeneXpert MTB/RIF automated real-time PCR test were used and were negative. For the second, the MALDI-TOF MS test was used and was positive to P. micra. In this case it was not possible to carry out an antibiogram.\n\nThe MALDI (Matrix-Assisted Laser Desorption/Ionization) technique, coupled to a TOF (time of flight) analyzer, is an ionization technique used in mass spectrometry, which allows the analysis of ribosomal proteins, typically between 2000 to 20 000 Da, from previously isolated bacteria, and compares them with ribosomal proteins from other bacteria in its database. This allows the identification of aerobic and anaerobic pathogens, quickly and reliably.\n\nTherapeutic intervention\nFor the management of the patient, the taking of samples of the empyema for the etiological diagnosis, placement of the TDT, initiation of antibiotic coverage and dental evaluation were considered. Prior to the identification of P. micra, empirical treatment with piperacillin/tazobactam was initiated, at a dose of 4.5 grams intravenous every 6 hours. After two weeks, when a notable clinical, imaging and laboratory improvement was observed, the withdrawal of the TDT and the continuation of the same intravenous antibiotic treatment in an associated clinic was decided, until completing six weeks, and then, the possibility of decortication was evaluated.\n\nThe dental evaluation found scarce calcified plaque subgingival, predominantly in the posterior teeth, congestive gingiva, at the level of the lower third molars (teeth 38 and 48), partially erupted, which is compatible with chronic pericoronitis. The tomographic study of the facial mass evidenced the chronic infectious process and the retention of teeth 38 and 48, which will require, subsequently, defocalization by means of complex exodontia and comprehensive dental treatment.\n",
    "summary": "A young immunocompetent patient with a history of pulmonary tuberculosis presented to the hospital with a clinical picture of subacute persistent fever, weight loss, dyspnoea and abolition of the vesicular murmur. A chest tomography showed an extensive empyema in the left hemithorax. Samples were taken for the detection of common germs and a thoracic drainage tube was placed and antibiotic therapy was initiated. The MALDI-TOF MS test identified Parvimonas micra, an anaerobic bacterium, a commensal of the oral flora, associated with severe periodontitis, which is rarely reported in pleural empyema, especially in immunocompetent people. The dental evaluation led to the diagnosis of gingivitis and pericoronaritis of the third molar. The patient had a favourable evolution.\n"
  },
  {
    "id": "multiclinsum_gs_en_204.txt",
    "fulltext": "A 33-year-old pregnant Japanese woman, G (1), P (0), received routine obstetrical screening at 14 weeks of gestation. Fetal biometry was consistent with the corresponding gestational age. With a three-vessel trachea view on multiplanar view by color Doppler with STIC, PLSVC on the left side of the pulmonary artery was noted, and a narrowing aortic isthmus was suspected. A narrowing isthmus was also suspected with an aortic arch view. HDlive Flow with STIC (Voluson E10 BT20, GE Healthcare, Zipf, Austria) with a curved array trans-abdominal transducer (GE eM6C G2, 2–7 MHz) clearly showed spatial relationships among the right superior vena cava, aorta with narrowing isthmus, pulmonary artery, and PLSVC. A preductal ‘shelf’ was also suspected. PLSVC could be clearly identified on the panoramic view. No other fetal anomaly was noted. A narrowing isthmus and PLSVC with right ventricular dominance were confirmed in the second- and third-trimester scans. The pregnancy course was non-eventful.\n\nA female newborn was vaginally delivered by vacuum extraction at 40 weeks and 6 days of gestation with a body weight of 2,586 g and length of 46 cm. The umbilical artery pH was 7.288. She had an Apgar score of 8/9 at 1 and 5 min, respectively. Neonatal echocardiographic diagnosis was CoA (isthmus diameter=2.4 mm) (normal range of isthmus diameter for Japanese infant with a height of 46 cm: 2.51–8.79 mm) and PLSVC. No blood pressure difference was noted between the arm and leg. There was no need for prostaglandin E1 use after delivery. On the 28th neonatal day, ductus arteriosus closure was confirmed with color Doppler ultrasound, and no effect on the circulatory hemodynamics of the baby was ascertained. So, close follow-up was decided. The neonate followed a favorable course without operation after delivery.",
    "summary": "We present the trans-abdominal HDlive Flow features of CoA and PLSVC at 14 weeks of gestation. With a three-vessel trachea view on multiplanar view using color Doppler with STIC, PLSVC on the left side of the pulmonary artery was noted, and a narrowing aortic isthmus was suspected. A narrowing isthmus was also suspected with an aortic arch view. HDlive Flow clearly showed the spatial relationships among the right superior vena cava, aorta with narrowing isthmus, pulmonary artery, and PLSVC. A preductal ‘shelf’ was also suspected. No other fetal anomaly was noted. Neonatal echocardiography after delivery confirmed CoA and PLSVC."
  },
  {
    "id": "multiclinsum_gs_en_530.txt",
    "fulltext": "Case background\nOn June 13, 2022, a 32-year-old woman was admitted to the hospital following a sudden episode of syncope. She had a 10-year history of Hashimoto thyroiditis, managed with levothyroxine replacement therapy.\n\n\nMedical history\nThree years prior: the patient was hospitalized at a local facility for a rash and lower limb edema. A renal biopsy confirmed SLE with class IV lupus nephritis. She was treated with glucocorticoids and cyclophosphamide (CTX) for 6 months, which alleviated her symptoms. However, persistent mild proteinuria and hypoalbuminemia necessitated the addition of tacrolimus.\n\nOne year prior: the patient presented to our hospital with transient lumbar soreness. Imaging studies revealed a retroperitoneal mass. The mass demonstrated delayed enhancement, suggestive of RPF or lymphoma. PET-CT indicated mildly increased metabolic activity. The patient declined further evaluation and hospitalization.\n\nFrom January to March 2022: To prepare for pregnancy, she discontinued glucocorticoids and CTX and switched to traditional Chinese medicine (details unknown). During this period, she did not undergo regular monitoring.\n\nHospital course\nOn June 13, 2022, the patient was readmitted to the emergency department after another episode of syncope. Laboratory tests revealed severe pancytopenia, hypoalbuminemia, and active lupus. Imaging studies showed a significant increase in the size of the retroperitoneal mass, accompanied by massive ascites (enhanced CT).An ultrasound-guided biopsy confirmed RPF, with negative immunohistochemical staining for IgG and IgG4.\n\nTreatment and follow-up\nDuring hospitalization: the patient received high-dose methylprednisolone pulse therapy (500 mg/d for 3 days), followed by a gradual taper. She was also treated with intravenous immunoglobulin (20 g/d), rituximab (500 mg, single dose), and supportive care. Laboratory results showed gradual improvement in hematologic parameters and complement levels. MRI revealed a reduction in the size of the retroperitoneal lesion.\n\nOver the 10-month follow-up period\nMedication adjustments: the patient continued treatment with low-dose glucocorticoids, tacrolimus (1 mg twice daily), and belimumab (600 mg). Glucocorticoid doses were gradually tapered to the minimal effective dose.\n\nTreatment response: The retroperitoneal lesion decreased significantly in size. Proteinuria resolved (24-hour urinary protein decreased from 7.6 g to 280 mg), and serum albumin and immunological markers progressively normalized.\n\nInfection management: during follow-up, the patient experienced upper respiratory tract infections, pneumonia, and herpes zoster, all of which were promptly treated with favorable outcomes.",
    "summary": "Patient concerns: A 32-year-old woman presented with sudden-onset syncope. Her medical history revealed a 5-year history of SLE, and imaging studies identified a retroperitoneal mass.\n\nDiagnoses: A comprehensive diagnostic workup, including magnetic resonance imaging (MRI) and biopsy, confirmed retroperitoneal fibrosis secondary to SLE.\n\nInterventions: The patient was treated with high-dose corticosteroids, immunosuppressive therapy, and the biologic agent rituximab.\n\nOutcomes: The patient's symptoms markedly improved, and follow-up MRI demonstrated significant regression of the retroperitoneal lesion."
  },
  {
    "id": "multiclinsum_gs_en_227.txt",
    "fulltext": "A 24-year-old man of Persian ethnicity presented with a chief complaint of mouth malodor after a period of mild coronavirus disease 2019 (COVID-19) recovery, which he wanted to resolve as soon as possible. His dentist noticed bone loss and bleeding on probing in the interproximal area of teeth numbers 18 and 19 clinically. Scaling and root planing was performed, and periapical and panoramic radiographs were ordered for patient evaluation. However, the patient refused to take radiographs. The patient’s halitosis subsided after 1 week of treatment. After 2 months, patient returned to his dentist with the chief complaint of cold sensitivity in his mandibular incisors. The dentist performed a vitality test, and the teeth were vital except teeth numbers 23 and 24. The dentist took a periapical radiograph, and a radiolucent lesion in the anterior mandible was evident.\n\nIn panoramic radiograph, a large, well-defined lytic radiolucent lesion with scalloped borders extending from tooth number 31 on the right side to the left ascending ramus was evident. Further cone beam computed tomography (CBCT) study revealed a large multilocular lytic lesion, with a relatively distinct margin, which caused thinning and perforation of buccal and lingual cortexes and signs of scalloping.\n\nAfter examination, the patient was referred to an oral and maxillofacial surgeon. In the medical interview, the patient explained his mitral valve prolapse; history of recurrent episodes of otitis from the first year of his life; history of septicemia with an unknown origin when he was 1 year of age after episodes of diarrhea and vomiting; history of bronchodilator usage for seasonal allergy; history of levothyroxine, cabergoline, desmopressin acetate (DDAVP) spray, and testosterone gel usage for 4 years after diagnosis of empty sella syndrome following polyuria and polydipsia; and finally, a history of recent COVID-19 infection (3 months earlier). His familial history revealed Hashimoto’s thyroiditis in his maternal family; his grandfather, mother, and all three of his aunts suffered from this kind of hypothyroidism. The patient’s past surgical history included a repair of an inguinal hernia 10 years prior without any complications. In addition, the patient was obese, with a body mass index (BMI) of 34.5.\n\nOn clinical examination, extraoral and intraoral findings were unremarkable. Laboratory tests, including complete blood count (CBC), were normal, except for an increase in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. An incisional biopsy was performed in the anterior mandible, and the specimen was sent to the department of oral and maxillofacial pathology at the Shahid Beheshti University of Medical Sciences. Sections showed diffuse infiltration of large pale-staining cells such as histiocytes with indented and numerous eosinophils in the fibrous background. An immunohistochemistry (IHC) examination revealed scattered positive for cluster of differentiation-1a (CD-1a) (+ +), strongly positive for Langerin (CD-207) (+ + +), and more than 50% positive for S-100.\n\nAccording to clinical, radiological, and histopathological data, the diagnosis of LCH was reached. Differential diagnoses were osteomyelitis, eosinophilic granuloma, and bone metastasis. However, owing to laboratory tests, radiologic data, and clinical history, the diagnosis of LCH was confirmed. Therefore, for further examination, the patient was referred to the nuclear medicine department for positron emission tomography with fluoro-2-deoxyglucose and computed tomography (FDG PET/CT), which revealed hypermetabolic lytic lesions in the mandible, right parietal, left frontal, and left sphenoid bones, and hypermetabolic opacity in the left ethmoid sinus. In addition, increased metabolic activity in the sellar region, communicating hydrocephaly, and prominent hypermetabolic palatine tonsils were observed. Moreover, heterogeneous-increased metabolic activity in bilateral tibia and femurs was evident.\n\nA brain MRI revealed a remarkable enlargement of sella-containing cerebrospinal fluid (CSF) intensity material. Adenohypophysis appeared as a thin layer at the base of enlarged sella, and enhanced homogeneous and inflammatory changes were seen at the left mastoidal air cells. Extension of inflammation toward the left middle ear was seen (it is noteworthy that the patient suffered from otitis for many years). According to multifocal involvement of disease and its questionable prognosis, the patient was referred to the oncology department for systemic chemotherapy. Further tests revealed mutations in the BRAF oncogene and no detectable mutations in KRAS and NRAS. The oncologist chose a denosumab, vinblastine, etoposide, 6-mercaptopurine, methotrexate, and pegfilgrastim regimen; however, follow-up was not possible as the patient died following an accident.",
    "summary": "A 24-year-old male patient of Persian ethnicity presented with a chief complaint of halitosis following coronavirus disease 2019 recovery to his general dentist's office. Intraoral and extraoral examinations revealed no specific problem. In the follow-up session after phase I periodontal treatment, teeth sensitivity to cold stimulus was evident, and radiographs revealed a large lytic intraosseous lesion in the mandible. An incisional biopsy revealed Langerhans cells and a positive reaction to Langerin and cluster of differentiation 1a, thus, he was diagnosed with Langerhans cell histiocytosis. After performing positron emission tomography with fluoro-2-deoxyglucose and computed tomography, magnetic resonance imaging, and cone beam computed tomography, owing to generalized disease involvement, the patient was referred to an oncologist. Ultimately, it was found that the patient's childhood health issues, including endocrine problems, were likely caused by an undiagnosed Langerhans cell histiocytosis. The oncologist chose denosumab, vinblastine, etoposide, 6-mercaptopurine, methotrexate, and pegfilgrastim regimen. The follow-up was not possible as the patient died following an accident."
  },
  {
    "id": "multiclinsum_gs_en_314.txt",
    "fulltext": "The patient was a 16 year-old boy who was referred to our hospital in July 2022 because of severe heart failure.\n\nAt age 13, he was diagnosed Becker muscular dystrophy carrying with the causative mutation in gene DMD (chrX:32,841,413–32,862,977, Hemizygous mutation), and gene testing showed the comorbid mutations of ABCB4(chr7:87041219, heterozygous mutation) and DSC2(chr18:28659938, heterozygous mutation). He had a history of mild breath shortness and chest distress on exertion and received treatment for cardiac dysfunction; however, heart function became worse and he was referred to our hospital for the first time. Physical examination at his first referral showed a height of 173 cm, body weight of 78 kg, blood pressure of 110/90 mmHg, heart rate of 76 beats/minute regularly, respiratory rate of 20 times/minute, body temperature of 36.5 °C, and SpO2 of 100% under room air. There was no jugular vein dilatation in the neck. His lung and cardiac auscultation sounds were normal. His abdomen was flat. There was slight edema in both instep and ankle. The patient did not show wing-like shoulder blades or lordosis. Pseudohypertrophy of the bilateral gastrocnemius muscle was observed. Gower’s sign was negative. Laboratory test showed that N-terminal prohormone of brain natriuretic pee (NT-proBNP) level was 471.55pg/ml, myohemoglobin was 272.61ng/ml, creatine kinase (CK) was 5,493 U/L, creatine kinase-MB (CK-MB) was 115 U/L, creatine kinase-MM (CK-MM) was 5,378U/L. Alanine aminotransferase (ALT) was 138 U/L, aspartate aminotransferase (AST) was 92 U/L, lactate dehydrogenase (LDH) was 393U/L. The transthoracic echocardiography showed a 19% left ventricular ejection fraction (LVEF), dilation of left atrium, left ventricle and right atrium, mild mitral valve regurgitation, severe LV systolic dysfunction, decreased whole heart diastolic function. Leg MRI revealed that muscular dystrophy changes in bilateral thighs. Medication treatments were started including sacubitril-valsartan, carvedilol, ivabradine, tolvaptan, trimetazidine and adjusted according to the heart failure treatment guidelines in the coming 3 years’ of follow-up. Follow-up echocardiographic LVEF value fluctuated at 30–35%.\n\nOn the first day of this referral, the patient suffered deteriorating chest distress, palpitation, and shortness of breath at rest indicating progressive heart failure. He was referred to our hospital at 9:00 p.m. On physical examination, blood pressure of 106/63mmHg, heart rate of 120 beats/minute irregularly, respiratory rate of 20 times/minute, body temperature of 37℃, and SpO2 of 97% on room air. A chest examination revealed moist crackles in both lungs. His heart sounds were intact but irregular, and no heart murmur was observed. His muscle strength was 5/5. Laboratory tests showed the following results: white blood cell count, 10.56 × 109/L with neutrophils 60.5%; hemoglobin, 144 g/L; platelet count, 177 × 109/L. Coagulation function was sightly abnormal, as follows: Prothrombin time (PT), 14.8 s; activated partial thromboplastin time (APTT), 27.1 s; D-Dimer, 0.27 mg/L. Biochemical examination showed potassium of 3.9 mmol/L, creatinine of 67µmol/L. His total bilirubin level was normal, but his liver enzyme levels were slightly elevated, as follows: ALT, 109 U/L; AST, 87 U/L; LDH, 376U/L. NT-proBNP was markedly elevated to 9,171pg/ml. cTnT level was 0.107ng/ml. The electrolyte levels were normal. Electrocardiogram showed atrial fibrillation with rapid ventricular rate and intraventricular heart block.\n\nAt 10:00 p.m. on the first day, chest distress was aggravating. 150 mg of amiodarone through intravenous injection failed cardioversion. Ventricular rate was 120 bpm. Then, 450 mg of amiodarone was used for rate and rhythm control through continuous intravenous dripping (6ug/Kg/min). At the same time, we provide continuous infusion of recombinant human brain natriuretic peptide to improve clinical heart function. ECG monitor showed atrial fibrillation with ventricular rate of 90 bpm.\n\nAt 1:00 pm on the second day, the patient became pale, sweating and orthopnea. The patients’ blood pressure dropped to 75/50 mmHg, heart rate was 74 bpm. Therefore, amiodarone and recombinant human brain natriuretic peptide was discontinued and intravenous infusion of dopamine and dobutamine was administrated. All oral medications were stopped at the same time. ECG showed a normal sinus rhythm of 84 bpm and second-degree type II atrioventricular block. Emergency bedside echocardiography showed that dilatation of whole heart with reduced systolic function of left and right ventricle (LVEF 25%), mild pulmonary artery hypertension, infinitesimal pericardial effusion. Physical examination showed blood pressure of 89/60mmHg, heart rate of 74 bpm regularly and SpO2 of 99% under 3 L/minute oxygen. Skin mottling was visible on both lower limbs. The urine volume on the second day was 1,000 ml.\n\nOn the third day, abdominal ultrasound revealed gallstones and cholecystitis. Meropenem (0.5 g q12h ivgtt) was used empirically to control infection. The urine volume decreased to 400 ml.\n\nOn the 4th day, the patient complained of relief of chest distress. Laboratory tests showed the following results: ALT, 7,391 U/L; AST, 5,671 U/L; LDH, 8,089U/L; CK, 2,875pg/ml, CK-MM, 28,522U/L; CK-MB, 229U/L; urea nitrogen, 29.8mmol/L; uric acid, 859µmol/L; creatinine, 305 µmol/L; eGRF, < 30 ml/min/1.73m2; platelet,104 × 109/L; PTs, 29.3 s; APTT, 29.9 s; Fibrinogen, 163 mg/dl; D-Dimer > 40 mg/L. He was referred to ICU for further treatment.\n\nWe provided bedside continuous renal replacement therapy. Administrations of isoglycyrrhizinate, reduced glutathione and polyene phosphatidylcholine were given to protect liver function. Dopamine and dobutamine (1.3ug/kg/min) was administrated to sustain blood pressure and strengthen heart contraction. Laboratory examinations were conducted to monitor patient’s related indexes. Coagulation function: PTs was 22 s. D-Dimer was higher than 40 mg/L. Liver function were as follows: total bilirubin level of 75.5µmol/L, ALT of 5,060 U/L, AST of 1,952 U/L, LDH of 8,089U/L. Renal function: blood urea nitrogen of 23.8mmol/L, uric acid of 604 µmol/L, creatinine of 322 µmol/L, and eGRF 23 ml/min/1.73m2. NT-proBNP was 5701 pg/ml, CK was 11476U/L, CK-MM 11308U/L, CK-MB 168U/L. ECG showed a normal sinus rhythm of 62 bpm, intraventricular heart block, left atrial hypertrophy and left axis deviation.\n\nAt 10:00 pm on the 5th day, dopamine was discontinued. Blood pressure fluctuated 90–112/50-70mmHg. We administrated oral sacubitril-valsartan 25 mg bid and trimetazidine 35 mg bid on July 10th. Ivabradine (5 mg bid p.o.) and tolvaptan (10 m qd p.o.) were administrated on the 10th day due to stable hemodynamics, improved renal function and increased daily urine volume. Dobutamine was stopped on the 11th day. Low molecular weight heparin was started on the 12th day.\n\nOn the 15th day, reexamination of laboratory examinations suggested significant amelioration of liver function. Alanine aminotransferase was down to 255 U/L, aspartate aminotransferase to 35U/L. The daily amount of transfusion was 2,106 ml with daily urinary output of 1,125 ml. Therefore, polyene phosphatidylcholine was stopped. Hemodialysis catheters were removed.",
    "summary": "We present a case of a 16-year-old boy admitted with heart failure and atrial fibrillation (AF). He was diagnosed with Becker muscular dystrophy (BMD) and gene testing showed comorbid mutations in gene DMD, ABCB4 and DSC2. Amiodarone was prescribed to control the paroxysmal atrial fibrillation intravenously. However, his liver enzyme levels were sharply elevated, along with cardiac shock, renal failure and coagulation disorders. After bedside continuous renal replacement therapy, the patient’s liver function and clinical status rehabilitated."
  },
  {
    "id": "multiclinsum_gs_en_97.txt",
    "fulltext": "The patient was a 34-year-old primigravid Japanese woman who had hypothyroidism, for which she had been prescribed levothyroxine sodium hydrate (50 μg/day). She presented to another clinic with genital bleeding and a 2-week delay in menstruation and obtained a positive result on a urine pregnancy test 2 weeks later. The patient was referred to our hospital for perinatal care. At 6 weeks of gestation, she had mild abdominal pain and no genital bleeding. Examination using a vaginal speculum revealed cervical erosion and moderate white discharge. Transvaginal ultrasonography revealed a gestational sac, a 9-mm fetus with a heartbeat, and a subchorionic hematoma in the uterus.\n\nAt 7 weeks of gestation, the patient experienced a miscarriage. She had a fever of 37.0–37.5°C, and her white blood cell count was within the normal range, with a C-reactive protein level of 1.0–2.0 mg/dL. Ultrasonography showed a 3 cm subchorionic hematoma, and her hemoglobin level was 9.0–10.0 g/dL, indicating mild anemia but no bleeding. Laboratory test results showed abnormal serum albumin (3.2 g/dL) and creatinine (6.69 mg/dL) levels, whereas sodium, potassium, and chlorine levels were within the normal ranges. She was seronegative for the human immunodeficiency, hepatitis B, and hepatitis C viruses, as well as the cardiolipin, antinuclear, anti-glomerular basement membrane, and anti-neutrophil cytoplasmic antibodies (c-ANCA and p-ANCA). However, she was seropositive for lupus anticoagulant. Protein C and S activity levels were normal. The patient had no history of diabetes mellitus, heart failure, pyelonephritis, sepsis, or hyperemesis gravidarum. She also experienced no symptoms of systemic lupus erythematosus, such as malar rash, oral ulcers, arthritis, leukopenia, and thrombocytopenia. The patient experienced oliguria, and her serum creatinine and blood urea nitrogen levels were abnormally increased. Qualitative urine test results showed strong positivity for occult blood and white blood cells but exhibited negativity for protein. Urine sedimentation test results showed erythrocytes; leukocytes; other tubular epithelial cells; and vitreous, granular, and epithelial cylinders. N-acetyl-β-D-glucosaminidase and β2 microglobulin were also detected in the urine.\n\nA renal biopsy was performed without any complications approximately 10 days after miscarriage. Optical microscopy revealed cytoplasmic vacuolar degeneration of the tubular epithelium throughout the cortex. Focal tubular epithelial cell shedding, necrotic debris in the tubular lumen, and medullary tubular epithelium degeneration were also observed. The tubular interstitium showed mild edema and occasional focal infiltration of inflammatory cells, which were predominantly lymphocytes mixed with neutrophils and eosinophils. Immunofluorescence analysis revealed negativity for immunoglobulin G, immunoglobulin A, immunoglobulin M, complement component 3, complement component 1q, and complement component 4. Notably, no glomerular lesions were observed on light or electron microscopy; that is, renal biopsy findings indicated only tubulointerstitial damage. She was diagnosed with stage III AKI according to the RIFLE, AKIN, and KDIGO criteria. However, she was not diagnosed with septic abortion or hyperemesis gravidarum.\n\nThe patient underwent manual vacuum aspiration under general anesthesia. At the time of surgery, her serum albumin and creatinine levels were 2.5 g/dL and 9.81 mg/dL, respectively. Urinalysis results showed a protein level of 0.28 g/dL and no white or red blood cells. Moderate bleeding occurred intra-operatively; however, the patient tolerated the procedure well. During the peri-operative period, the patient was treated with loop diuretics, and the urine output exceeded 0.5 mL/kg/h after treatment.\n\nNotably, the patient’s urinary output and laboratory findings, including serum creatinine and blood urea nitrogen levels, improved without additional treatment. Urinalysis revealed no abnormalities. Histopathological examination of the resected endometrial tissue revealed decidual and implantation-related changes. Moreover, chorionic villi without enlargement, which consisted of syncytial trophoblast and cytotrophoblast cells, were observed. There were no findings indicative of molar pregnancy. After manual vacuum aspiration, the patient’s laboratory parameters and renal function recovered, and she had no complications. Antiphospholipid syndrome was ruled out as the lupus anticoagulant was negative postoperatively. The patient was discharged 3 days postoperatively.",
    "summary": "A 34-year-old primigravid woman was referred to us for perinatal management at 6 weeks of gestation. Unfortunately, she was diagnosed with miscarriage 1 week later. The patient had no history of hyperemesis gravidarum or septic abortion; however, she developed oliguria, and her serum creatinine and blood urea nitrogen levels were abnormally increased. Consequently, she underwent a renal biopsy to evaluate renal dysfunction, which indicated tubulointerstitial damage. The patient also underwent manual vacuum aspiration for a miscarriage. Postoperatively, her urine output increased, and her renal function improved. She was determined to have experienced Pr-AKI due to her miscarriage."
  },
  {
    "id": "multiclinsum_gs_en_127.txt",
    "fulltext": "The patient was a 44-year-old Japanese man with a history of acute appendicitis at the age of 15 years. He had no known allergies. He was a chronic smoker (15 cigarettes/day for 25 years) and consumed alcohol occasionally. From the age of 20 years, he experienced recurrent painful subcutaneous nodules on his limbs. At the age of 39 years, he developed polyarthritis and myalgia. Blood investigations performed at a local public hospital revealed elevated C-reactive protein (CRP) level. Myeloperoxidase-anti-neutrophil cytoplasmic antibody and proteinase-3-anti-neutrophil cytoplasmic antibody were negative, eosinophil count was normal, and urine tests were unremarkable. He had no symptoms affecting the eyes, nose, or mouth. Furthermore, chest computed tomography showed no signs of interstitial pneumonia. He tested negative for HBV.\n\nA skin biopsy from a subcutaneous nodule on his left lower leg showed infiltration of numerous lymphocytes and neutrophils in the medium-sized vessels in the deep dermis. Based on Watts criteria, a diagnosis of PAN was established, and treatment with PSL 40 mg was initiated. AZP was included later in the treatment. Five months into treatment, on PSL 10 mg and AZP 25 mg, he was referred to our hospital because of severe pain despite taking NSAIDs three times daily. At the first visit to our hospital, he was 40 years old, 171 cm tall, and weighed 80 kg. His vitals were as follows: blood pressure of 132/74 mmHg; pulse of 91 bpm; respiration rate of 12 breaths/min; SpO2 of 97% (room air), and body temperature of 36.0°C. Despite ongoing treatment, he showed no improvement in joint pain, myalgia, and painful rashes; the CRP level was 0.66 mg/dl. An ultrasound revealed tenosynovitis in the right posterior tibial and flexor digitorum longus tendons, with inflammation at the navicular tuberosity attachment of the posterior tibial tendon. Moreover, magnetic resonance imaging of the right elbow showed high signal intensity in multiple muscles on spectral attenuated inversion recovery (SPAIR) sequence. Despite changes in immunosuppressants, his symptoms and CRP levels did not improve, and PSL could not be tapered.\n\nAlthough the administration of TCZ every two weeks normalized the CRP levels, he showed no symptomatic improvement. Even when the TCZ dosing interval was reduced to weekly, tapering of PSL was not possible. Subsequently, switching to UPA resulted in a relatively rapid resolution of joint pain, myalgia, and rashes. MTX, PSL, and NSAIDs were gradually discontinued, and after one year of UPA use, there were no relapses or side effects.",
    "summary": "We report a 44-year-old Japanese man with refractory PAN who was unresponsive to various immunosuppressants (including tocilizumab). Upadacitinib treatment led to relatively rapid symptom improvement, allowing for tapering and eventual discontinuation of immunosuppressants, including prednisolone. During his 1-year follow-up, no relapse or side effects were noted."
  },
  {
    "id": "multiclinsum_gs_en_251.txt",
    "fulltext": "64-year-old patient admitted with a 8-month history of asthenia, anorexia, jaundice, weight loss of 30 kg and a mass in the right lung on chest radiograph, recently detected. In the last few days he added disorientation and apathy. A computed tomography (CT) of the chest was performed showing a 30x25 mm mass in the lateral segment of the middle lobe, homogeneous, with a small hypodens image inside, as well as bilateral pleural effusion. In the admission laboratory, a hepatogram alteration was observed (total bilirubin: 6.5 mg/dL, direct bilirubin: 6.3 mg/dL, glutamic oxaloacetic transaminase: 174 IU/L, glutamic pyruvic transaminase: 41 IU/L, alkaline phosphatase: 604 IU/L, tricyto-penia (haematocrit: 28, haemoglobin: 9.3 g/dL, white blood cell count: 3200/ mm3. Neutrophils: 89.6%, lymphocytes: 6.6%, eosinophils: 0%, monocytes: 3.8%, basophils: 0%, platelets: 100 000/ mm3), hypoalbuminaemia (1.8 g/dL), moderate hyponatraemia (127 mEq/L) and hypergammaglobulinemia (2.21 g/dL), the rest of the basic laboratory determinations being normal. Serum ammonium was normal. Serological tests for hepatitis A, B and C, VDRL and HIV were negative. The test for the detection of antinuclear antibodies (ANA/FAN) was positive with a titre of 1/1280 and a homogeneous nuclear pattern (AC-1). The tests for the following autoantibodies were positive: anti double-stranded DNA, anti cyclic citrullinated peptide, anti ribosomal P antigen and anti C1q, and negative for anti smooth muscle (AML), anti LKM, anti antimitochondrial antibodies, anti myeloperoxidase, anti proteinase 3, anti Sm, anti La, anti Ro, anti RNP and anti rheumatoid factor. The direct Coombs test was positive.\n\nThe complement fractions C3 and C4 were found to be decreased. C3: 28 g/dL (normal value: 90-180 g/dL), C4: 5 g/dL (normal value: 10-40 g/dL). The neutrophil count was decreased. Erythrocyte series with decreased haemoglobin was observed. Myeloid series with some elements with asynchronous maturation. These findings were interpreted as reactive changes. The abdominal ultrasound and Doppler port-a-cath scan were performed, and a mild ascites was found without hepatic focal lesions or signs of portal hypertension. A magnetic resonance imaging of the brain with gadolinium was performed, which showed mild cortical atrophy with a predominance of the frontal lobe, and no other relevant findings. The puncture of the pulmonary mass was performed under CT guidance, and the sample was sent to the anatomic pathology laboratory. The microscopic examination showed a predominance of neutrophils, and no neoplastic cells were found. The PAS, Ziehl-Neelsen and Grocott stains were negative. In the bacteriological laboratory, the sample obtained by puncture of the pulmonary mass was processed following the manual procedure. After 6 days of incubation, development was observed in the liquid media. With Gram staining, Gram-positive branched bacilli were observed, and a Kinyoun stain was performed on the liquid medium, and the result was positive. After 48 hours of subculture of the liquid medium in the solid culture medium, the growth of whitish colonies was observed. The identification was carried out by conventional tests and by mass spectrometry (MALDITOF MS), corresponding to Nocardia cyriacigeorgica (identification score 1.97). The thoracocentesis was performed, and the liquid was obtained with characteristics of uncomplicated exudate. Cells: 350/ mm3 (polymorphonuclear 19%, lymphocytes 60%, monocytes 21%, with presence of reactive mesothelial cells). The culture of the pleural liquid was negative. The liver biopsy showed mild and variable mixed inflammatory infiltrate in the portal spaces, with absence of interphase hepatitis and presence of a perivenous duct reaction highlighted by the immunohistochemical cytokeratin 7 technique. A level of acinar bilirubinosis was observed. No necrotic-inflammatory foci were observed. Mild perivenular and periportal fibrosis was objectified. The thoracocentesis was performed, and the liquid cerebrospinal fluid (CSF) was obtained with the following characteristics: appearance of rock crystal, proteinorracia: 69.8 mg/dL (normal value: 20-40 mg/dL), glucorracia: 35 mg/dL (glucose: 86 mg/dL) and chloride: 115mEq/L (normal value: 114 to 118 mEq/L). Culture for common germs, acid-alcohol resistant bacilli, fungi and Nocardia was negative. PCR was negative for herpes virus. The patient met 8 criteria of SLE according to the criteria of the SLICC group 2012 (ANA positive with a titre of more than 1/80, leucopenia, thrombocytopenia, delirium, pleural effusion, hypocomplementemia, anti-DNA antibodies positive and positive Coombs test in the absence of anaemia) and 24 points according to the EULAR/ACR 2019 criteria (entry criteria ANA positive, plus additional criteria: leucopenia: 3 points, thrombocytopenia: 4 points, delirium: 2 points, pleural effusion: 5 points, decrease of C3 and C4: 4 points and anti-DNA antibodies: 6 points). He received antibiotic treatment with ceftriaxone-trimetoprim-sulfamethosazole (TMS) for 1 month, then was changed to oral treatment with minocycline-TMS. As an immunosuppressive treatment, he started meprednisone 40 mg/dL and hydroxychloroquine 200 mg/dL, which normalised the hepatic panel. After observing a reduction in the size of the pulmonary mass in the CT, and in the face of a diagnosis of neuropsychiatric involvement due to lupus, pulse cyclophosphamide was initiated, achieving a frank improvement in consciousness. After 2 months of hospitalisation, he was discharged for follow-up as an inpatient, but still with nutritional support. After one year of being discharged, he had regained weight, was lucid, and in good health.\n",
    "summary": "A 64-year-old man was admitted for delirium associated with jaundice with a cholestatic pattern in the hepatic panel and a mass in the right lung in the context of weight loss and constitutional syndrome of 8 months of evolution. A puncture of the pulmonary mass was performed and the culture developed off-white colonies identified as Nocardia cyriacigeorgica by mass spectrometry (MALDI-TOF MS). The diagnosis of systemic lupus erythematosus (SLE) was reached by presenting 8 of the criteria according to the SLICC 2012 group and 24 points according to the EULAR/ACR 2019 criteria. The liver biopsy showed mild and variable mixed inflammatory infiltrate in the portal spaces, with absence of interphase hepatitis and presence of peripheral ductular reaction. These findings were interpreted as linked to hepatic disease due to SLE based on the discard of other diseases. He received antibiotic treatment and after the reduction of the size of the pulmonary mass was observed, intravenous pulses of cyclophosphamide were administered. He evolved favorably, with normalization of the hepatic panel and the state of consciousness, and progressive weight recovery. After one year he was found in good health.\n"
  },
  {
    "id": "multiclinsum_gs_en_447.txt",
    "fulltext": "39-year-old male with no significant history. He presented with a non-severe COVID-19 infection in August 2021, receiving the following corticosteroid regimen for 10 days: dexamethasone 8 mg intramuscular every 24 hours + deflazacort 6 mg orally every 12 hours for the first six days. The total corticosteroid doses received by the patient were as follows: 80 mg dexamethasone + 72 mg deflazacort = 560 mg prednisone/560 mg prednisolone over a 10-day period. During a seven-month period since the diagnosis of COVID-19, the patient presented with 10/10 left-dominant coxalgia on the visual analogue scale (VAS), which increased progressively, limiting the range of motion of the hip and making it difficult to walk.\n\nAfter the physical examination, we found claudicatio intermittens in the left lower limb; flexion of 45o, abduction of 30o, extension of 20o, external and internal rotation of 15o. A posterior-anterior radiograph of the pelvis was requested as an initial study, which showed loss of the sphericity of the left femoral head, as well as geodes and a crescent-shaped sclerotic image. Magnetic resonance arthrography was performed, which showed collapse of the left femoral head, both hips with diffuse hyperintensity zones and a crescent-shaped image in the left hip. After the radiographic findings and the significant limitation of mobility for the development of daily activities, a total replacement of the left hip was proposed and performed through a posterior-lateral approach. During the surgical event, the femoral head was observed macroscopically, which showed areas of bone necrosis and geodes inside. As for the articular components, non-cemented components were used as described below: acetabular cup #54 (G7 ZimmerBiomet), short stem #4 (Taperloc Microplasty ZimmerBiomet), ceramic head #36 ± 0 mm and Liner 54/36 UHXLP. During the postoperative period, he walked without incident and began walking with a walker 12 hours after surgery, with a decrease in left hip pain to 2/10 on the visual analogue scale (VAS), as well as a significant improvement in mobility arcs.\n",
    "summary": "A 39-year-old male patient with a diagnosis of avascular necrosis of the left hip following administration of corticosteroids for the treatment of COVID-19 is described. The dose of steroids capable of causing avascular necrosis is not clear or well described; however, there are reports in the literature where doses of 2,000 mg of prednisone (or equivalents) are reported to develop. The treatment of avascular necrosis aims to relieve pain, slow the progression of the condition, prevent collapse in the early stages and restore joint function.\n"
  },
  {
    "id": "multiclinsum_gs_en_261.txt",
    "fulltext": "A 2-year-old girl presented to emergency department with 5 days of high grade fever, cough and bilateral eyelid swelling. Prior to the onset of this illness, there were edema and a perinasal face skin furuncle. She had previously been otherwise healthy.\n\nPhysical examination revealed a very ill girl with periorbital and facial edema, high-grade fever, increased respiratory rate, decreased SpO2, and chest crepitation.\n\nAn eye exam revealed swelling around the eyes on both sides. Both globes showed axial proptosis. Examinations also showed injection, purulent discharge in both eyes with slow-reacting pupils, severe conjunctival chemosis, and external ophthalmoplegia affecting the third, fourth, and sixth cranial nerves.\n\nThe vertical disk ratio of the right eye was 0.3, while that of the left eye was 0.4. There was no evidence of engorged retinal veins or disc edema.\n\nLaboratory investigations showed a significantly high white blood cell count (WBC = 32,000 cells/mm3), low hemoglobin (5.5 mg/dL), and high C-reactive protein (112 mg/L). Blood culture was negative.\n\nOrbital CT demonstrated extensive bilateral periorbital soft tissue thickening and facial subcutaneous edema. In addition; Contrast enhanced CT of thorax revealed Multiple peripheral located cavitary lesions in the bilateral lungs (Septic emboli) and associated bilateral moderate pneumothorax with consolidation areas with air bronchogram in the left lower lung of the lung.\n\nThe patient was admitted in the pediatric ICU and treatment was initiated with intravenous (IV) ceftriaxone 500mg 12 hourly, IV clindamycin 100mg 8 hourly, Voltaren eye drop 8 hourly, Lomefloxacin eye drop 12 hourly after an initial loading dose of one drop every 5 min for 25 min, chloramphenicol ointment nocte and oral ibuprofen syrup 8 hourly. Bilateral chest tube were inserted for pneumothorax decompression.\n\nHer white blood cell count normalized and chest x ray was significantly improved. She was discharged from hospital after 15 days with orally administered antibiotic therapy (co_amoxiclav syrup 400mg) to be taken for one week.",
    "summary": "A 2-year-old girl presented with high-grade fever, cough, and bilateral eyelid swelling for 5 days preceded by edema and a perinasal facial skin furuncle. Examination revealed bilateral axial proptosis and orbital and thoracic CT bilateral orbital cellulitis, septic pulmonary embolism, and bilateral pneumothorax."
  },
  {
    "id": "multiclinsum_gs_en_114.txt",
    "fulltext": "15-year-old patient, previously healthy, with no significant pathological history, with full vaccinations for his age. Originally from a rural area in the province of Buenos Aires, Argentina. His father worked in the countryside. They had dogs and chickens at home. There was a shed where seed bags were stored, and there were usually pigeons in the eucalyptus groves.\n\nThe patient consulted for productive cough and pain in the side of a month of evolution, without febrile records or associated respiratory difficulty. Initially a chest radiograph was performed that evidenced two images of condensation in the left pulmonary base. With these images it was decided to perform a Computed Tomography of the chest in which images of nodular consolidation in the left base were found. With suspicion of pneumonia, antibiotic treatment with Amoxicillin was initiated. He was referred to our institution.\n\nThe tomography images were interpreted as pulmonary nodules and a Positron Emission Tomography (PET-CT) was performed to measure the metabolic activity of 18 fluorodeoxyglucose and to identify the uptake of glucose in the tissues through the standardized uptake value (SUV). Neoplastic cells as well as inflammatory and infectious processes show an elevated metabolism in this study.13 The examination showed multiple pulmonary lesions in the lower left lobe with increased metabolism by SUV in a range of 10.88-13.53. No lesions were found in the central nervous system, abdomen or pelvis. The tomographic characteristics could correspond to fungal or granulomatous involvement.\n\nThe complete laboratory examinations were in the normal range (hemogram, liver profile, renal function, electrolyte panel, coagulation tests), with negative acute phase reactants. Ultrasound examinations of the abdomen, kidneys, testicles and thyroid were performed without pathological findings. In the context of the study of pulmonary nodules, a tuberculosis census was performed, without finding evidence of close contacts for this disease; intradermal reaction of the purified protein derivative (PPD) with a negative result of 0 mm; serial bacilloscopy in sputum by Ziehl-Neelsen staining and culture were negative.\n\nConsidering the images and epidemiological risk factors such as rural origin and contact with bird droppings, the possibility of a mycosis was considered. It was decided to carry out a bronchoalveolar lavage, in which samples were taken for microbiological study. The culture was negative for bacteria, fungi and mycobacteria. The determination of serologies for Aspergillus in the bronchoalveolar lavage was negative, as was the polymerase chain reaction for histoplasma.\n\nA biopsy was performed using a tomographically guided needle. Direct mycological examination and Giemsa staining revealed yeast. The culture of the biopsy was positive for Cryptococcus neoformans grubii, which is sensitive to fluconazole (minimum inhibitory concentration 4 ug/ml) and itraconazole (minimum inhibitory concentration 0.06 ug/ml). The pathological anatomy showed a granulomatous inflammatory process with the presence of multinucleated giant cells and spherical structures positive with Schiff's periodic acid staining (PAS), which could correspond to a deep mycosis, without neoplastic cells.\n\nAs a patient with no history of immunosuppression, an immunological study was requested with a count of B lymphocytes, CD3, CD4, CD8, NK that was within normal limits, as well as the quantification of immunoglobulins (Ig) IgG, IgA, IgM and IgE and the determination of complement C3, C4 and CH-50. The HIV test by Elisa was negative.\n\nA high serum cryptococcal antigen titre (1:128) was reported and a central nervous system scan was normal. A lumbar puncture was performed and the physical and chemical findings, negative tinta china stain, and cryptococcal antigen search in cerebrospinal fluid (CSF) and culture were negative. The determination for the analysis of antigens in serum and CSF was carried out in the Francisco Javier Muñiz Infectious Diseases Hospital, CABA and the analysis was performed by latex agglutination test.\n\nHe received treatment with Itraconazole 200 mg per day for 4 weeks, until a definitive diagnosis was made, and then completed 10 months with fluconazole 200 mg per day. He did not experience adverse effects from the treatment.\n\nA metabolic re-evaluation of the pulmonary lesions was performed by a body PET-CT scan 6 weeks after the start of treatment. The nodular opacities were smaller and had a metabolism with SUV of 3.01 to 5.19. There were no new foci. The initial symptoms had subsided and he remained clinically asymptomatic.\n\nAt the end of the 10 months of treatment, a chest X-ray was performed with no pathological findings to highlight and a search for antigen in blood was also performed with a negative result.\n",
    "summary": "A 15-year-old, previously healthy patient from a rural area presented with a one-month-old cough and left-sided chest pain without fever or respiratory distress. Two pulmonary base nodules were seen on a chest X-ray. Computed tomography showed the nodules to be nodular. A suspected neoplastic disease was confirmed by a positron emission tomography scan that showed hypermetabolic nodular lesions. The tomographic characteristics could correspond to fungal or granulomatous involvement. Given the imaging and epidemiological risk factors, such as rural origin and contact with bird droppings, the possibility of a fungal infection was considered. A pulmonary biopsy was performed under tomographic guidance. Cryptococcus neoformans was identified in the microbiological culture. The patient received treatment with itraconazole and fluconazole with good clinical and imaging response after 10 months of therapy and follow-up.\n"
  },
  {
    "id": "multiclinsum_gs_en_74.txt",
    "fulltext": "We present the case of a 28-year-old male with no medical history who is referred to our unit for intermittent jaundice, pruritus and coluria of 6 months evolution. The physical examination was completely normal. The blood analysis showed a mild elevation of total serum bilirubin (1.35 mg/dL) with a predominant direct (0.8 mg/dL), gamma-glutamyl transferase (126 IU/L), alkaline phosphatase (329 IU/L) and liver enzymes (ALT 76 IU/L; AST 115 u/L). The abdominal ultrasound revealed intrahepatic bile duct dilatation. Magnetic resonance cholangiopancreatography was performed with abdominal scanning with gadolinium that showed a solid formation of defined edges of intermediate intensity, predominantly hypointense in T2 with slight enhancement after intravenous contrast administration; the same conditioned compression of the common hepatic duct with intrahepatic bile duct dilation to the left. The CEA and CA 19-9 tumour markers were normal. Endosonography was requested that showed a solid lesion in the liver hilum, hypoechoic, heterogeneous of defined edges of 39 mm that obstructs the common hepatic duct and displaces the hepatic artery and portal vein. A fine needle biopsy was performed with 22G needle diagnosing a well-differentiated neuroendocrine neoplasm; the immunomarking evidenced: CK (+), CD-56 (+), Ki-67 3%, chromogranin (+) and β-catenin (+) cytoplasmic. The positron emission tomography with gallium identified a hypercapturing soft tissue density lesion (SUV 34.5) in the liver hilum topography. The chromogranin-A was elevated (167 μg/L, reference value <100 μg/L). In the multidisciplinary oncological hospital, surgical procedure was decided. The intraoperative findings revealed the presence of a nodular tumour located in the common bile duct, next to the cystic insertion. There was no evidence of hepatic, ganglionic or peritoneal spread. Cholecystectomy, resection of the compromised bile duct with oncological margins, hepatic pedicle lymphadenectomy and biliopancreatic bypass through a Roux-en-Y end-to-end hepaticojejunostomy was performed. The patient was discharged on the fifth day of hospitalisation, without complications during the immediate postoperative period. The histopathological analysis of the operative piece showed a well-differentiated neuroendocrine tumour G1 of 2.8 cm (2 mitoses/10 high-powered fields) with a Ki 67 index of 3-20%. The surgical margins were free of tumour without presence of metastatic ganglion (6 isolated ganglia). After 1 year of follow-up, the patient remains free of disease without signs of recurrence.\n",
    "summary": "28-year-old man with a 6-month history of intermittent jaundice, pruritus and coluria. A magnetic resonance imaging of the pancreatic and biliary tract, a PET-CT scan and an endoscopic ultrasound were performed, which concluded that the neoplasm was a well-differentiated neuroendocrine neoplasm. A complete resection of the main bile duct was performed with a lymphadenectomy of the hepatic pedicle with a Roux-en-Y hepaticojejunostomy, without complications. The patient had a good evolution and is disease-free.\n"
  },
  {
    "id": "multiclinsum_gs_en_376.txt",
    "fulltext": "This is a case of a 12-year-old male child from Yirgalem city in southern Ethiopia who presented to Yirgalem General Hospital pediatric emergency with right upper quadrant pain of 3 days duration which was severe, colicky, and lasted around 10 minutes per episode with no aggravating or relieving factors. The pain was followed by nausea and non-bilious vomiting. He had a history of passing Ascaris worm one month back for which he was treated with oral albendazole at the local health center. Otherwise, the patient had an unremarkable history. Physical examination revealed that the vital signs were within the normal range and there was a slightly icteric sclera. The liver was slightly tender with a total liver span of 11cm.\n\nInitial laboratory investigation revealed a normal complete blood count and ova of Ascaris lumbricoides on stool examination. Liver enzyme Aspartate transaminase (AST) was 86U/L, and alanine transaminase (ALT) was 141U/L. The total and direct bilirubin was 1.84 and 1.31 mg/dl, respectively. Abdominal ultrasound done on the same day showed two adjacent, well-defined, tubular, and hyperechoic structure with a central lucency on subcostal axial view seen within the common bile duct (CBD) and right intrahepatic duct. The CBD was dilated to 1 cm, and the proximal intrahepatic duct is slightly dilated. The report concluded that there were two Ascaris worms within the biliary tree.\n\nThe patient was admitted to the wards with the assessment of obstructive jaundice secondary to intrabiliary ascariasis for conservative management. He was kept nil per mouth and was put on maintenance fluid. The pain subsided on the second day of admission and the icterus disappeared on the third day of admission. The direct bilirubin had also dropped to 0.54 mg/dl on the third day of admission. A follow-up ultrasound on his fifth post-admission day showed that the duct was empty and the worm had moved out of the biliary system. Liver function test done on the Sixth day showed that ALT has returned to 36 U/L and AST was 48 U/L. Subsequently, he was dewormed with albendazole 400mg single dose and was discharged home on his seventh admission day. Currently, he is doing well with no symptoms, and he has returned to his school.",
    "summary": "A 12-year-old male Ethiopian child presented with colicky right upper quadrant pain, nausea, and vomiting for 3 days. Physical examination showed slightly icteric sclera and slightly tender hepatomegaly. Laboratory and ultrasound examinations were suggestive of obstructive jaundice secondary to intra-biliary ascariasis. The child was admitted and followed by conservative management including maintenance fluid, nil per mouth, and analgesics. The abdominal pain and icterus resolved on his second and third day of admission, respectively. A follow-up ultrasound showed that the worm had migrated from the common bile duct. The patient was dewormed with a single dose of oral albendazole 400mg and discharged home. Currently, the patient is well and attending school."
  },
  {
    "id": "multiclinsum_gs_en_126.txt",
    "fulltext": "A 43-year-old man who began to have episodes of generalized weakness in relation to intense emotions and certain physical activities, such as walking on tiptoes, jumping or turning suddenly. He also developed excessive daytime sleepiness and the need to take naps, which were only occasionally restorative.\n\nThe excessive daytime sleepiness and nighttime sleep quality scales showed pathological daytime sleepiness and poor nighttime sleep quality, and the ESS score was 19 and the total PSQI score was 7. Neuroimaging and EEG with wake and sleep activity did not show pathological findings. Blood and urine tests, including autoimmunity and anti-neuronal antibodies, were normal. The cerebrospinal fluid showed orexin levels of less than 50 pg/mL. The integrated video-recorded polysomnographic study did not show findings of interest. The next day, the multiple sleep latency test was performed with four 20-minute daytime naps separated by two hours, and a mean latency of 1.52 minutes and two REM sleep entries were obtained.\n\nAfter the diagnosis of narcolepsy type 1 with severe hypersomnolence was made, he was prescribed increasing doses of venlafaxine and modafinil. In addition, he was given a guide with sleep hygiene guidelines adapted to his needs. Despite these measures, the patient did not perceive adequate control of the symptoms and was inevitably forced to abandon certain sports and social habits. In the following months, excessive daytime sleepiness worsened and cataplexy attacks became more frequent and occurred in response to emotionally neutral stimuli. Therefore, the dose of both medicines was increased and sodium oxybate was associated. Nevertheless, the response to treatment was still insufficient. Subsequently, venlafaxine was discontinued due to adverse effects (nausea, tiredness, episodes of confusion and altered memory and attention) and was replaced with clomipramine, of which a daily dose of 75 mg was reached. With this therapeutic scheme, adequate control was achieved for 19 months. From that moment on, the symptoms began to exacerbate and parasomnias appeared as a side effect of sodium oxybate.\n\nGiven the refractoriness of the disease to treatment, it was decided to associate pitolisant. To avoid drug interactions, a dose of 4.5 mg was started and a slow progressive increase was made until 18 mg per day. From that moment a frank improvement was evident, both of excessive daytime sleepiness and cataplexy, and a decrease in the score on the ESS and PSQI scales was observed (12 and 6, respectively). The patient returned to his previous lifestyle and recovered abandoned sports and social activities. After a few months of stability, the dose of clomipramine and modafinil could be reduced without clinical worsening.\n",
    "summary": "A 43-year-old man began to experience acute excessive daytime sleepiness and episodes of cataplexy. After a thorough study, he was diagnosed with type 1 narcolepsy. During the course of the disease, he was prescribed antidepressants, neurostimulators and sodium oxybate, either alone or in combination. The response to pharmacological treatment was insufficient and was accompanied by numerous side effects. After the introduction of pitolisant, a frank improvement in symptoms was observed and it was possible to reduce the dose of the other drugs and their adverse effects.\n"
  },
  {
    "id": "multiclinsum_gs_en_297.txt",
    "fulltext": "Patient with nine years and 11 months, male, previous diagnosis of autism spectrum disorder (ASD), oppositional behavior, bipolar affective disorder, cognitive deficit, difficult-to-control epilepsy and obesity, admitted via emergency and transferred from his city's hospital for suspected COVID-19. History of fever up to 39.5 ° C for four days associated with sporadic cough, hyaline secretion, convulsive escape and reduced appetite and urinary volume. Throughout the day, on April 1, he presented a worsening of the sensory, being referred to the Pediatric Intensive Care Unit (UTIP), with a Glasgow coma scale of 3, myotic pupils, SpO2 = 80%, and immediate tracheal intubation was performed. A computed tomography of the chest was performed, compatible with a frosted glass standard. The SARS-CoV-2 search was positive.\n\nAfter four days, he began physiotherapy three times a day with the goals of bronchial clearance, improvement of gas exchange and prevention of deleterious effects related to bed rest, such as decreased range of motion and loss of muscle mass, with the following procedures: compression/decompression, endotracheal tube and upper airway aspiration, passive kinesiotherapy, limb stretching and functional positioning in bed. On the same day, the NIV was adjusted to ensure a tidal volume of 7.5 ml/kg, and the oxygen saturation index (OSI) was evaluated, resulting in 6.5, characterizing mild acute respiratory distress syndrome (ARDS).\n\nAfter 14 days of admission, the patient showed clinical and haemodynamic improvement, good response to diuretic therapy and prone position (performed four times during admission), progressive ventilatory improvement, tolerating weaning from ventilatory support. He was extubated after 17 days of VMI. He remained on non-rebreathing mask oxygen therapy (7 L/min), maintaining SpO2=96%, with the need for frequent aspiration of the airways due to accumulation of secretions and ineffective cough. In physiotherapy, the maneuvers mentioned previously were performed, as well as periods of non-invasive mechanical ventilation (NMV), bilevel IPAP mode = 14 cmH2O, EPAP = 8 cmH2O, FiO2 = 40%, because of pulmonary hypoexpansion, aspiration of the airways, passive kinesiotherapy progressing to assisted kinesiotherapy, stretching and training of transfers.\n\nIn order to prevent the dispersion of aerosols, the aspiration during the VMI was done via a closed system and the VMNI was done via a mechanical ventilator with a double branch, total face interface (non-ventilated), a HEPA filter in the expiratory branch and a HME filter proximal to the patient. Over the course of the days, the child tolerated a reduction of oxygen and transition to nasal glasses at 3 L/min. She maintained a stable condition and progressive improvement, enabling her to be discharged from the PICU after 22 days. At that time, she scored 17 on the FSS-Brasil, a score characterized as severe dysfunction.\n\nThe day after the patient was discharged from the ICU, he was admitted to the pediatric inpatient unit. He developed somnolence, hyporesponsiveness and difficulty in managing airway secretions. A chest X-ray was performed, showing atelectasis, and, in addition to the procedures described previously, the HM technique was used with self-inflating bag and HEPA filter (twice a day, three cycles of 10 repetitions each), in order to avoid aerosol dispersion. After three days, a chest X-ray was repeated with total reabsorption of the atelectasis, supplemental oxygen was discontinued and the HM technique was discontinued, as there was no need for airway aspiration. The pulmonary auscultation was without adventitious noises. Also, according to the tolerance and collaboration of the patient, assisted and active kinesiotherapy and training of transfers (orthostatic and ambulation in the room with assistance) were performed. It was possible to progress to resisted kinesiotherapy and independent ambulation. Physiotherapy took place twice a day.\n\nPatient was discharged after 41 days of hospital admission with negative PCR for SARS-CoV-2, 8 points in FSS-Brasil, a score characterized as mild dysfunction, and 60 points in muscle strength as assessed by the Medical Research Council (MRC).\n",
    "summary": "male, 9 years old, with previous psychiatric illness and obesity, progressed with a picture of sensory decline and need for intensive treatment, with the patient placed on invasive mechanical ventilation on arrival at the unit and SARS-CoV-2 infection confirmed. He underwent physiotherapy for bronchial clearance, pulmonary reexpansion and early mobilization, showing ventilatory improvement throughout the hospital stay, and after 17 days was successfully extubated. He progressed from passive to assisted and resisted kinesiotherapy in the paediatric hospital, managing to walk without assistance, and was discharged with a functional condition prior to hospital admission.\n"
  },
  {
    "id": "multiclinsum_gs_en_329.txt",
    "fulltext": "The patient, a 56-year-old female, was admitted for “10+days of right eye droop and 1 day of aggravation”. 10+days ago, the patient had no obvious inducement of right eye face droop without limb movement restriction, accompanied by right parietal and occipital pain, no nausea, vomiting, dizziness, walking unsteadily, feeling of cotton stepping, no slurred words, no choking or coughing of drinking water. The patient was treated outside the hospital, and improved relevant examinations to consider the diagnosis of “cerebral aneurysm”. 1+days ago, the patient’s right eye droop was aggravated, so she went to the neurosurgery department of our hospital. History of previous diseases: No history of hypertension, diabetes, family history of aneurysms, respiratory or neurological diseases. Physical examination after admission: the patient’s vital signs were stable, and her mind was clear. The left pupil, with a diameter of about 3mm, is sensitive to light reflection; the right pupil, with a diameter of about 5mm, is slow to light reflection; the right eye has a drooping face; the right eye has limited eye movement; the right eye has decreased vision; the left eye has no obvious abnormality in vision and eye movement; the limbs have normal muscle strength and muscle tension; the bilateral pathological signs are negative; the meningeal stimulation sign is positive; and the spine is bent. After admission, 3D reconstruction and enhanced scanning of CT head vessels showed that the end of C7 segment of the right internal carotid artery was swollen and two saccular processes with a length of about 0.4 cm were seen, which were multiple aneurysms with daughter aneurysms. Diagnosis after admission: 1. C6 aneurysm of the right internal carotid artery 2. Ophthalmoplegia of the right side 3. Anesthesia and surgical procedure: sevoflurane was given to retain spontaneous respiration induction and after successful tracheal intubation with visual laryngoscope, the mechanical ventilation was normal. Subsequently, craniotomy aneurysm clipping was successful performed. During the 3.6-hour surgery, 3200mL liquid (1600mL crystal and 1300mL of colloid) was input, 1700mL of urine was urinated, and 200mL of blood was bled. The last blood gas analysis (FiO2 50%) during the operation showed that pH was 7.45, PaCO2 was 40.3mmHg, PaO2 was 212.7mmHg, Na was 137.9mmol/L, K was 3.24 mmol/L, and Ca was 1.0mmol/L. After the operation, the patient was transferred to the small recovery room with a tube. SpO2 99%, BP 100/50 mmHg, HR 68 bpm, EtCO2 32 mmHg at the time of admission. One hour after entering the anesthesia recovery room, the patient recovered from spontaneous breathing, but the tidal volume was low, about 90mL. Half an hour later, the patient developed dyspnea in the inspiratory phase, severe triple concave sign, and mild blood liquid ejected from the endotracheal tube. SpO2 96%, BP 110/70 mmHg, HR 58 bpm, EtCO2 48mmHg were immediately aspirated into the trachea, sucking out a large amount of pink foam liquid, with manual ventilation conducted, and the airway resistance was high (35cm/H2O). The tidal volume is about 60mL. Confirm the catheter and withdraw the tracheal catheter to 16cm, yet the airway resistance is not significantly improved. The fiberoptic bronchoscope showed that the left and right main bronchi were edematous, the lumens were narrowed, and there was fluid exudation inside. After anti heart failure treatment, they retained the tracheal catheter and sent it to the intensive care unit for further symptomatic support treatment. They provides patients with diuretic, hormonal, anti infective, and invasive ventilator treatments. Fiber bronchoscopy examination showed that edema of left and right main bronchi basically disappeared. Eight hours later, they pulled out the trachea catheter and separated from the ventilator. The symptoms were relieved on the fifth day after surgery and they were discharged from the hospital. Three months after discharge, they recovered well after follow-up.",
    "summary": "A 56-year-old female patient was admitted to the hospital for \"10+days of right eye droop and 1 day of aggravation\". After admission, the physical examination found that the patient had severe scoliosis. 3D reconstruction and enhanced CT scan of the head vessels showed that the right internal carotid artery C6 aneurysms were clipped under general anesthesia. After the operation, the patient had increased airway pressure, with a large number of pink foam sputum attracted from the trachea catheter, and the lungs were scattered with moist rales during auscultation, After the treatment of anti-heart failure, the patient returned to the ICU through the trachea catheter. Eight hours later, the trachea catheter was pulled out and the patient was released from the ventilator. The symptoms were relieved on the fifth day after the operation."
  },
  {
    "id": "multiclinsum_gs_en_347.txt",
    "fulltext": "17-year-old woman from Tucumán, presented with a case of upper airway and mild haemoptysis. Computed tomography of the thorax reported a 25x24x24 mm, round, regular, smooth-walled image in the upper right lobe, surrounded by a faint, glass-like, peripheral halo. There was no enhancement with intravenous contrast. A possible bronchogenic cyst was suggested, so a thoracic MRI was performed that reported a 25 x 24 x 24.5 mm, round, regular, smooth-walled image with a liquid signal intensity. Due to the central location of the lesion, a video-assisted, upper right lobectomy was performed. Since the intraoperative pathological study was indeterminate, the pulmonary resection was complemented with a mediastinal lymph node dissection. The definitive pathological anatomy reported a 2 x 1.7 cm sclerosing pneumocytoma. Immunostaining was positive for TTF1, CK, CK7 and napsin.\n",
    "summary": "We report a 17-year-old female patient with a diagnosis of a rare sclerosing pneumocytoma.\n"
  },
  {
    "id": "multiclinsum_gs_en_84.txt",
    "fulltext": "Object\nThe patient, a 37-year-old woman, was admitted to the Department of Endocrinology of Peking Union Medical College Hospital (PUMCH) in September 2022 due to \"bilateral lower limb pain for four years\". She was born at full term with a birth weight of 3.75 kg, and the length was unknown. She was breastfed for one year and she showed no significant differences in growth, development, intelligence or activity compared to her peers. She experienced early loss of her permanent teeth (the exact age was forgotten) and underwent full-mouth dental implant surgery at the age of 24 years. Since 2018, she has experienced progressively worsening lower limb pain, along with decreased tolerance for activity and a diminished quality of life. By the end of 2022, she was unable to walk independently and relied on assistance for daily activities. She denied that her parents were consanguineously married and reported no family history of similar diseases. Physical examination revealed that her height was 162 cm, weight was 44.0 kg, and BMI was 16.77 kg/m2. She entered the clinic room in a wheelchair and had all 28 teeth as dental implants. The thyroid was not enlarged, and there were no obvious abnormalities in the lungs or heart. Both hands displayed ulnar deviation of the middle fingers. No other significant skeletal deformities were noted, although mild atrophy of the lower limb muscles was observed.\n\nThe study protocol was approved by the scientific ethics committee of PUMCH. The patient signed informed consent before participating in this study.\n\nLaboratory evaluation\nFasting blood samples were collected in the morning at about 8:00 AM. Serum calcium, phosphate, ALP, alanine aminotransferase (ALT), and creatinine (Cr) were analyzed using an automatic biochemical analyzer (ADVIA 1800, Siemens, Germany). An automated Roche electrochemiluminescence system (Roche Diagnostics, Switzerland) was used to detect serum concentrations of parathyroid hormone (PTH), and 25 hydroxyvitamin D (25-OHD), β-isomerized C-terminal telopeptide of type I collagen (β-CTX), and procollagen type 1 amino-terminal peptide (P1NP). In addition, erythrocyte sedimentation rate (ESR) was measured using an automatic biochemical analyzer (ADVIA 1800, Siemens, Germany). Free triiodothyronine (FT3), free thyroxine (FT4), thyroid-stimulating hormone (TSH), blood cortisol, and carcinoembryonic antigen (CEA) were measured using an automated Roche electrochemiluminescence system (Roche Diagnostics, Switzerland). Serum immunofixation electrophoresis (IFE) was performed using an electrophoresis instrument (ProteomeLab, Beckman Coulter, United States) for differential purposes. All biochemical indicators were measured uniformly in the central laboratory of PUMCH.\n\nBone mineral density and X-ray examination\nDual-energy X-ray absorptiometry (DXA, Lunar Prodigy, GE Healthcare, Madison, WI, USA) was used to measure areal bone mineral density (BMD) at lumbar spine 1–4 (LS), femoral neck (FN), trochanter, and total hip (TH) at baseline and follow-up. Radiographs of the spine, pelvis, and bilateral lower limbs were obtained at baseline. Based on the patient's clinical presentation and radiological findings, regular follow-up radiographs of both femora were scheduled every 3–6 months to closely monitor the healing process of the fractures.\n\nDetection of gene mutation\nGenomic DNA was extracted from the peripheral leukocytes of the patient using the QIAamp DNA Mini Kit (Qiagen, Germany) according to the manufacturer's instructions. Mutation detection was performed using next-generation targeted exon capture sequencing. All mutations and potential pathogenic variants were validated by Sanger sequencing. The pathogenicity of the variants was assessed according to the American College of Medical Genetics and Genomics and Association for Molecular Pathology (ACMG/AMP) Standards and Guidelines. The pathogenicity of the missense mutation was predicted using MutationTaster software (http://www.mutationtaster.org/).\n\nTreatment and follow-up\nAfter being diagnosed with adult-HPP complicated by non-healing bilateral fractures, severe bone pain, and limited mobility, the patient requested further treatment. As AA was not yet available in mainland China, the patient was treated with experimental subcutaneous daily injections of 20 µg teriparatide to promote fracture healing. Simultaneously, the patient received daily supplementation with 600 mg calcium and 0.25 µg calcitriol every other day. However, after 6 months of the above treatment, bone pain persisted, and there was no radiographic evidence of healing in the bilateral femoral fractures.\n\nThe patient then initiated AA (Strensiq, Alexion Pharmaceuticals Inc., Boston, MA, USA) therapy and discontinued teriparatide treatment. Based on previous studies, we recommended administration of AA treatment for the patient through subcutaneous injections of 2 mg/kg per dose, three times a week. At 1, 4, 6, and 10 months of AA treatment, bone metabolic markers, BMD, femoral fracture imaging, and drug-related adverse reactions were monitored. The AA dosage was adjusted according to the improvement in the patient’s symptoms and fracture healing status. Initially, the patient received 2 mg/kg per dose, three times a week for 4 months, followed by 1 mg/kg per dose, three times a week for 2 months, and finally, 1 mg/kg per dose, once a week for 4 months.",
    "summary": "A 37-year-old woman wheelchair-bound was diagnosed with HPP due to an extremely low serum alkaline phosphatase (ALP) level (4-10 U/L), who suffered from bilateral femur pain and non-union of femoral shaft fractures on both sides. Compound heterozygous missense mutations (c.382G > A and c.461C > T) were identified in exon5 of ALPL gene. The patient received teriparatide sequential AA therapy. Serum levels of ALP, β-isomerized carboxy-telopeptide of type I collagen (β-CTX) and procollagen type 1 amino-terminal peptide (P1NP), bone mineral density (BMD) and skeletal X-ray were measured during the treatment. Literature was searched by keywords of \"Hypophosphatasia\", \"HPP\", \"ALPL\", \"TNSALP\", \"ALP\" combined with \"Asfotase alfa\", \"AA\", \"enzyme replacement therapy\", and \"ERT\".\n\nResults: After unsuccessful 6-month teriparatide treatment for femoral fracture, AA treatment was initiated, at a dose of 2 mg/kg, 3 times a week. After the first month of AA treatment, serum ALP level increased from 4 to 9206 U/L, and serum calcium and phosphate levels decreased, with increase in PTH, β-CTX, and P1NP levels. After 4 months of AA treatment, her bone pain significantly alleviated, accompanied by significant shortening of the fracture line. After 10 months of AA therapy, the fracture demonstrated complete healing and the patient could walk independently. BMD at lumbar spine and hips was significantly increased. Among 295 adult patients with HPP reported in the literature, 213 (72.2%) exhibited skeletal-related symptoms and 91 (30.8%) presented with bone fractures. In addition to skeletal manifestations, the patients presented with early tooth loss, muscle weakness and ectopic calcification. AA treatment, spanning 9 weeks to 3 years, has been shown to increase ALP levels, promote fracture healing, improve mobility, and alleviate bone pain."
  },
  {
    "id": "multiclinsum_gs_en_272.txt",
    "fulltext": "A 22-year-old pregnant woman, gravida 5, para 1, three miscarriages in the 5th week of gestation was admitted to the Department of Endocrinology for the evaluation of severe hypokalemia detected during pregnancy testing in the gynecology department. 16 years prior, at the age of 6 years, she began to have cramps after crying or losing her temper, without dizziness, seizures, or other symptoms. Laboratory tests revealed hypokalemia (data missing), and the symptoms were relieved after potassium supplementation. Subsequently, she experienced recurring cramps after crying, losing her temper, or fatigue. The symptoms were relieved without any treatment and had no effect on her daily life; therefore, she did not pay attention to these symptoms. Two days prior to admission, she underwent a laboratory test for pregnancy. Her blood test result showed severe electrolyte disturbances: her serum potassium level was 2.42 mmol/L and magnesium level was 0.65 mmol/L, but she had no symptoms. After intravenous and oral potassium chloride supplementation in the emergency department, the patient was admitted to the Department of Endocrinology for investigation of hypokalemia.\n\nAt presentation, the patient had no sweating, vomiting, diarrhea, or anorexia. She denied laxative or diuretic abuse, hypokalemia, or cramps in other family members. Physical examination revealed a height of 149 cm, weight of 46.3 kg and blood pressure of 97/71 mmHg. There were no positive signs on physical examination, except for the Trousseau sign. Detailed laboratory examinations were performed for further diagnosis and treatment. Laboratory analysis revealed hypokalemia, metabolic alkalosis, renal potassium wasting, hypomagnesemia, hypocalciuria, hyperreninemia, and hyperaldosteronism with normal blood pressure, which indicated a clinical diagnosis of GS. The diagnosis was confirmed when a heterozygous mutation c.1077C>G (p.Asn359Lys) and c.965-1_976delGCGGACATTTTTGinsACCGAAAATTTT in SLC12A3 was identified by whole exome sequencing. After the electrolyte levels were maintained within a relatively optimal range, the intravenous treatment was changed to oral supplementation.",
    "summary": "The patient had no specific symptoms but exhibited hypokalemia, metabolic alkalosis, hypomagnesemia, hypocalciuria, hyperreninemia, hyperaldosteronism, and normal blood pressure. Together, these symptoms indicated the clinical diagnosis of Gitelman syndrome, which was confirmed by genetic analysis. Many drugs have limited safety data during early pregnancy, and optimum potassium and magnesium levels are necessary for a successful pregnancy."
  },
  {
    "id": "multiclinsum_gs_en_312.txt",
    "fulltext": "An 82-year-old woman with type 2 diabetes mellitus and chronic renal failure was admitted to the hospital with a 7-day history of fever, delirium, and dyspnea. She had undergone an aortic valve replacement (Perceval sutureless bioprosthesis) 18 months prior due to aortic stenosis. The immediate post cardiac surgery period was complicated by paroxysmal atrial fibrillation, transudative left-sided pleural effusion, and oligoanuric renal failure. She did not present any infectious complications and the median sternotomy incision closed normally. Between 1 and 14 months after aortic surgery, she was admitted to the hospital five times because of severe clinical heart failure of unclear cause and some episode of paroxysmal atrial fibrillation. No fever or other signs of infection were detected at all this time, and did not receive any antibiotic treatment. A transesophageal echocardiogram performed 3 months after surgery showed an aortic prosthesis without alterations. On physical examination, her temperature was 39 °C, she was confused and tachypneic. A 3/6 systolic ejection murmur in the aortic position and basal crackles were identified. She presented grade II uninfected pressure ulcers on heels and sacrococcygeal region. Laboratory tests showed a normal blood cell count, a serum creatinine of 2.14 mg/dL, and an increased C-reactive protein (13 mg/dL) and hyperglycemia (628 mg/dL). A chest X-ray showed bilateral pleural effusion and interstitial pulmonary edema. Two sets of aerobic and anaerobic blood culture bottles were drawn at admission, and empiric ceftriaxone (2 g daily) and levofloxacin adjusted to renal function (250 mg daily, intravenous) were started. After 26 to 80 h of incubation into the BACTEC FX system (Becton, Dickinson and Company), all four blood culture bottles were positive. Gram stain showed coryneform gram-positive bacilli with occasional branching forms. After incubation on CNA agar and chocolate agar, colonies were less than 2 mm in size, glistening and yellow. The colonies penetrated into the agar upon further incubation. On the 5th day of admission, blood cultures were again obtained, and the same organism grew in 1 of the 4 bottles. The isolates were initially identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS, Bruker Daltonics) as C. cellulans. Thereafter, the identification was confirmed by API Coryne strip (bioMérieux; code number 7572767), which was an “excellent identification” for C. cellulans with a reliability of 99.9%, and by sequencing the 16S rRNA (using the BLAST Sequence Analysis Tool of GenBank database), showing a 100% similarity with C. cellulans and 99.8% with C. funkei. Antimicrobial susceptibility tests were performed using a microdilution microtiter panel MICroSTREP plus 6 (MicroScan Walk Away, Beckman Coulter). Following EUCAST breakpoints criteria for Corynebacterium, the isolate was susceptible or presumably susceptible (for antibiotics without EUCAST breakpoints, but with low MIC) to amoxicillin-clavulanate (MIC = 2 mg/L), daptomycin (MIC = 0.5 mg/L), levofloxacin (MIC = 2 mg/L), linezolid (MIC≤1 mg/L), tetracycline (MIC≤1 mg/L), trimethoprim-sulfamethoxazole (MIC = 0.006 mg/L) and vancomycin (MIC = 0.5 mg/L), and resistant or presumably resistant to amikacin (MIC = 32 mg/L), cefotaxime (MIC> 2 mg/L), ciprofloxacin (MIC> 2 mg/L), clindamycin (MIC> 2 mg/L), erythromycin (MIC = 1 mg/L), gentamycin (MIC = 4 mg/L), imipenem (MIC = 4 mg/L), meropenem (MIC = 8 mg/L) and rifampin (MIC = 1 mg/L). The MICs of amoxicillin-clavulanate, cefotaxime, meropenem, trimethoprim-sulfamethoxazole and vancomycin were also determined by Etest® (bioMérieux) using Mueller-Hinton agar plus 5% blood, and similar results were found.\n\nOn the 7th day, a transthoracic echocardiogram did not show alterations. Therapy was switched to amoxicillin-clavulanate (1 g three times daily, intravenous), and new blood cultures obtained 24 h later were negative. A transesophageal echocardiogram performed on the 9th day of stay revealed an echogenic and mobile vegetation of 6 × 9 mm on the prosthetic aortic valve attached to the commissure between the right coronary cusp and the non-coronary cusp. Prosthetic valve function was otherwise normal. On the 11th day, amoxicillin-clavulanate was switched to vancomycin adjusted to renal function (750 mg daily) plus linezolid (600 mg twice daily, intravenous). Surgical replacement was considered inappropriate in this patient due to comorbidity, advanced age, limited mobility and family rejection. In the following days, she developed severe anemia, acute confusional state and refractory heart failure. End-of-life decision-making was implemented, prioritizing symptom control, and antibiotic therapy was switched back to amoxicillin-clavulanate on day 22nd of admission. On the 28th day, she was discharged to another hospital for palliative care, dying 7 days later because of sepsis and severe heart failure. A postmortem examination was not performed.",
    "summary": "An 82-year-old woman with aortic prosthetic valve presented to the hospital with fever and heart failure. Further work up revealed the diagnosis of C. cellulans infective endocarditis (IE). The strain was identified by MALDI-TOF MS, API Coryne and 16S rRNA sequencing. The patient was deemed not to be an operative candidate and died despite the antibiotic therapy 35 days after admission."
  },
  {
    "id": "multiclinsum_gs_en_400.txt",
    "fulltext": "A 17-year-old healthy female patient presented to the orthopedic clinic complaining of right-groin pain for 9 months. The patient initially started complaining of right-groin pain upon walking long distances. She had no history of trauma. The pain gradually progressed, and eventually also occurred at night. This pain was associated with an increased swelling in the same region. The patient denied any constitutional symptoms.\n\nPhysical examination revealed a mildly tender, hard, localized swelling over the right pubic area with no overlying pulsations or skin changes. The range of motion of the right hip was within normal.\n\nA pelvic radiograph revealed an expansile lytic lesion involving the right superior pubic ramus. A pelvic MRI showed an expansile multicystic bony lesion measuring 6.8 × 3.3 × 4.5 cm with multiple fluid–fluid levels involving the right pubic ramus.\n\nRoutine hematological investigations including complete blood count (CBC), kidney function tests, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and alkaline phosphatase were within normal ranges.\n\nBased on these clinical and radiological features, the patient was preliminarily diagnosed with an aneurysmal bone cyst of the right superior pubic ramus. Following a discussion of the initial diagnosis, prognosis, and treatment options with the patient and her parents, the patient was scheduled for curettage and grafting of the right superior pubic ramus.\n\nWe started the procedure by taking a percutaneous biopsy. The frozen section confirmed the benign nature of the lesion. Afterwards, using a modified Stoppa approach, an extensive curettage of the cyst was done followed by irrigation with alcohol and saline. Demineralized bone matrix and synthetic biphasic calcium phosphate granules bone graft were subsequently impacted. The cyst components were sent for histopathological evaluation. The final histopathology result revealed blood-filled cystic spaces lined with multinucleated giant cells and separated by cellular septae containing fibroblasts, giant cells, and woven bones with hemosiderin deposition consistent with an aneurysmal bone cyst.\n\nThe patient was followed up for 14 months, she progressed to full weight-bearing and was symptom-free. The follow-up pelvic radiographs at 17 days, 8 months, and 12 months post-operatively demonstrated that the bone grafted site has matured satisfactorily, respectively. The patient is planned to be followed-up in an orthopedic clinic for at least five years after the surgery.",
    "summary": "A 17-year-old female presented with progressive pain and swelling in the right inguinal region. Pelvis radiograph showed a lytic expansile lesion of the superior pubic ramus. A multiloculated cystic lesion was evident on magnetic resonance imaging, and postoperative histopathological evaluation confirmed the diagnosis of ABC. The patient was treated successfully with an intralesional curettage and bone grafting. The postoperative course was uncomplicated with complete healing and no recurrence after 14 months of follow-up."
  },
  {
    "id": "multiclinsum_gs_en_513.txt",
    "fulltext": "In November 2019, a boy aged 12 was admitted to the Wuxi Children’s hospital for intermittent dizziness, headaches for more than a month, and unstable walking for half a month. It is noted that the patient had a mild cough a week before the onset, and it resolved spontaneously without intervention. Furthermore, the boy has not received any vaccinations since he was 6 years old. Some neurological tests, such as the Oppenheim test, Brudzinski's sign, Kernig's sign, and Babinski's sign, yielded negative results, whereas the Tandem Gait and finger-to-nose test yielded positive results, particularly in the right hand. In addition, a spectrum of demyelinating diseases in the central nervous system, such as antibodies against aquaporin-4, myelin oligodendrocyte glycoprotein, and glial fibrillary acidic protein, were negative. The following autoimmune encephalitis relevant tests revealed that AMPA1/2 receptors, and GABABR in CSF were negative, but the NMDA-IgG was positive with a titer of 1:32. Brain MRI revealed aberrant signals in both cerebellar hemispheres, indicating significant cerebellar atrophy. Eventually, the boy was diagnosed with anti-NMDAR encephalitis. The detection of some tumor markers, including alpha-fetoprotein, carcinoembryonic antigen, carbohydrate antigen (CA) 125, and CA 19–9, was performed to rule out the possibility of tumors, and all were negative. Then, this patient was treated with pulse therapy of methylprednisolone sodium succinate (20 mg/kg, 3d) and later changed to prednisolone tablets (40 mg, po, qd). Finally, the boy's symptoms were relieved, and he was discharged from the hospital. Follow-up visits in January and May 2020 revealed that this child was in good health with no noticeable symptoms. However, the child was readmitted to the hospital in August 2020 with dysgraphia for 6 days. The neurological examination results were comparable to the last time, with the finger-to-nose test remaining positive, but the Tandem Gait was negative. The NMDAR-IgG titer was 1:10 in serum and 1:3.2 in CSF, and MRI imaging revealed worsened lesions in the cerebellar hemispheres. Besides, the CSF oligoclonal IgG band test was performed, and the result was positive. The positive anti-NMDAR-IgG combined with imaging results led to the diagnosis of relapsing anti-NMDAR encephalitis. A similar therapeutic schedule was applied, and the boy was discharged after improving his symptoms. Later follow-ups revealed that the patient's symptoms were eased to a certain extent, but there was a recurrence. Additionally, his memory and learning skills were somewhat impaired.\n\nCSF transcriptome sequencing was performed in both episodes to help further interpret the etiology of this case. Before the examination, informed consent was obtained from the boy and his parents. Briefly, the total RNA of CSF was extracted using the RNeasy Micro Kit (Qiagen) following the manufacturer's instructions, from which the host rRNA was removed before the sequencing library construction. The library was then constructed using the Trio RNA-seq Kit (Nugen), and the meta-transcriptomic sequencing was performed on the Illumina hiseq X-ten platform as described previously. The resulting raw reads were first trimmed to remove those of low quality and adapters using Trimmomatic software, and the reads of human origin were removed using the in-house script. The generated clean reads were then directly applied to the blast analysis against the nr database in NCBI to parse the taxonomic composition using BLAST + 2.12.0. Afterward, the reads of interest were mapped to the reference sequences to resolve the coverage using bowie2, and then de novo assembled using the Megahit program under default parameters. Then, the assembled contigs were used as queries for the Blast analysis to confirm their taxonomic status. Furthermore, the MEGA program was used to align and build a maximum likelihood tree for the phylogenetic relationship with other reference strains.\n\nFor the sequencing in the first episode, there were 37,013,105 paired reads generated in total, among which the majority were assigned to Homo sapiens as expected. Based on the read blast analysis, those probably belonging to eukaryota, bacteria, and viruses accounted for 70.54%, 17.04%, and 7.61%, respectively, of the reads irrelevant to humans. Moreover, similar results were achieved from the blast analysis using assembled contigs as queries. Among these reads from putative exogenous agents, a total of 2459 can be mapped to hRSV type B (strain SE01A-0135-V02) with coverage of 98.5% of its genome sequence (accession no. MZ516143). In particular, most reads concentrated on the location of genes NS1, NS2, and L. RT-PCR and sanger sequencing were used to fill in the gaps in the assembled contigs and confirm the genome sequences. Finally, with a total of 15,184 bases, the sequence of the whole genome was recovered, except for part of the 3' UTR region. Furthermore, it had been deposited in the Genbank (accession no. ON630422). Based on the sequence analysis, the acquired genome sequence shared 99.69% nucleotide identity with SE01A-0135-V02. Afterward, using the ML tree based on the G gene, the phylogenetic relationship of the Wuxi strain with other genotypes of hRSV group B was disentangled. The results indicated that this strain grouped with SE01A-0135-V02 inside B6, the most prevalent hRSV genotype in group B worldwide. The remaining reads were dispersed to other taxonomic groups with low read numbers or short assembled contigs. The second sequencing resulted in 34,609,924 paired reads, and except for reads from human beings, no reads associated with agents were confirmed relevant to human disease conditions. Due to the absence of the antibody or antigen tests of hRSV at the time of onset, we conducted the test of serum IgG to the hRSV after the CSF sequencing using the Human RSV-IgG ELISA Kit (SHUANGYING BIOLOGICAL), and the result was positive.",
    "summary": "The child was noted to have ataxia and positive anti-NMDA receptors in the cerebrospinal fluid, diagnosed as anti-NMDA receptor encephalitis in combination with cranial MRI images. After high-dose hormone pulse therapy and medication, the disease improved, and he was discharged. However, a relapse occurred almost a year later, and the cranial MRI imaging showed progressive cerebellar atrophy. An hRSV strain from group B was detected in his cerebrospinal fluid, and the whole genome sequence was recovered using transcriptome sequencing."
  },
  {
    "id": "multiclinsum_gs_en_179.txt",
    "fulltext": "27-year-old woman from the province of Buenos Aires with no personal or family history of significance, consulted for vaginal bleeding. Colposcopic study showed a pedicled polypoid formation that protruded through the external cervical os. A biopsy sample was taken for evaluation. With the diagnosis of sarcoma, chemotherapy was initiated to reduce the lesion mass. After the lesion was reduced in size, the woman was referred to our institution for surgical treatment. A total hysterectomy with adnexa was received, fixed in 10% formalin. Body 5 × 5 × 3.2 cm, neck 3.5 × 3 × 2 cm, both tubes 4.5 × 0.7 cm and ovaries 4 × 2.5 × 2.5 cm. When the piece was opened, a pedicled polypoid formation of 8.5 cm in diameter was observed at the level of the cervical-isthmic junction, which emerged into the endocervical canal and externalized through the external cervical os. The outer surface was brown, lobed, with reddish sectors. When cut, it was white, soft, with gelatinous-looking sectors and cystic formations of up to 0.6 cm in maximum dimension. After routine processing, histological sections were stained with hematoxylin and eosin (H-E), which showed alternating cell sectors with lax, myxoid areas, along with typical isthmic-endometrial glands. The predominantly fusocellular atypical proliferation was arranged in nests, consisting of cells with wide eosinophilic cytoplasm and eccentric nuclei with homogeneous chromatin, some pleomorphic. Transverse cytoplasmic striations were observed in these cells. The stroma was largely myxoid and richly vascularized. Distinct areas of densely condensed cells immediately and closely adjacent to the intact epithelial lining, but separated from it by a thin layer of lax stroma, were noted. This is known as the cambium layer. Immunohistochemical techniques were performed for desmin, actin-specific muscle (ASM) and myogenin (MYF4), which were positive, while actin of the smooth muscle was negative. This immunolabelling allowed the striated muscle lineage to be identified and, ultimately, the diagnosis, along with the morphological picture, of embryonic RMS. Also, the presence of grouped rhabdomoblasts constituting the cambium layer at the subepithelial level was essential and necessary to typify embryonic RMS as botryoid, independently of the macroscopic presentation in the form of polypoid clusters.\n",
    "summary": "We present the case of a 27-year-old woman who consulted for vaginal bleeding and who was found to have a white, polypoid lesion that was externalized through the external cervical orifice. The histological study revealed alternating cellular sectors with lax, myxoid areas, along with typical isthmic-endometrial glands. The atypical fusocellular proliferation was arranged in nests, consisting of cells with large eosinophilic cytoplasm with transverse cytoplasmic striations and eccentric nuclei with homogeneous chromatin. There were areas of densely condensed cells immediately and near the intact epithelial lining, but separated from it by a thin layer of lax stroma (cambial layer). The immunomarking profile was positive for desmin, muscle-specific actin and myogenin, and negative for smooth muscle actin. A diagnosis of uterine body botryoid embryonal rhabdomyosarcoma was made.\n"
  },
  {
    "id": "multiclinsum_gs_en_139.txt",
    "fulltext": "A 19-year-old primigravida at 35 weeks of gestation with no medical or family history, without consanguinity, was referred for assessment of a fetal pelvic mass found on the third-trimester ultrasound. On admission, vital signs were within normal limits and prior fetal ultrasound scans were also within normality.\n\nThe patient was hospitalized for workup of the fetal malformation. The transabdominal obstetric ultrasound showed a single female fetus in longitudinal position, complete breech presentation and adequate biometrics and fetal weight for gestational age. The anatomical findings included fetal head with hypotelorism and microphthalmia; fetal abdomen with a 58 × 59 × 69 mm circular hypogenic image of irregular contours and a volume of 124 cubic centimeters localized posterior to the bladder, with no uptake of color doppler; uncompromised fetal urinary system, with a diagnostic impression of fetal hydrometrocolpos. Complementary fetal magnetic resonance imaging confirmed the finding of hypotelorism, microphthalmia and, in the fetal pelvis, a 74 × 64 × 52 mm cystic lesion of significant size and round morphology extending from the pelvis to the abdomen, of high signal intensity in T2 and low in T1, with no septations or solid components on the inside. It caused anterior displacement of the bladder and posterior displacement of the rectum. A small saccular formation was observed in the upper portion, suggesting the presence of fluid in the uterus, consistent with the diagnostic impression of fetal hydrometrocolpos.\n\nDuring the hospitalization, the patient had preterm uterine activity; infection was ruled out with complete blood count, C reactive protein and normal urinalysis. Late preterm lung maturation was instituted. Progression of the preterm labor and a complete breech presentation required an immediate cesarean section at 36 weeks to deliver a single fetus with normal amniotic fluid, female newborn weighing 2,550 g, APGAR of 2, 0, 0 at one, five and ten minutes, respectively. Unresponsive to neonatal resuscitation maneuvers, the outcome being perinatal death.\n\nAutopsy examination revealed low-set ears, micrognathia, broad nasal bridge and bilateral anophthalmia; neck and chest of normal appearance; ballooning abdomen; syndactyly in upper and lower limbs; external female genitalia with imperforate hymen. Internal exam of the skull and brain sections showed no evidence of gross malformations or focal lesions. In the chest, heart, lung and diaphragm were normal. In the abdomen, liver, spleen, kidneys and bladder had normal morphology. Uterus and vagina had a cystic appearance and were markedly dilated from content of yellowish material associated with vaginal atresia. These findings confirmed a definitive diagnosis of FS.",
    "summary": "A 19-year-old primigravida presenting at 35 weeks of gestation, with prenatal finding of hydrometrocolpos associated with hypotelorism and microphthalmia. Pre-term cesarean delivery was performed due to breech labor and perinatal death. The autopsy confirmed hydrometrocolpos secondary to vaginal atresia and imperforate hymen, associated with cryptophthalmos, syndactyly, nasal and pinna malformations, confirming the diagnosis of Fraser syndrome."
  },
  {
    "id": "multiclinsum_gs_en_518.txt",
    "fulltext": "A two-day-old neonate was brought to the hospital with an absent penis. The baby was born to a 34-year-old primigravida mother with no antenatal follow-up. The delivery was at home and the baby cried immediately after birth. He was sucking well after birth, but failed hours later. The infant was tachypneic and, had subcostal and intercostal retraction, bilateral fine crackles on auscultation, and respiratory distress. He was 2.8 kg weight at the time of arrival. Absent penis, well-formed scrotal rugae, and normally descended bilateral testis. The urethral opening was absent in the perineum and scrotal folds. The urine passes through the rectum, but it is difficult to localize the urethral orifice in the rectum. The anal opening and sphincter were normal. The results of other system examinations were normal.\n\nThe white blood cell count was normal for age, serum electrolytes were within the normal range (sodium 142meq/l and potassium 4.8meq/l), and serum creatinine was 2.8_mg/dl. Abdominal ultrasonography revealed a horseshoe kidney and bilateral ureterohydronephrosis on the bedside. The echocardiographic findings were normal. Because the patient was critical and had no portable X-rays, chest X-rays, and other sophisticated investigations were not performed. The patient was resuscitated and tried to stabilize, but died after a 2-hour stay in the neonatal intensive care unit because of neonatal distress syndrome. The family refused postmortem examination.",
    "summary": "A two-day-old neonate presented to Arba Minch General Hospital with an absent penis. The delivery was performed at home by a 34-year-old primigravida mother with no antenatal follow-up. As the mother described, the baby cried immediately after birth. The baby was sucking initially but failed to suck hours after delivery. The neonate died of neonatal distress syndrome after two hours of resuscitation."
  },
  {
    "id": "multiclinsum_gs_en_275.txt",
    "fulltext": "An eight-year-old female of South Indian descent was presented to the emergency department for evaluation of headaches. She had headaches for several days, which were managed with acetaminophen at home. She denied history of blurry vision, dizziness, sleep apnea, syncope, and head trauma. There was no history of recent sore throat, skin infection, vomiting, and diarrhea. In the past, she had headaches of similar nature on an intermittent basis for about a year. There was no history of worsening of headaches with light or sound. Urine output was normal and there was no history of swelling of feet or abdomen or facial puffiness. There were no other known significant past medical problems including congenital heart disease. There was no history of administration of erythropoietin stimulating agents or recent travel to high altitude. She was born full term with no perinatal complications. Family history was significant for parental consanguinity, who were the first cousins. There was no family history of migraine headaches and erythrocytosis.\n\nUpon examination, the vital signs showed an afebrile child with heart rate of 90 beats per minute, respiratory rate of 18 per minute, and manual blood pressure of 190/100 mm Hg, which remained persistently elevated upon repeat examinations. Her oxygen saturation was found to be low at 90–92% consistently, but did not require oxygen supplementation. The height was at the 75th centile and weight was at the 55th centile. Physical examination was remarkable only for strabismus. There was no periorbital puffiness, ascites, or pedal edema. She continued to have headaches. A non-contrast computed tomography scan of the brain showed no evidence of hemorrhage, infarction, or thrombosis. Hypertension was managed with intravenous hydralazine and labetalol. She was admitted for further evaluation of hypertension. Renal function test showed blood urea nitrogen of 14 mg/dL and serum creatinine of 1.6 mg/dL. Serum albumin was 3.1 gm/dL. The rest of the electrolytes were normal. Complete blood count showed hemoglobin 17 gm/dL, hematocrit 51%, white blood cell count of 7.2 × 109/L, and platelet count of 247 × 109/L (normal: 150–300 × 109/L). Serum iron saturation was 18% (normal: 20–55%), iron was 45 µg/dL (35−150 µg/dL), transferrin was 176 mg/dL (200–360 mg/dL), total iron binding capacity (TIBC) was 246 µg/dL (225–430 µg/dL), and ferritin was 98 ng/mL. Serum vitamin B12 and folate levels were normal. Bone marrow biopsy was not obtained. Urinalysis showed 4 + proteinuria without microscopic hematuria. Random urine protein to creatinine ratio was 14.6. There was hypercholesterolemia. Serum complements were normal. Antinuclear, antineutrophil cytoplasmic, anti-glomerular basement membrane, and anti-double stranded DNA antibodies were negative. Hepatitis panel, human immunodeficiency virus, and tuberculin test were all negative. Thyroid function tests, serum catecholamines, plasma renin activity, and serum aldosterone were normal. Renal bladder sonogram showed bilateral echogenic kidneys with right kidney of 8.2 cm and left kidney of 8.7 cm in length with no hydronephrosis. Renal artery duplex study showed no evidence of renal artery stenosis. Chest X-ray showed no radiographic evidence of consolidation, pneumothorax, or effusion. Abdominal sonogram was normal. Nasopharyngeal swacnb for respiratory viruses were negative. Her oxygen saturation remained low for few days. Echocardiogram showed evidence of mild left ventricular hypertrophy, but no other abnormalities. Treatment consisted of intravenous hydration and initiation of antihypertensive agents, amlodipine, and labetalol. Blood pressures stabilized, but polycythemia was persistent (hemoglobin 15–16 gm/dL). Work-up for polycythemia included normal serum EPO (11 mU/mL; normal: 4–27 mU/mL) and normal gene sequence analysis of nine gene variants associated with erythrocytosis (genes tested: BPGM, EGLN1, EPAS1, EPOR, HBA1, HBA2, HBB, JAK2, and VHL).\n\nSerum creatinine over the next few days increased to 1.8 mg/dL (Schwartz estimated glomerular filtration rate 32 mL/1.73 m2/min). Serum intact parathyroid hormone was 217 pg/mL (normal: 12–88 pg/mL). Nephrotic range proteinuria persisted, but the spot urine protein to creatinine ratio decreased to values ranging from 5 to 7 after addition of lisinopril. A percutaneous renal biopsy performed a week after the initial presentation showed evidence of FSGS with severe tubular atrophy and interstitial fibrosis. There was partial foot process effacement. Genetic testing for FSGS showed heterozygous mutations in ACTN4, INF2, and KANK1 and homozygous mutation in NUP93 by next generation sequencing. Owing to inherited gene mutations and the likelihood of steroid resistance, she was not treated with steroid or immunosuppressive agents. Hypertension was managed with lisinopril, amlodipine, and labetalol with stabilization of blood pressures. Antiplatelet agent was added. Iron therapy was started for mild iron deficiency anemia (IDA). Her oxygen saturation returned to normal at the time of discharge and polycythemia resolved without the need for phlebotomy. She subsequently progressed to end stage renal disease (ESRD) ten months after the initial presentation and was started initially on chronic hemodialysis followed by peritoneal dialysis. She received a deceased donor renal transplant four months after being on dialysis with no occurrence of recurrent FSGS during her most recent follow-up two months post-transplant. Her maintenance immunosuppression consisted of tacrolimus, mycophenolate, and prednisone.",
    "summary": "Here, we describe an 8-year-old girl with erythrocytosis in association with NS and advanced CKD. The patient was found to have erythrocytosis during the evaluation for hypertensive urgency. She also had nephrotic range proteinuria without edema. Serum hemoglobin and hematocrit were 17 gm/dL and 51%, respectively, despite hydration. Renal function test showed an estimated glomerular filtration rate of 30 mL/min/1.73 m2. There was mild iron deficiency anemia with serum iron saturation of 18%. Serum EPO level was normal. Urine EPO was not measured. Renal biopsy showed evidence of focal segmental glomerulosclerosis. Genetic testing for NS showed mutations in podocyte genes: NUP93, INF2, KANK1, and ACTN4. Gene sequence analysis of genes associated with erythrocytosis showed no variants in any of these genes. She required chronic dialysis ten months later and, subsequently, a renal transplantation 14 months after the initial presentation."
  },
  {
    "id": "multiclinsum_gs_en_358.txt",
    "fulltext": "A 50-year-old, P3A1 woman was referred to our urogynecology clinic due to malodorous fecal passage through the vagina for 6 months. The condition worsened since she had an extraction of copper T 380 mm IUD. She had IUD insertion for contraception 16 years ago. She had no history of any surgery. The patient denied any abdominal pain or fever. Upon admission, her laboratory examinations were within the normal range: Hemoglobin of 14.2g/dl, white blood count of 6600/µL, ureum 23.9 mg/dL, serum creatinine 0.73 mg/d, CRP 0.62, and fecal analysis within normal limit. Pelvic examination revealed vaginal atrophy and malodorous yellowish vaginal discharge. Vulva was within normal limits. A vaginal speculum examination showed the passage of feces from the cervical canal increased with coughing and straining.\n\nAbdominal ultrasonography found normal size uterus measuring 4.00×4.51 x 7.55 cm with homogeneous parenchyma. No abnormality was found on the adnexa. Fecal passage through the vagina is highly suggestive of the presence of a fistula (colovaginal or uterocolon), thus after discussion with the digestive department, the patient was referred for several imaging examinations. Fistulography showed contrast via anal verge and filled rectum until distal sigmoid colon.\n\nAbdominal and pelvic CT with contrast confirmed multiple rectovaginal fistulas with a diameter of 0.87 cm and a 0.34 cm communication that connected the 1/3 medial vagina to the distal rectum. Another fistula was 0.54 cm in diameter and 0.31 cm in length that connected the distal 1/3 of the vagina with the distal rectum. Rectum was normal without luminal narrowing or visible lesions. The uterine fundus was divided into 2 separate structures, suggesting uterine didelphys. MSCT scan of the abdomen and pelvis showed multiple rectovaginal fistulas, suspected uterine didelphys, and enlargement of the right paraaortic lymph node.\n\nColonoscopy did not show the fistula. Diagnostic laparoscopy and diagnostic hysteroscopy were performed and revealed severe adhesion between the sigmoid colon and the right posterior fundus of the uterus, the fistula was found during hysteroscopy and it connected the posterior right fundus to the sigmoid colon. The umbilicus was incised by 2 cm and veress needle was inserted. A hanging drop test was positive, then insufflation was conducted with CO2 gas, 14 mmHg. In this incision a 10 cm trocar was inserted. Another 5 mm trocar was inserted in the right hypogastric region. Laparoscopy was started and after peritoneum was penetrated, exploration was carried out and it appeared that the sigmoid colon had adhesions with the posterior uterus, bilateral adnexa within normal limits. After making sure there was no bleeding, the trocar from the laparoscope was removed with direct observation. Hysteroscope was then inserted through the cervical canal. On exploration, we found a uterine defect in the right posterior section with a size of ± 2x1x1 cm, connecting with the colon (visible haustra in the lumen).\n\nHistory taking, physical examination, and imaging findings suggested recto-uterine fistula. The patient was scheduled for elective colostomy with adhesiolysis, reanastomosis using intraluminal stapler, and hysterorrhaphy. This was a joint surgery between urogynecology and digestive surgeon.",
    "summary": "P3A1 woman, 50 years old with a history of IUD use for 16 years presented with complaints of fecal discharge from the vagina 8 months ago which worsened after IUD extraction. Physical examination revealed no abdominal tenderness. Speculum examination found feces in the cervical canal. CT scan examination showed multiple uterocolon fistulas and uterine didelphys. Diagnostic laparoscopy and hysteroscopy were carried out and found a recto-uterine fistula, then the patient was scheduled for colostomy and reanastomosis with the stapler method."
  },
  {
    "id": "multiclinsum_gs_en_175.txt",
    "fulltext": "67-year-old woman with a history of long-term diabetes mellitus, with poor adherence to treatment and glycemic control, who denied that she suffered from any other disease and had no surgical history. Her seven-day-old condition began with abdominal cramps, which began in the mid-abdomen and after 12 hours became generalized, accompanied by progressive abdominal distension, nausea and vomiting of bile, difficulty in passing gas and no bowel movements; the woman went to the emergency room two days after the onset of the symptoms. During her initial assessment at the physical examination, a distended abdomen was found, with increased peristasis, without signs of peritoneal irritation. Initial laboratory studies showed no alterations: Hb 14.9 g/dL, leukocytes 8.4 x 103 mm3, neutrophils 73%, platelets 352.0 x 103 mm3, albumin 4.2 g/dL, glucose 310 mg/dL, lipase 52 U/L. The patient was given an abdominal X-ray in which air-hydrogen levels were observed without any other relevant data, so a nasogastric tube was placed with a 300 ml output of bile content and admission was decided for medical management based on intestinal rest and management of solutions.\n\nDuring her stay in the surgery floor, the patient had a stationary clinical picture, which after two days of admission presented an unfavorable evolution, characterized by an increase in the number of vomiting, which was up to five per day despite the use of nasogastric tube, which had a reported 24-hour expense of 120 ml, so the repositioning of this was decided and the patient underwent an abdominal tomography, where the dilatation of loops of small intestine was observed. At that time the patient did not present data of peritoneal irritation or data of systemic inflammatory response, so the medical management was continued.\n\nAfter her fifth day of medical management, the patient continued with emesis (three per day) of gastobiliary content, with nasogastric tube with average 24 hour expenditure of 100 ml. On physical examination with distended abdomen, the patient presented generalized deep palpation pain, without data of peritoneal irritation or data of systemic inflammatory response syndrome. The tomography was reevaluated and dilatation of loops of small intestine was observed, as well as a transition zone at the level of the terminal ileum without being able to identify the cause of this; therefore, as it was a mechanical obstruction in an evident transition zone, it was decided to carry out surgical management.\n\nDuring the surgical procedure, a laparotomy was performed and a 5 x 7 cm lithiasis was found impacted at the level of the ileocecal valve. An enterotomy was performed 60 cm from the ileocecal valve and the lithiasis was removed. Subsequently, the enterotomy was closed and the gallbladder was explored, where a cholecysto-duodenal fistula was documented, which was not operated on. The surgical procedure was concluded without complications or incidents.\n\nThe patient was kept on a bowel rest for three days and started oral intake of liquids with subsequent progression to soft diet with adequate tolerance, as well as adequate gas passage and with present evacuations. She was discharged on the fifth day of the postoperative period without complications or incidents.\n\nThe patient is currently being monitored by the Outpatient Department, with adequate tolerance to the oral route, without alterations in the intestinal evacuation pattern and without clinical or laboratory manifestations of pathology at the level of the biliary tract.\n",
    "summary": "The clinical case of a 67-year-old patient with a history of long-term diabetes mellitus without medical control, without previous surgical history, whose condition began two days before admission to the emergency department with signs and symptoms of intestinal occlusion, is presented. She was given medical treatment without improvement and there was a delay in diagnosis of mechanical intestinal occlusion, which was surgically treated seven days after the onset of the clinical picture. In the exploratory laparotomy a biliary ileus was found, with satisfactory resolution of the pathology despite the delay in diagnosis.\n"
  },
  {
    "id": "multiclinsum_gs_en_371.txt",
    "fulltext": "A 48-year-old woman was admitted to hospital on 21 February 2020, 2 weeks after hysterectomy with a complaint of excessive vomiting. The patient was diagnosed with ET with confirmation of JAK2V617F mutation in June 2019. She had myoma, but operations were rescheduled several times due to high count of thrombocytes and low count of red blood cells which could lead to complications. After medications and transfusions, she was approved to be operated by the doctors earlier in February 2020.\n\nThe patient returned because of vomiting. She was then hospitalized and the nasogastric tube was inserted. Patient was given hydrea 1000 mg BID and anagrelide 0.5 mg BID. On 24 February 2020, patient was unable to pass neither gas nor stool. Therefore, laboratory examinations were conducted, and the results showed elevation of platelets. Meanwhile, whole abdomen CT scan showed fluid collection in pelvic pouch, partial obstruction due to small intestine adhesions, right lobe hepatomegaly, and atherosclerosis of the abdominal aorta, bilateral common iliac artery, right internal iliac artery, and left femoral artery.\n\nBased on the presentations above, the patient was diagnosed with obstructive ileus due to intra-abdominal abscess and intestinal adhesion. The patient also experienced bleeding post hysterectomy operation. She was still unable to pass gas or stool until 26 February 2020. Thus, consultation with a surgeon was made on 27 February 2020 which resulted ina suggestion to conduct a laparoscopic operation despite the high level of thrombocytes. Therapies given were anagrelide 0.5 mg BID, vitamin K, and transamin. Before the operation, she was also given one unit thrombocyte concentrate (TC) and another unit if needed during the operation. Two bags of Packed Red Blood Cell (PRC) and 3 units of Fresh Frozen Plasma (FFP) were given before operation. The operation was conducted on 29 February 2020 through supraumbilical approach with 11 mm and 5 mm incision on the right abdomen and left abdomen, respectively. The small intestines were inflated and adhered to omentum with several adhesive bands. In addition, the small intestines were adhered to the lateral abdomen which had the hematoma. Removal of adhesion and adhesive bands was made, followed by cleaning of abdominal fibrin and blood and drainage.\n\nPost-operation, on 1 March 2020, laboratory tests showed hemoglobin 14.1 g/dL, hematocrit 43%, leukocyte 18,000/mm3, and thrombocytes 675,000/mm3. Flatulence was regained on 2 March 2020 and defecation was regained on 3 March 2020. Patient was given antibiotic. Post-operative pain was felt up to 3 March 2020. On 4 March 2020, the patient complained about diarrhea, 4 to 7 times at night, with black brownish stool and pain in the abdomen and no fever. The patient's stool examination found erythrocytes. Fecal Occult Blood Test (FOBT) was also found positive. Esomeprazole, vitamin K, and transamin were given. On 5 March 2020, the patient’s stool was dark red and her hemoglobin was 8.6 g/dL, hematocrit 25%, leukocyte 9700/mm3, thrombocyte 707,000/mm3. Twelve hours later hemoglobin decreased to 8.2 g/dL, hematocrit 25%, erythrocyte 2,920,000/mm3, ESR 66 mm/hour, and thrombocytes 700,000/mm3. Follow up on 6 March 2020 showed hemoglobin 8.1 g/dL, hematocrit 25%, leukocyte 8300/mm3, thrombocyte 643,000/mm3, aPTT 59 seconds with control 37.3 seconds, PT 10.8 seconds with control 10.8 seconds, and normal thrombocyte aggregation. Patient was then given PRC for 600 ml and TC for 1 unit. Haemoglobin increased to 8.9 g/dL, haematocrit 27%, erythrocyte 1,300,000/mm3, ESR 99 mm/hour, and thrombocytes 689,000/mm3 twelve hours after PRC administration. In addition, one bag of PRC and 500 cc of FFP were given. The patient then had gastroscopy on 7 March 2020. The result was iatrogenic erosive gastritis. Biopsy sample was also taken for pathological anatomy diagnosis. Pathology anatomy diagnosis showed chronic gastritis with no Helicobacter pylori. Therapies given were PRC, TP, and Fresh Frozen Plasma (FFP). On 10 March 2020, patient’s stool was yellow. She was given anagrelide 1 mg OD, transamin 250 mg TID, and was instructed to stop consuming aspirin.\n\nThe patient was discharged after 3 weeks with hemoglobin 10.9 g/dL, hematocrit 34%, reticulocyte 3.4%, ESR 61 mm/hour, and thrombocyte 850,000/mm3. Therapies given were esomeprazole 40 mg BID, sucralfate 15 cc QID and anagrelide 0.5 mg BID. Four days after, the patient showed haemoglobin 11.4 g/dL, haematocrit 34%, reticulocyte 1.6%, ESR 69 mm/hour, thrombocyte 647,000/mm3. Eight months later, laboratory examinations showed hemoglobin 16.2 g/dL, hematocrit 52%, erythrocyte 7,000,000/mm3, thrombocyte 653,000/mm3. Therapies given were hydroxyurea 1000 mg taken once every two days, aspirin 80 mg OD, anagrelide 1 mg OD, and amlodipine 10 mg OD.",
    "summary": "A 48 year-old-female was admitted to the emergency unit on 21 February 2020 due to vomiting and inability to pass gas/stool. The patient previously had an operation for uterine myoma two weeks before which showed thrombocyte count of 688,000/mm3. The patient was previously diagnosed with essential thrombocythemia with positive JAK2V617 point mutation on 24 June 2019. Laboratory examination showed thrombocyte 1,134,000/mm3 and leukocyte 22,700/mm3 suggestive of neutrophilia. CT scan showed fluid collection with blood density in the abdomen and pelvis. She was then diagnosed with obstructive ileus due to abdominal abscess and intestine adhesion. Adhesiolysis by laparoscopy was performed on 29 February 2020 with thrombocyte count of 727,000/mm3. Patient was able to pass flatus and defecate three days post-surgery. However, a decrease of hemoglobin to 8.2 g/dL on 3 March 2020 with thrombocyte count of 700,000/mm3 was suggestive of internal bleeding. She was discharged three weeks post-surgery after improvement of clinical condition with thrombocyte count of 850,000/mm3. She was given hydroxyurea 1000 mg once every two days, aspirin 80 mg OD, anagrelide 1 mg OD, and amlodipine 10 mg OD."
  },
  {
    "id": "multiclinsum_gs_en_315.txt",
    "fulltext": "69-year-old woman with a history of hypertension, insulin-dependent diabetes mellitus, chronic headaches and smoking. She reported a week ago headaches, confusion and vomiting. The examination in the emergency room revealed coma (Glasgow coma scale 5), neck stiffness and absence of pupillary changes.\n\nComputed tomography (CT) showed diffuse HSA, mild intraventricular hemorrhage and hydrocephalus. Computed tomography angiography demonstrated a supraclinoid right internal carotid artery aneurysm. Once admitted to the intensive care unit (ICU), she received treatment with invasive mechanical ventilation, tranexamic acid, nimodipine and enteral VPA (400 mg, three times daily). External lumbar drainage and endovascular embolisation of the aneurysm were performed, with no evidence of angiographic vasospasm. Initial CT showed hydrocephalus, and external ventricular drainage was performed.\n\nAs an initial complication, the patient developed neurocardiogenic dysfunction, with an electrocardiogram showing diffuse repolarization changes and elevated troponin (716 ng/mL). The transthoracic echocardiogram demonstrated systolic dysfunction (left ventricular ejection fraction of 35%) and regional parietal contractility abnormalities, which were interpreted as stress cardiomyopathy. During the stay in the ICU, despite withdrawal of sedation, the patient remained in a coma (Glasgow coma scale 5 on the sixth day). Subsequent CT scans were negative for hydrocephalus, ischemic lesions or other complications.\n\nThe liver, renal, and thyroid functions were normal, and she had no electrolyte imbalances. No extraneural complications were found. The external ventricular drain was removed with sterile cultures. The transcranial Doppler was negative for vasospasm and showed a normal pulsatility index. The MRI did not detect abnormalities. The standard EEG ruled out ictal patterns, but demonstrated a predominantly frontal DPG pattern, which was characterized as a continuous periodic discharge pattern with triphasic morphology and without spontaneous fluctuation, as seen in toxic and/or metabolic brain disorders. (4) Given these findings, the VPA dose was 65.3µg/mL (therapeutic range 50 - 100µg/mL), and the ammonia dose was 160.2µg/mL (normal range 18.7 - 86.0µg/mL). No hepatic insufficiency or gastrointestinal bleeding was observed. VPA administration was then discontinued, and hyperammonemia treatment with lactulose and a protein-restricted diet was initiated. The ammonia level decreased progressively to normalization (81.7ug/mL), which was correlated with a neurological improvement evidenced by response to command on Day 12.\n\nSubsequent EEGs progressively improved to normal. The patient required tracheostomy for weaning from mechanical ventilation and had a tracheo-esophageal fistula as a complication. She died 85 days after admission.\n",
    "summary": "We present the case of a patient with subarachnoid hemorrhage who received anticonvulsant prophylaxis with valproate and developed neurological deterioration associated with elevated plasma levels of ammonia and periodic discharges on the electroencephalogram, with no other identifiable causes. Interruption of valproic acid treatment and normalization of plasma ammonia levels resulted in neurological and electroencephalogram improvement.\n"
  },
  {
    "id": "multiclinsum_gs_en_296.txt",
    "fulltext": "44-year-old male, HIV history since 2004, no antiretroviral treatment (ART), smoker, alcohol drinker, and syphilis. After sexual contact without condom, he developed two ulcers on the tongue, for which he received treatment with benzathine penicillin G. He developed a progressive glossal lesion, oral cavity involvement, and left foot ulcer necrosis, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a progressive glossal lesion, oral cavity involvement, and left foot ulcer necrosis, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, penile skin, and extensive ulcerative necrosis of the left foot, requiring surgical toilet of the affected areas and placement of a bladder catheter. He developed a superficial necrosis of the glans, pen\n",
    "summary": "A 44-year-old man with acquired immunodeficiency syndrome and severe monkeypox presented with obstructive respiratory failure due to airway compromise and extensive generalized lesions of the tegument, genitals, and oropharynx.\n"
  },
  {
    "id": "multiclinsum_gs_en_71.txt",
    "fulltext": "History\nA 27-year-old male patient presented to the emergency room with a complaint of progressive Right gluteal swelling of 1-day duration after he sustained a road traffic accident (RTA) while he was traveling with a wheeled vehicle. He had associated pain, lightheadedness, and heavy sensation around his buttocks. He states he had small swelling over the buttock since childhood which remained stable in size over the years. Otherwise, he has no abdominal pain, chest pain, shortness of breath, or loss of consciousness. No history of bleeding diathesis, antiplatelet or anticoagulant drug use, family history of bleeding disorder, or other known chronic medical illness.\n\nPhysical exam\nUp on arrival at emergency, he was acutely sick looking and in pain. Vital signs were: Pulse rate: 122 beats per minute, Respiratory rate: 24 per minute; blood pressure: 90/50 mmHg. He had pale conjunctivae, dry lips and buccal mucosa, a nodular mucosal lesion over the tongue, and huge tender, ecchymotic, pendulous swelling over the right buttock. Further skin exam revealed numerous skin-colored fleshy nodules (neurofibromas) of variable size, and multiple hyperpigmented macules (café au lait spots) over the trunk and lower extremities. The rest of the examination was unremarkable.\n\nInvestigations\nThe lab showed hemoglobin of 6.1 g/dl, Platelets of 344,000/mm3, and INR of 1.78. Imaging with gluteal ultrasound and computerized tomography (CT) scan was done. Ultrasound findings were extensive intramural collection with intra-echo debris and thick septa suggestive of hematoma measuring around 1500 ml. CT scan reading states predominantly cystic infiltrative mass lesion with solid components and locally aggressive features including skin thickening.\n\nWith the preoperative diagnosis, NF1 (new diagnosis at the emergency room) with intratumor bleeding and expanding hematoma the patient was resuscitated with 2 units of NS blood prepared, an ICU bed reserved and the patient was taken to the operating room (OR) within 3 h of arrival to ER. Under general anesthesia (GA) and endotracheal intubation (ETT) in the prone position.\nIntraoperatively, there was a 15 cm ∗ 20 cm firm mass at the right gluteal area which infiltrated the skin and underlying glues maximus muscle with 2000 ml of hemolyzed blood within the tumor.\nThrough an elliptical skin incision, the hemolyzed blood evacuated, the tumor excised en bloc with overlying skin, and soft tissue and involved part of the underlying gluteus maximus muscle, weighting 1.6 kg.\n\nHemostasis secured drain left in situ and the wound closed. Tissue sent for pathology Patient was transfused with 4 units of whole blood intraoperatively and transferred to the Post Anesthesia Care Unit (PACU) with stable vital signs. There were no intraoperative complications.\nTen hours postoperative hemoglobin was 10.6 g/dl, the wound dressing changed and the drain was minimal and removed on the second postoperative day. On subsequent days wound was healing well, and there was no hematoma or signs of infection. The patient was discharged on 4th postoperative day. With appointment.\n\nOutcome and follow-up\nUp on 2 weeks postop follow-up – the patient had no complaint, and the wound was healing with no signs of infection or swelling. The biopsy result showed plexiform neurofibroma, an abdominal ultrasound was done, and showed liver hemangioma and splenomegaly, the patient was linked to medical and ophthalmology clinics for further evaluation. Upon 6 months' follow-up, the patient had no complaints and the wound site had healed completely.",
    "summary": "We present the case of a 27-year-old male patient from Ethiopia who presented to the emergency room with progressively increasing swelling in the right gluteal area following a road traffic accident (RTA) that occurred one day earlier. Upon evaluation, the patient was in hypovolemic shock with right gluteal swelling accompanied by skin ecchymosis and findings suggestive of NF1. Imaging revealed soft tissue tumors with internal bleeding and hematoma.\nA clinical diagnosis of NF1 with bleeding into a tumor was established. The patient was resuscitated and taken to the operating room, where an en bloc tumor excision and hematoma evacuation were performed. The patient was discharged on the fourth postoperative day with follow-up appointments scheduled and referred to neurology and ophthalmology clinics for further evaluation."
  },
  {
    "id": "multiclinsum_gs_en_429.txt",
    "fulltext": "40-year-old male presented with a 2-month history of progressive memory loss and behavioral changes. He became apathetic and forgetful of recent events, and his job performance as a cashier at a gas station deteriorated. A systemic history revealed a previously unknown history of recurrent oral thrush for 5 years, occasional acneiform lesions, new onset headaches, and episodes of fever in the past few months. Four months prior to presentation, he had a painful loss of vision and was diagnosed with idiopathic bilateral sequential panuveitis.\n\nNeurologic examination showed anterograde amnesia with preservation of autobiographical memory. He was able to recall only one of three words spontaneously and another with semantic cues. All other cortical functions and neurologic examination were normal, and there was no evidence of meningeal irritation. A detailed systemic examination found only an axillary temperature of 37.7°C and an isolated oral aphthae. A formal neuropsychologic evaluation identified a deficit in verbal memory that did not improve with semantic cues, a decreased semantic fluency, and constructive apraxia.\n\nThe blood test showed elevated C-reactive protein (4.32 mg/dL). The head CT scan, plain chest X-ray, urinalysis, and toxicologic screening were normal. A lumbar puncture was performed with normal opening pressure, normal glucose (49 mg/dL in the cerebrospinal fluid, 78 mg/dL in the concurrent blood glucose), hyperproteinemia (1.4 g/L), and pleocytosis (440 leukocytes/uL, 80% mononuclear).\n\nOur diagnostic orientation was a subacute-chronic meningoencephalitis with predominantly limbic involvement. The recent uveitis was within the so-called uveomeningeal syndromes, and the history of recurrent oral aphthae suggested the possibility of EB.\n\nBrain MRI showed bilateral hyperintensities in the limbic regions, confirming the clinical suspicion of limbic encephalitis (LE), as well as leptomeningeal enhancement. An awake EEG was normal. An extensive study of microbiology and autoimmunity in serum and cerebrospinal fluid was normal. HLA-B51 was also negative. Ophthalmologic evaluation identified signs of bilateral retinal vasculitis, with no evidence of active uveitis.\n\nRecurrent oral aphthae and posterior uveitis are key manifestations of EB, and retinal vasculitis is another typical ocular manifestation. While inflammatory meningoencephalitis is a common form of NB, EL is not a typical presentation. Therefore, although the patient met the diagnostic criteria for EB, other alternative etiologies for his neurological presentation had to be excluded.\n\nIn particular, we were looking to exclude the possibility of concurrent paraneoplastic EL. Consequently, a full panel of cell binding assays to detect onconeuronal and neuronal surface antibodies was requested and was negative. In addition, the possibility of a paraneoplastic EL with negative autoantibodies was raised. In accordance with current recommendations, a whole-body 18F-fluorodeoxyglucose positron emission tomography/computed tomography was performed, which excluded an underlying tumour and showed bilateral temporal hypomethabolism at the brain level, supporting the diagnosis of EL. In addition, a testicular ultrasound excluded the presence of a testicular neoplasm.\n\nConsequently, after ruling out other alternative etiologies, the patient was diagnosed with NB. He received five days of high-dose intravenous glucocorticoid treatment with clinical and cerebrospinal fluid improvement, followed by a tapering regimen of oral glucocorticoid, azathioprine and infliximab. A follow-up MRI two months later also showed almost complete resolution of the lesions.\n",
    "summary": "40-year-old male presenting with new onset subacute headaches, memory problems and apathy. A systemic history revealed a previously unknown history of recurrent oral aphthae for years, fever and recent general involvement, as well as a history of bilateral panuveitis four months prior to presentation. His general and neurological examination revealed low grade fever, an isolated oral aphthae, anterograde amnesia and signs of bilateral retinal vasculitis. MRI showed a pattern of limbic meningoencephalitis involvement and his cerebrospinal fluid showed mononuclear inflammation. The patient fulfilled the diagnostic criteria of EB. Considering that EL is a very rare presentation of NB, alternative etiologies including infectious, autoimmune and paraneoplastic encephalitis were thoroughly searched and excluded. Consequently, the patient was diagnosed with NB and showed a good recovery with immunosuppressive treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_582.txt",
    "fulltext": "A 76-year-old female patient is brought to the emergency department with low consciousness and a tendency to sleep.\n\nInterstitial pulmonary disease, dyslipidemia and arterial hypertension are of interest as medical history.\n\nOn physical examination, the patient is stuporous, unresponsive, with atony of the 4 extremities and conjugate deviation of the gaze to the right, without fever and with a slight dryness of skin and mucous membranes. The blood test does not show significant alterations.\n\nThe patient is evaluated by the neurology service, who considers the urgent performance of a brain CT scan in view of the suspicion of intracranial pathology of acute evolution. The imaging tests reveal the presence of numerous air bubbles that are arranged in the cerebral sulci, corpus callosum and both thalami, as well as hypodensities in cortico-subcortical areas of patchy distribution in the left cerebellar hemisphere and bilateral parieto-occipital areas, all of which are compatible with subacute cerebral ischemia secondary to gas embolism.\n\nIn the presence of a personal history of diffuse interstitial pulmonary disease, a chest X-ray in anteroposterior projection and a thoracic CT scan were also performed, which showed a left apical pneumothorax and ectopic air in the upper mediastinum.\n\nThe patient was admitted to the stroke unit of the center for close monitoring of vital signs, however, she presented a torpid evolution with death on the second day of admission due to multiple organ failure.\n",
    "summary": "A 76-year-old patient with pre-existing diffuse interstitial pulmonary disease experienced a massive stroke due to a spontaneous pneumomediastinum. Her presentation included confusion, seizures, and motor weakness. Imaging studies revealed air bubbles in the cerebral sulci and hypodensities in the cerebellum and parieto-occipital areas. In addition, pneumothorax and air in the upper mediastinum were observed on chest radiographs and thoracic computed tomography. Despite therapeutic measures such as hyperbaric oxygen, the patient unfortunately died due to multiple organ failure.\n"
  },
  {
    "id": "multiclinsum_gs_en_374.txt",
    "fulltext": "A 72-year-old man with a history of hypertension and nonvalvular atrial fibrillation was referred to our hospital with a suspected posterior mediastinal tumor. Chest computed tomography (CT) revealed a well-encapsulated tumor 3 cm in diameter with a heterogeneous interior adjacent to the right side of the 8th to 10th thoracic vertebrae. Magnetic resonance imaging (MRI) could not be performed due to claustrophobia. Based on these imaging findings and localization, we suspected a neurogenic tumor and planned surgical excision using RATS.\n\nThe patient was placed in a slightly forward tilt, left lateral decubitus position under general anesthesia. RATS was performed via the right intercostal approach using the da Vinci Xi system (Intuitive Surgical, Mountain View, CA, USA) with three arms. An 8 mm trocar was first inserted into the sixth intercostal space (ICS) along the middle axillary line. Another 8 mm trocar for the right arm was inserted along the posterior axillary line at the fourth ICS. A third 8 mm trocar for the left arm was inserted into the ninth ICS along the posterior axillary line. The three robotic trocars were placed in an inverted triangular configuration relative to the lesion, allowing precise instrument manipulation without collisions. After maintaining the pressure in the thoracic cavity at 10 mmHg, the da Vinci robot was docked. On the left, a Cadiere grasper was installed, while on the right, Maryland bipolar forceps was placed. The tumor was well encapsulated and dark red and presented as a soft oval mass located in the posterior mediastinum, bordering the Th9 to Th10 thoracic vertebrae. The tumor was completely resected without damaging the capsules. The cut surface was yellowish with a homogeneous solid mass. No serious complications were observed during the postoperative course. The chest drain was removed on the first postoperative day, and the patient was discharged on the fifth postoperative day. Postoperative microscopic examination revealed predominantly mature adipose tissue with hematopoietic tissue comprising erythroblasts, megakaryocytes, and granulocytes. Based on these findings, the patient was diagnosed with ML originating from the posterior mediastinum. He has been well for 3 years after surgery without recurrence.",
    "summary": "A 72-year-old man with an abnormal shadow on a chest roentgenogram was referred to our hospital. Computed tomography revealed extrapulmonary paravertebral lesions in the right posterior mediastinum. Despite the tumor's fragility, complete resection was achieved with robot-assisted thoracic surgery while preserving the lesion integrity. The tumor was diagnosed as a myelolipoma using histopathology of the resected section, and the patient was discharged with no complications on the fifth postoperative day."
  },
  {
    "id": "multiclinsum_gs_en_519.txt",
    "fulltext": "Patient information: A 35-year-old man presented at the emergency department at night with acute lower back pain that had been present for 8 weeks but was getting worse despite optimal analgesic treatment. He reported a common surfing injury 5 weeks before the onset of the pain. He had already consulted twice about his complaints, a radiograph of the lower back had been taken and had shown no anomalies. Physiotherapy sessions had been prescribed without improvement.\n\nHe also describes the appearance of a cold sore a few days before the onset of the back pain. The patient has no particular ATCDs and has moderate consumption of tobacco, alcohol and cannabis. The intensity of the pain is greater at night and the patient sleeps little. These pains are described as intense burns.\n\nClinical findings: the clinical examination in the emergency department revealed a disappearance of all facial mimicry. The patient said he had consulted his general practitioner about this problem a week before; the latter had concluded that it was a case of paralysis a frigore due to a virus and no diagnosis and targeted treatment had been initiated. The facial paralysis was initially unilateral on the left at the time of the consultation but had become bilateral 48 hours later. The patient was not overly concerned because the treating doctor had reassured him about the trivial nature of the condition, especially since the nocturnal lower back pains were bothering him more.\n\nDiagnostic approach: the anamnesis describes a difficult opening of the eyes without visual disturbance, a modification of the taste and an absence of cephalgia. The clinical examination shows an apyretic patient with a facial diplagia with a sigle of Bell present bilaterally. There is no sensory deficit in the face. The ocular movements are normal without nystagmus. The pupils are isocore and reflective.\n\nHe has a slight stiff neck with no deficit of strength in the 4 limbs. His reflexes are moderately diminished in the 4 limbs (2/4). The cutaneous-plantar reflex is in bilateral flexion. The Barré held and his gait is normal. He has a hyperesthesia in the dorsolumbar with Lasègue present at 60° bilaterally.\n\nTherapeutic intervention: In view of the above, a lumbar CT scan is proposed before lumbar puncture and is normal.\n\nThe lumbar puncture is clear and demonstrates the presence of 29 nucleated elements with a predominance of lymphocytes (75%) in the cerebrospinal fluid (CSF) and the very high presence of immunoglobulin M (IGM) type immunoglobulins of Borrelia in the CSF (> 190 UA/ml) as well as a proteinorachia of 3.662 g/L.\n\nPCR for Herpes simplex 1 and 2 is negative. Serology for Herpes simplex virus (HSV) and Herpes zoster virus (HZV) are negative. Serology for Borrelia is doubtful for the IGM and positive for the immunoglobulin G (IGG).\n\nFollow-up and results: we concluded to a disseminated early phase neuroborreliosis; with facial diplagia, a lymphocytic meningitis and a dorsal-lumbar as manifestations.\n\nThe police background check revealed that the patient had stayed in the Landes for 3 months previously and had been bitten by mosquitoes and possibly a tick. He also described an erythema in his armpit that had lasted 4 weeks but was labelled as a sweat rub.\n\nThe patient was then given initial and rapid antibiotic therapy for 14 days with 2 grams of intravenous ceftriaxone daily, associated with acyclovir at the beginning; the latter was discontinued as soon as the herpes serologies were negative. After a few days, an improvement in symptoms was observed, both in terms of paralysis and pain. After four weeks, the neurological examination was normalised with a total recovery of the diplegia.\n",
    "summary": "We report the case of a 35-year-old man with a picture of disabling dorsalgia preceded by a monoplegia facialis treated wrongly as a paralysis a frigore and then as a post-traumatic lumbosciatalgia. The appearance of a facial diplegia will finally allow to evoke and confirm the diagnosis. The administration of ceftriaxone will allow the progressive resolution of the symptoms.\n"
  },
  {
    "id": "multiclinsum_gs_en_333.txt",
    "fulltext": "A 51-year-old female patient with a history of allergic reactions to nitrofurantoine and phenazopyridine, who had breast implants since 2010, developed a blistering pemphigus in 2015 (diagnosed by biopsy) and an apparent diagnosis of acquired haemophilia in 2016, with the presence of spontaneous ecchymosis in the arms and legs, intermittent non-inflammatory gonalgia, accompanied by myalgia in the upper and lower limbs and prolonged haemorrhages without petechiae, a painful condition in the left iliac fossa, resulting from left renal haemorrhage with ipsilateral pleural effusion.\n\nShe presented to the emergency department on September 22, 2020 with a hemorrhagic syndrome in the right breast, which began with an increase in volume and alteration of the consistency of the right breast, causing a displacement towards the midline, without medical management. She subsequently presented with hives with erythema around the areola, approximately 5 mm in diameter, painful, hypersensitive, not pruritic, with a spontaneous outpouring of blood. Physical examination revealed an evident growth in the right breast, lateral deviation of the nipple, a haematic outpouring from the infra-alveolar medial zone, concluding with a Baker grade IV capsular contracture of the right breast and grade I of the left breast. She was treated with antibiotics and factor VIII in the emergency department, without improvement.\n\nHe was then admitted to the haematology department on suspicion of coagulopathy, with a marked prolongation of activated partial thromboplastin time (APTT) of 107.4 seconds (control 27.6 s) and a PT of 14 s (control 11.8 s). The study was repeated with APTT > 180 s and coagulation corrections-dilutions resulting in no correction, and plasma was collected for the Bethesda method, as well as a change in treatment to factor VIIa (NovoSeven) at a dose of 5 mg every three hours intravenous (IV). Given these characteristics, acquired haemophilia was suspected, and was confirmed with a result of 30,000 Bethesda units, a high response.\n\nA computed axial tomography (CAT) scan was performed, which showed a hematoma in the implant of the right breast, respecting its capsule. For this reason, the plastic surgery department was contacted for the removal of both breast implants.\n\nThe patient was scheduled to be admitted to the operating room on September 28, 2020 at 4:00 p.m. A bilateral capsulectomy was performed, obtaining an intracapsular hematoma of 320 ml, as well as the macroscopic pathological inspection of the affected capsule. The procedure concluded successfully.\n\nBefore the surgical procedure described above, the haemostasis control was carried out by the haematology service, using factor VIIa (NovoSeven) with a dose (70-90 mcg/kg/every 3 hours) in relation to the weight (70 kg), corresponding to 5 mg every 3 hours for 7 days, achieving adequate haemostasis. After the surgery (72 hours) weekly rituximab (600 mg for four doses) was indicated; on October 3, 2020, the factor VIIa was replaced with tranexamic acid (650 mg every 8 hours orally) for a complete haemostatic control and for the outpatient management of the patient, so her discharge was decided, after an intrahospital stay of 12 days and continuing, later, on December 9, 2020 with deflazacort (30 mg/day) by the rheumatology service.\n\nThe patient is currently asymptomatic, denies the presence of hemorrhagic episodes and reports clinical improvement of inflammatory events in muscles and joints. The scar of the surgical event is without hemostatic problems.\n\nThe histopathological result of the right breast implant capsule, with mature fibroadipose and fibroconective tissue, allowed the identification of a prominent transmural mixed inflammatory infiltrate (acute and chronic), accompanied by few multinucleated giant cells of the foreign body type, while the left breast implant capsule presented a discrete inflammatory lymphoplasmocitary infiltrate.\n",
    "summary": "We present the case of a 50-year-old woman with a history of silicone breast implants who developed a spontaneous hemorrhagic coagulopathy, acquired type A hemophilia, i.e. autoantibodies against coagulation factor VIII. Thanks to the work of a multidisciplinary team, the patient was successfully diagnosed and treated with bridging agents, removal of the implants and management of associated symptoms.\n"
  },
  {
    "id": "multiclinsum_gs_en_218.txt",
    "fulltext": "A 46-year-old female patient was admitted to our hospital due to chest tightness and shortness of breath that lasted for over a month. Her medical history included a partial thyroidectomy, and she had no history of smoking or alcohol consumption. She was treated with regular medications (Metoprolol succinate extended-release tablets, Sacubitril valsartan sodium tablets, Spironolactone, Dapagliflozin tablets) for HF, but the response was poor. During the physical examination, the patient was conscious and well-oriented. Her heart rate was 68 beats per minute, blood pressure was 150/98 mm Hg, respiratory rate was 20 beats per minute. There were no signs of bleeding or jaundice on the skin or mucous membranes, and no jugular venous distention was observed. The thyroid gland was not enlarged. Breath sounds were coarse in both lungs, with wet rales present at the lung bases. The heart rate was 68 bpm with a regular rhythm. The abdomen was soft, with no tenderness or rebound tenderness, and the liver and spleen were not palpable below the rib cage. The hepatojugular reflux sign was negative, but there was edema in both lower limbs.\n\nShe was hospitalized and underwent relevant examinations. Biochemical tests showed thyroid stimulating hormone (TSH) of 7.190 uIU/mL, triglycerides of 0.81 mmol/L, low-density lipoprotein cholesterol ((LDL-C)) of 2.61 mmol/L, serum lipoprotein (a) of 435 mg/L, and NT-proBNP of 6245 pg/mL. An electrocardiogram (ECG) examination showed sinus bradycardia, T-U wave abnormalities, and QRS duration of 90 ms. Further transthoracic echocardiography revealed left-atrium (LA) diameter (anteroposterior) of 41 mm, left-ventricle diameter (LVD, anteroposterior) of 54 mm; interventricular septum thickness in diastole (IVSD) of 9 mm, end-diastolic left-ventricular posterior wall thickness (LVPWd) of 9 mm, left-ventricular ejection fraction (LVEF) of 28% (M-mode), fraction shortening (FS) of 13%, and pulmonary artery pressure of 29 mm Hg. No significant coronary artery lesions were observed on coronary computed tomography angiography (CTA). The patient was diagnosed with dilated cardiomyopathy, class III heart failure with reduced LVEF according to the New York Heart Association (NYHA). Combined with the parameters, it can be observed that the volumes of the left atrium and left ventricle are gradually shrinking, indicating that the diastolic function of the left ventricle is improving. CCM treatment is reversing myocardial remodeling. In addition, E/e′ reflects the left ventricular filling pressure. The normal value should be less than 8. It can be observed that in this case, E/e′ returns to the normal value three months after CCM implantation. These two points both reflect the role of CCM in improving myocardial diastolic function in the treatment of heart failure. In summary, the patient had the following characteristics: (1) LVEF improved but remained as low as 30% after optimal drug therapy for heart failure; (2) Chest tightness and discomfort with slight activity, cardiac function grade III; (3) ECG shows narrow QRS. Considering the positive preoperative of levosimendan test, after general discussion and full communication with the patient and his family, it was decided to perform CCM implantation treatment.\n\nThe CCM implantation procedure was similar to that of traditional pacemaker implantation. The patient was placed in a supine position, disinfected with a towel, and the left subclavian vein was punctured twice under local anesthesia, and the capsular bag was made after the guidewire was inserted. Under the guidance of the guidewire, two tear-off sheaths were fed, and two ventricular pacing leads (Medtronic 3830–69) were fed through the sheath, and the position of the wires was adjusted to the right ventricular septum surface with a distance of 3 cm. During the operation, the near-field electrode (RV) was tested, showing a pacing capture threshold of 0.5 V, a sensed R-wave amplitude greater than 10 mV, and a lead impedance of 1080 Ω; the far-field electrode (LS) showed a pacing threshold of 0.5 V, a sensed R-wave amplitude greater than 15 mV, and a lead impedance of 900 Ω. These measurements met the criteria for successful electrode implantation. Both leads were securely anchored into the right-ventricular septum. After ensuring the absence of palpable diaphragmatic stimulation with a 10 V pacing pulse at 0.4 ms pulse width, the leads were connected to the Optimizer Smart pulse generator. Subsequently, the output pulses were set, and parameters were programmed and optimized.\n\nImmediate postoperative ECG monitoring indicated normal CCM pulse delivery (Figure 1C). We observed the patients’ response to CCM by adhering to a standardized follow-up protocol. Utilizing a comprehensive array of assessment tools, including cardiac color Doppler ultrasonography, NT-ProBNP blood tests, six-minute walk tests (6MW), and the Minnesota Living with Heart Failure Questionnaire (MLHFQ), we systematically evaluated the clinical statuses of the patients. The patient experienced no chest tightness or shortness of breath, and there was a marked improvement in exercise tolerance and quality of life.",
    "summary": "We present a patient of a 46-year-old female patient was admitted to our hospital due to chest tightness and shortness of breath that lasted for over a month. Echocardiography revealed left-ventricle diameter (anteroposterior) of 54 mm, electrocardiogram showed sinus bradycardia, and QRS duration of 90 ms. The patient experienced no chest tightness or shortness of breath, and there was a marked improvement in exercise tolerance and quality of life after cardiac contractility modulation implantation."
  },
  {
    "id": "multiclinsum_gs_en_22.txt",
    "fulltext": "A 62-year-old Japanese male was diagnosed with Stage IV advanced rectal cancer with liver metastasis. There was no personal medical history other than rectal cancer, and he has smoked 20 cigarettes per day for 40 years. He was initially treated with capecitabine plus oxaliplatin and bevacizumab as first-line chemotherapy. After 11 cycles of the regimen, the patient developed a skin rash, which was induced by infusion of these agents; thus, the treatment was changed to TAS-102 regimen. Approximately 2 months after initiation of TAS-102, the patient developed high fever and was emergently admitted to our hospital. The patient had received antibiotics from a few days before this visit, and vital signs on admission were as follows: blood pressure 100/68 mmHg, heart rate 82 beats/min, body temperature 37.4°C, and oxygen saturation was 90% on room air. High-resolution computed tomography (HRCT) of the chest revealed bilateral diffuse ground glass opacities in all lung lobes with traction bronchiectasis. Laboratory findings were as follows: white blood cell count 3400/μL (31.1% of lymphocytes, 1.8% of eosinophils), C-reactive protein level 9.96 mg/dL, and lactate dehydrogenase level 275 IU/L. Serum Krebs von den Lungen-6 and surfactant protein D levels were 528 IU/mL (normal < 500 IU/L) and 235 ng/mL (normal < 110 ng/mL), respectively. There were no elevated levels of serum antibodies associated with autoimmune diseases, and no evidence of any infectious agent, including general bacteria and acid-fast bacillus in sputum, on urine and blood culture. Although we initiated broad-spectrum antibiotics after emergent admission, the patient’s oxygen levels worsened. The patient then received non-invasive positive pressure ventilation, followed by nasal high-flow oxygen therapy and steroid pulse therapy using methylprednisolone 1 g for 3 days as treatment for suspected TAS-102-induced interstitial pneumonia. The patient was treated with 1 mg/kg of corticosteroid after steroid pulse therapy. The corticosteroid dose was then gradually decreased. During these treatments, the drug lymphocyte stimulation test result for TAS-102 was positive (stimulation index: 251%); therefore, the patient was diagnosed with TAS-102-induced interstitial pneumonia based on the Japanese Respiratory Society (JRS) guideline for management of drug-induced lung disease. Oxygenation and chest radiological findings improved after corticosteroid treatment, and the patient was discharged 23 days after emergency admission.",
    "summary": "We report a case of a 62-year-old male who was diagnosed with advanced rectal cancer. The attending gastro-enterologist initiated chemotherapy using capecitabine plus oxaliplatin and bevacizumab; however, this treatment regimen was discontinued, as the patient developed a skin rash. Once the skin rash improved, chemotherapy was re-initiated using a combination of trifluridine and tipiracil hydrochloride (TAS-102). The patient developed high fever and dyspnea 2 months after initiation of TAS-102. Chest high-resolution computed tomography showed bilateral diffuse ground glass opacities in all lung lobes with traction bronchiectasis. At this time, the gastro-enterologist consulted our department. The patient was put on non-invasive positive pressure ventilation due to worsening respiratory symptoms. The patient was suspected to develop TAS-102-induced interstitial pneumonia based on positive TAS-102 drug-induced lymphocyte stimulation test. The patient's respiratory symptoms and radiological findings improved after corticosteroid treatment. The corticosteroid dose was gradually decreased by 5 mg. Thereafter, chemotherapy was re-initiated using different anti-cancer agents."
  },
  {
    "id": "multiclinsum_gs_en_461.txt",
    "fulltext": "A 67-year-old woman with dilated cardiomyopathy, diagnosed 10 years ago with left ventricular (LV) ejection fraction of 35% (reference range: 50%–70%) and moderate MR, was referred for New York Heart Association (NYHA) Classes II and III dyspnoea. She had no significant cardiovascular risk factors or other comorbidities that would affect the treatment strategy. Her symptoms persisted despite optimal medical therapy with carvedilol 10 mg, enalapril 2.5 mg, spironolactone 25 mg, azosemide 30 mg, and tolvaptan 3.75 mg daily. On physical examination, the patient was 160 cm tall, weighed 57 kg, blood pressure of 123/71 mmHg, and heart rate of 100/min. Cardiac examination revealed a Levine Grade II/VI systolic ejection murmur at the left third intercostal space and mild lower extremity oedema.\n\nOutpatient B-type natriuretic peptide levels ranged from 150 to 250 pg/mL (normal range: < 125 pg/mL). Transthoracic echocardiography revealed LV end-diastolic diameter of 70 mm (reference range: 35–52 mm), LV ejection fraction of 31%, and severe functional MR between A2 and P2 scallops, characterized by a regurgitant fraction of 59% (threshold for severe MR: 50%) and effective regurgitant orifice area of 0.27 cm² (threshold for severe MR: 0.20 cm2). Transoesophageal echocardiography (TEE) confirmed significant tethering with vena contracta width >11 mm (threshold for severe MR: 7 mm). Despite a low Society of Thoracic Surgeons score (1.89%), our multidisciplinary team chose M-TEER using two second-generation MitraClip devices considering the LV dysfunction, the functional aetiology of MR, and patient preference for early mobilization.\n\nMitral valve transcatheter edge-to-edge repair was performed under general anaesthesia. During clip preparation, slight resistance was noted when the clip introducer was sliding over the clip. Although the clip appeared to function normally during checks, the introducer was not thoroughly inspected. The clip was then advanced through the system without difficulty. Following transseptal puncture and advancement to the straddle position, the clip was positioned over the mitral valve without issues. However, when the lock lever was unlocked for opening in the LA, the clip showed restricted movement and would not open beyond 30°.\n\nInitial attempts to close and retrieve the clip were unsuccessful due to resistance in the arm positioner. As troubleshooting, we returned the arm positioner to neutral and pulled back the lock lever ∼5 mm. We then rotated the arm positioner slightly in the closing direction, followed by rotation in the opening direction. When this manoeuvre failed, we repeated the process with a stronger rotation in the closing direction, which generated unprecedented mechanical resistance. During subsequent rotation in the opening direction, the clip suddenly opened to 180° and detached from the clip delivery system (CDS), remaining connected only by the gripper line in its default raised position.\n\nUnder TEE and fluoroscopic guidance, we performed direct retrieval of the clip. Although the grippers temporarily displaced downward during detachment, they returned to their raised position during controlled traction toward the steerable guide catheter (SGC). The gripper position was maintained to ensure secure connection. Using gentle and steady traction on the CDS, the clip was gradually guided toward the SGC. The clip inverted during this process and partially entered the SGC, allowing safe withdrawal of the entire system into the right atrium. Transoesophageal echocardiography revealed a 2–3 mm atrial septal defect but no other mechanical complications were observed with stable haemodynamics. The CDS and SGC were retrieved via femoral cut-down. Careful inspection of the retrieved system revealed a tear in the introducer that was not visible during the initial preparation.\n\nFollowing the retrieval of the system, two MitraClip NT devices were successfully implanted using new CDSs and SGC, resulting in mild residual MR. X-ray and TEE confirmed no device components remained in the patient.\n\nThe patient was discharged on Day 4 without complications. During outpatient follow-up, pharmacotherapy was optimized: beta-blocker therapy was changed from carvedilol 10 mg to bisoprolol 3.75 mg daily, which was later uptitrated to 5 mg. The angiotensin-converting enzyme inhibitor was switched from enalapril 2.5 mg to perindopril 4 mg daily, and subsequently replaced with sacubitril/valsartan 200 mg daily. Empagliflozin 10 mg daily was added to the regimen following its regulatory approval. Her symptoms had improved to NYHA Class I and remained stable for 4.5 years.",
    "summary": "A 67-year-old woman with dilated cardiomyopathy underwent M-TEER for severe functional MR. Although resistance was noted during initial device preparation and loading, limited functional testing appeared normal and the procedure was continued. During clip manipulation in the left atrium, mechanical resistance in the arm positioner led to unexpected detachment of the MitraClip, connected only by the gripper line. Through careful traction under echocardiographic and fluoroscopic guidance, we successfully retrieved the clip percutaneously. The procedure was completed with new MitraClip systems, achieving mild residual MR. The patient's symptoms improved from New York Heart Association Classes II and III to I, with sustained improvement during 4.5 years of follow-up."
  },
  {
    "id": "multiclinsum_gs_en_226.txt",
    "fulltext": "The patient is a healthy 74-year-old lady, physically active with walking and horse riding. One month after cortisone injection treatment of insertional Achilles tendinopathy she sustained a total insertional Achilles tendon rupture during push off when biking. This rupture was treated conservatively in a Walker boot for 8 weeks. Then, during horse riding, a push off caused a total re-rupture in the insertion. The rupture was surgically treated with re-insertion of the Achilles into the calcaneus, using suture anchors. This was followed by immobilization in a cast. Postoperatively the patient sustained a deep wound infection not responding to antibiotics, signs of sepsis, and surgical exploration was indicated. During surgery the whole Achilles was found to be severely affected by infection, more or less destroyed, and the distal 7 cm of the Achilles (the whole free Achilles) had to be removed. This left a large defect without any tendon tissue, and the skin was sutured over the defect. After this procedure, immobilization and treatment with cloxacillin antibiotics, cured the infection and the wound healed properly. The foot was immobilized in a cast the first 10 weeks, from maximum plantarflexion initially, then gradually decreased plantarflexion until reaching neutral position. This was followed by immobilization in a dorsal cast, preventing from stretching of the Achilles in dorsiflexion, for another 3 months. She was told to gradually increase the load during walking, but to avoid stretching for altogether 6 months. After 6 months she was offered surgical reconstruction with a flexor hallucis longus graft, but because she then had a satisfactory function, she decided to wait and see. Her function gradually improved, and one year postoperatively when seeking help for pain in the other Achilles, the good function on the operated side was noticed. Ultrasound scanning surprisingly showed a tendon looking very similar to a slightly tendinopathic Achilles.",
    "summary": "This 74-year-old lady suffered from insertional Achilles tendinopathy. After treatment with a local cortisone injection, she sustained a total insertional Achilles tendon rupture. This rupture was treated conservatively, and after treatment the Achilles re-ruptured in the insertional area. The rupture was then treated with re-insertion into the calcaneal insertion. Early in the post-operative period the patient sustained a deep surgical wound infection and sepsis. Because of poor effect of treatment with antibiotics, and total tendon destruction, the whole Achilles was extirpated. After extirpation there was immobilization in a cast followed by mobilization and gradually increased loading. At a one-year follow-up, the patient was walking without a limp, could do heel-raise halfway up standing on one leg, there was a palpable Achilles tendon and ultrasound scanning showed a structure very similar to a slightly thickened and tendinopathic Achilles tendon. There was an obvious regeneration of the whole Achilles tendon, and the tendon function was surprisingly good."
  },
  {
    "id": "multiclinsum_gs_en_547.txt",
    "fulltext": "A 64-year-old male presented with exertional retrosternal pain. He had a past medical history of hypertension, dyslipidemia, obesity, bilateral carpal tunnel syndrome and underwent bilateral surgical release and cervical laminectomy. The resting electrocardiogram revealed an incomplete left bundle branch block, while the resting echocardiogram was completely unremarkable. He underwent a stress echocardiogram with dobutamine; at peak stress, the left ventricle developed regional wall motion abnormalities including hypokinesis of the inferior wall, associated with angina and soon followed by ventricular tachycardia, reversed with propranolol. The patient was hospitalized and underwent a coronary angiography which revealed slow flow, dominant right coronary artery with non-obstructive atherosclerosis and a left anterior descending artery (LAD) with intermediate lesions in mid and distal segments. A functional evaluation revealed a non-significant fractional flow reserve of 0.86 in the LAD, but a pathological CFR of 1.8 and an IMR of 61. Given the patient's symptoms, risk factors and diagnostic tests, he was considered to have microvascular angina and was treated with antiplatelet therapy, a statin, a calcium channel blocker and a transdermal nitrate, with symptomatic relief.\n\nThree years later he developed complete atrioventricular block and presented in the emergency department with sudden hemodynamic collapse. A dual chamber pacemaker was implanted, and he was discharged asymptomatic.\nShortly after, the patient developed progressive symmetrical tetraparesis, associated with marked muscle atrophy, hand numbness, orthostatic hypotension and dysphagia. The neurology workup led to the diagnosis of familial amyloidotic polyneuropathy (FAP), and the Val30Met mutation in the transthyretin (TTR) gene was detected.\nThe following year, he developed NYHA class II to III congestive heart failure (HF), requiring uptitration of diuretics. The repeat echocardiogram showed moderate concentric left ventricular hypertrophy, with preserved ejection fraction but an abnormal global longitudinal strain and elevated filling pressures. He repeated the coronary angiography which excluded CAD progression. He underwent a 99mTc-DPD scintigraphy that revealed significant myocardial tracer uptake, diagnosing TTR amyloid infiltration. He was stabilized with medical therapy and kept under close follow-up, requiring antianginal therapy uptitration for exertional microvascular angina.",
    "summary": "A 64-year-old male, with cardiovascular risk factors and previous history of bilateral carpal tunnel syndrome, presented with exertional retrosternal pain. The resting echocardiogram was unremarkable. A stress echocardiogram with dobutamine revealed hypokinesis of the inferior wall, associated with angina, followed by ventricular tachycardia. The coronary angiography revealed slow flow, a dominant right coronary artery with non-obstructive atherosclerosis and a left anterior descending artery with intermediate lesions in mid and distal segments. The invasive functional evaluation, including fractional flow reserve, thermodilution coronary flow reserve and index of microvascular resistance, led to the diagnosis of microvascular angina, treated with calcium channel blockers and transdermal nitrate, giving symptom relief.\n\nEvolution\nThree years later he developed complete atrioventricular block and a dual chamber pacemaker was implanted. Shortly after, the patient developed progressive symmetrical tetraparesis, associated with marked muscle atrophy, hand numbness, orthostatic hypotension and dysphagia. The neurology workup led to the diagnosis of familial amyloidotic polyneuropathy, with the Val30Met mutation in the transthyretin gene. The following year he developed congestive heart failure. The echocardiogram showed moderate concentric left ventricular hypertrophy with preserved ejection fraction. A 99mTc-DPD Scintigraphy showed significant myocardial tracer uptake, leading to a diagnosis of TTR amyloid infiltration."
  },
  {
    "id": "multiclinsum_gs_en_496.txt",
    "fulltext": "A 72-year-old woman was admitted to the hospital with bilateral lower limb edema for 7 days. The patient previously had hypertension and diabetes mellitus, and she experienced recurrent bilateral lower limb edema and generalized a recurrent cutaneous rash without receiving comprehensive systemic treatment in the last 2 years. The patient’s vital signs were within normal limits, with a blood pressure of 140/80 mm Hg. The initial physical examination revealed bilateral lower extremity edema, particularly the right ankle, and skin pigmentation. Laboratory examinations revealed blood counts, C-reactive protein, creatinine kinase, albumin, prothrombin time, partial thromboplastin time, serum biochemistry assays, immunoglobulin, and complement levels were all within the normal range. The chest and abdominal computed tomography scans revealed no notable abnormalities. Urine routine analysis was positive for occult blood.\n\nOn the 7th day of admission, urine routine analysis was positive for occult blood and urine protein. Serum biochemical tests revealed high creatinine levels, and the patient had abnormal kidney function. On the 8th day of admission, purpura emerged on the lower limbs and back. We identified the patient with HSP and administered vitamin C and other symptomatic treatments. On the 12th day of admission, the patient complained of abdominal pain, so we urgently reviewed the abdominal computed tomography. It showed segmental thickening of the intestinal wall and “concentric circles” in the ileocecal part, so we diagnosed intussusception. The patient’s conservative treatment was ineffective, so she underwent emergency surgery. During the operation, the ileum was lodged in the cecum to cause the intussusception. The intestinal mucosa is congested and edematous, while the intestinal wall is severely edematous and hemorrhagic. On the first postoperative day, the patient exhibited widespread purpura throughout the body; therefore, we administered glucocorticoids for symptomatic treatment. Unfortunately, the patient’s urine output gradually decreased, there was depressed edema of the lower limbs and renal function gradually deteriorated. Eventually, the patient developed acute renal failure. On the 6th surgical day, the patient underwent bedside hemofiltration and hemoperfusion therapies. After treatment, the patient’s edema gradually resolved, and her condition showed improvement. However, on the 9th postoperative day, the patient suddenly developed symptoms of heart failure, coughed up an amount of pink foamy sputum, with extensive wet rales in both lungs, blood pressure dropped. Two hours later, the electrocardiographic monitoring revealed ventricular escape rhythm, we immediately resuscitated the patient, and the patient resumed sinus rhythm after 5 minutes of cardiopulmonary resuscitation. Laboratory tests revealed higher levels of troponin, myoglobin and creatine kinase isoenzymes. The repeat transthoracic echocardiogram showed new-onset severe left ventricular (LV) systolic dysfunction with an LV ejection fraction of 38% (LV ejection fraction was 58% on admission). We considered myocardial involvement as the culprit. However, her family abandoned treatment, and the patient died.",
    "summary": "Patient concerns: A 72-year-old woman whose initial symptoms were unusual, and the progression of the disease is irregular.\n\nDiagnoses: The patient with HSP gradually developed intussusception, renal failure and cardiac involvement.\n\nInterventions and outcomes: The patient developed kidney injury and intussusception, we sequentially administered surgical intervention, glucocorticoids, hemofiltration and hemoperfusion, and her condition showed improvement. Unfortunately, by the time cardiac complications develop, the patient's condition deteriorated rapidly. At last, the patient died."
  },
  {
    "id": "multiclinsum_gs_en_367.txt",
    "fulltext": "A 42-year-old P1A0 woman was admitted to our hospital with a two-week history of chronic fever. Her fever was notable for being present mostly during evenings. She reported that she felt better with paracetamol, but her fever did not abate. During her fever, she complained of watery stools for two days, after which she was constipated. The patient did not complain of dysmenorrhea or dyspareunia. She lived in a rural area where tropical infections, such as typhoid and paratyphoid fever, are common. There was no family history of malignancy. Her last pregnancy occurred 21 years ago and she had undergone hormonal contraceptive injections for 20 years. The patient had an irregular menstrual cycle with a duration of 5–7 days. The patient had no relevant medical history. Laboratory workup results suggested typhoid fever.\n\nDuring observation in the ward, the patient suddenly developed severe, acute abdominal pain. The pain was unprovoked and started in the lower abdomen. It soon spread to the entire abdomen, and an acute abdomen was diagnosed. Subsequently, she underwent abdominal radiography, which showed excessive intestinal air distribution in the right upper abdomen and suspected localized ileus in the right upper abdomen. Diffuse peritonitis due to suspected hollow viscus perforation as a complication of typhoid fever was established, and an emergency laparotomy was performed immediately.\n\nIn the theatre, approximately 1000 cc of chocolate-like fluid was discovered after accessing the peritoneal cavity. The fluid was evacuated and ruptured bilateral ovarian cysts were observed. A gynecological surgeon performed the surgery and found bilateral endometriomas. The right endometrioma measured approximately 10 cm in diameter, whereas the left endometrioma measured approximately 15 cm. Adhesions with the surrounding organs were observed and successfully lysed. A bilateral cystectomy was performed.\n\nShe was transferred to a high-dependency unit before being transferred to the general gynecology ward. She was hospitalized for four days; fortunately, she recovered uneventfully. The pathological report confirmed the diagnosis of bilateral endometriomas.",
    "summary": "A 42-year-old woman presented to our hospital with abdominal pain. She had a history of fever for two weeks. She came from a tropical rural area where typhoid fever is common. She was advised to undergo emergency laparotomy because of the suspicion of diffuse peritonitis due to a hollow viscus perforation due to typhoid infection. Because of acute abdominal pain, a vertical incision was made to explore her abdominal cavity, and chocolate-like fluid and ovarian cysts were found during surgery. The diagnosis was changed to diffuse peritonitis due to spontaneous rupture of the endometrioma bilaterally."
  },
  {
    "id": "multiclinsum_gs_en_229.txt",
    "fulltext": "Patient information\nThe patient was a 31-year-old Caucasian man who was employed as a lumberjack. He presented with severe self-inflicted injuries, including the amputation of his penis and both auricles, multiple lacerations on his forearms, and frostbite on his feet and toes. The injuries were sustained under the influence of multiple psychoactive substances.\n\n\nMedical history\nThe patient had a history of substance abuse, including regular consumption of approximately 1.5 L of beer every other day, daily marijuana use (approximately 1 g/day, which had been reduced to every other day over the preceding 2 years), and occasional use of methamphetamine and psilocybin mushrooms. He had previously experienced psychotic episodes associated with his substance abuse. The patient did not take any prescribed medications and was not being treated for any chronic conditions. He had recently been diagnosed with prediabetes.\n\nThe patient’s first contact with alcohol occurred around the age of 15. He reports never consuming alcohol in the morning, but mentions episodes of short-term memory lapses (“blackouts”) following hard liquor. He started using THC (cannabis) at about 17 years of age; currently, he states that over the past two years he has reduced his use to approximately one “joint” every other day, primarily in the evening before bedtime (previously it could be one or two joints daily). He first tried methamphetamine (pervitin) at 19 but only on two or three occasions in total. He denies any intravenous use. He used hallucinogenic mushrooms (psilocybin) for the first time at 18, with an estimated total of about 10 episodes (most frequently in the fall). He also reports occasional use of other hallucinogens, such as LSD at music festivals, but cannot specify frequency or exact timing. He first tried kratom about a year ago and finds it difficult to specify how often he has used it. The patient acknowledges frequent combination of alcohol with other substances; due to recurring memory lapses, he often cannot be certain which substances he consumed or in what quantity.\n\nFor most substances (THC, hallucinogens, kratom), the patient describes oral or inhalation routes. He explicitly denies intravenous use (e.g., of methamphetamine). There is no record of formal, extended abstinence periods; the patient only mentions occasional “breaks” in cannabis and alcohol use in the past, without formal treatment or therapy.\n\nMedical records indicate that the patient engaged in self-harm in the context of mixed intoxication (alcohol, cannabis, psilocybin) in 2018. He was hospitalized following an episode of aggressive outburst and self-harm behavior, Documentation from this hospitalization mentions, among other findings, vulnera scissa in the thoracic and abdominal wall regions, a frontal hematoma, and bite wounds to the lips and tongue.\n\nDuring the aforementioned hospitalization, no florid psychotic symptoms persisted once acute intoxication resolved. Consequently, there was no specific psychiatric treatment for psychosis, and the patient was discharged without antipsychotic medication. No further specialized psychiatric treatment for drug-induced psychotic symptoms is noted in the available documentation.\n\nThe patient had his first more serious relationship in high school, followed by several long-term relationships in adulthood (lasting 4, 5, 3, and 0.5 years). The most recent relationship ended about a year ago due to long-distance issues. He reports first sexual intercourse around the age of 17.\n\n\nFamily history\nBoth the patient’s parents had a history of nicotine dependence and alcohol abuse. No other notable family medical conditions were reported by the patient.\n\n\nPsychiatric history\nDuring this episode, the patient experienced significant psychomotor agitation and paranoid delusions. His emotional response to his injuries and situation was inappropriate, indicating a lack of interest in the treatment or consequences. Psychosocial examinations revealed low intellectual performance, impaired social judgment, and an inability to control emotions. He denied regular use of other substances but admitted to the recent use of multiple drugs.\n\nThe patient had been hospitalized previously because of aggressive behavior and self-harm associated with substance use. These interventions included psychiatric evaluation and treatment, which led to temporary stabilization. However, he had not maintained long-term follow-up or adhered to any prescribed psychiatric or medical treatment, which resulted in recurrent episodes of substance-induced psychosis and self-harm.\n\n\nClinical findings\nOn admission, the patient underwent a comprehensive diagnostic assessment. Physical examination revealed severe self-inflicted injuries, including the amputation of both the auricles and penis, multiple lacerations on the forearms, and frostbite on the feet and toes. He was hemodynamically stable and exhibited no signs of acute distress other than the visible injuries. This self-inflicted injury occurred in January when it was freezing and temperatures reached minus 7 degrees Celsius, leading to frostbite of the lower extremities. We do not know the time interval after the patient was found after the automutilization, but apparently due to the freezing weather there was no massive bleeding and death. He was conscious, but displayed significant psychomotor agitation and paranoia. Despite cooperating during the physical examination, he lacked awareness of the severity of his injuries.\n\nInitial laboratory tests were conducted to evaluate the patient’s overall health status and detect any potential infections. Toxicological screening confirmed the presence of cannabinoids, mitragynine, 7-hydroxymitragynine, and other compounds. Imaging studies included computed tomography (CT) of the head and abdomen, which ruled out intracranial bleeding and intra-abdominal injuries, and indicated no acute abnormalities.\n\nAccording to the available toxicological findings immunochemical testing of the urine detected the presence of cannabinoids as a group (without specifying the exact derivative). Subsequent mass spectrometry explicitly confirmed morphine, mitragynine, and 7-hydroxymitragynin, but it did not provide detailed quantification or identification of the specific cannabinoid. In standard toxicological practice, this typically indicates the detection of THC metabolites (especially 11-nor-9-carboxy-THC), although in this instance, the mass spectrometry did not specify which particular cannabinoid was found.\n\n\nDiagnostic assessment and diagnosis\nThe patient underwent detailed psychiatric evaluation, which revealed significant psychomotor agitation and paranoia. He was cooperative during the examination but lacked awareness of the severity of his injuries. The results of the comprehensive psychological examination indicated low intellectual performance, impaired social judgment, and an inability to control emotions. The patient also displayed negative self-assessment and had difficulty identifying and fulfilling his own needs. He did not provide insights into his psychological or somatic state, or substance use.\n\nAs part of a comprehensive clinical evaluation, psychological screening was conducted using both standard observation and interview techniques as well as specific psychodiagnostic methods. The following tools were used: observation and clinical interview, WAIS-III (Wechsler Adult Intelligence Scale, 3rd edition), ROCFT (Rey–Osterrieth Complex Figure Test), TMT (Trail Making Test), VF (Verbal Fluency), ROR (Rorschach Test), Baumtest (Tree Drawing Test) and Human Figure Drawing. All these instruments contributed to assessing the patient’s cognitive performance, executive functions, emotional experience, and personality traits. Based on the findings, the patient demonstrates below-average intellectual performance (not reaching the threshold of mental retardation), impaired social judgment, and reduced verbal and mental flexibility. Although there are no signs of a florid psychotic disorder, discrete perceptual and thought disturbances, difficulties with affect control, and a lack of insight into both his substance use and current psychological state are evident. A sexological evaluation was performed, during which the patient expressed acceptance of his condition and identified himself firmly as a male with no desire to change gender. He reported several long-term relationships with women and denied any homosexual encounters, although he acknowledged the difficulty of remembering all past experiences.\n\nThe differential diagnosis was substance-induced psychosis, given the patient’s history of substance abuse and the presence of multiple psychoactive substances. A diagnosis of F19.5 psychotic disorder owing to multiple substance use was established. This was supported by the temporal relationship between substance use and the onset of psychotic symptoms as well as the patient’s history of similar episodes. At the age of 24, the patient had experienced a similar episode in which he became aggressive and self-harmed by cutting his chest after using alcohol, marijuana, and psilocybin mushrooms. The psychotic symptoms had resolved after detoxification, and the patient was discharged after several days.\n\nPrimary psychotic disorders, such as schizophrenia, were also considered but deemed less likely due to the temporal relationship between the substance use and the onset of psychotic symptoms. Organic causes were ruled out on the basis of negative CT imaging results and normal laboratory findings. Given the history of substance abuse, the diagnosis of an acute psychotic disorder (F23.x) was also considered, but was less likely. However, the patient’s sensitivity to the development of psychotic processes indicated a potential risk of future schizophrenic spectrum disorders if substance use continued.\n\nThe ultimate primary diagnosis was substance-induced psychosis with severe self-harm. It was supported by the patient’s history of similar episodes of substance use. Prognostically, patient recovery depends on their ability to abstain from substance use, adhere to psychiatric follow-up, and undergo successful surgical and rehabilitative interventions for their physical injuries.\n\nPatient case timeline\nThe patient was hospitalized for a total of 31 days, broken down as follows: 2 days in the urology department and 29 days in the psychiatric ward (including 12 days in a psychiatric detox bed – ICU). The entire hospitalization was involuntary and was reported to the court in accordance with the relevant legal framework.\n\nTherapeutic interventions\nOn admission, emergency surgery was performed to manage the amputation of the penis and both auricles. The procedure included hemostasis and wound debridement. Because the amputated parts were not recovered, replantation was not possible. Broad-spectrum antibiotics were administered to prevent infection, analgesics were administered for pain management, and sedatives were used to control psychomotor agitation and paranoia.\n\nDetailed psychiatric evaluation revealed significant psychomotor agitation and paranoia. Treatment with olanzapine (10 mg/day) was initiated to manage the psychotic symptoms and diazepam (5 mg as needed, up to 30 mg/day) for the anxiety and agitation. Owing to the patient’s psychotic behavior, initial sedation with standard doses was insufficient. The olanzapine dosage was consequently increased to 15 mg/day, and the diazepam dosage was adjusted to ensure adequate sedation and psychotic symptom control.\n\nDuring the hospital stay, the patient developed frostbite on his feet and toes. Conservative management, including wound care and monitoring for signs of infection or necrosis, was performed. The patient’s psychiatric medications were regularly reviewed and adjusted based on his response to treatment, leading to gradual stabilization of his mental state. The patient was presented to a plastic surgeon and informed of the possibility of surgical penile and auricular reconstruction. However, reconstruction was contingent on patient cooperation and full abstinence from substance use.\n\nA mental capacity assessment was conducted. This evaluation included a comprehensive psychological examination using the WAIS-III scale, which indicated that the patient’s current intellectual performance is in the below-average range (with no signs of mental retardation). The individual indices (Verbal Comprehension, Perceptual Organization, Working Memory) also fall within the below-average range, while only Processing Speed lies on the borderline between average and below average.\n\nMoreover, the patient exhibits significantly impaired social judgment, limited knowledge of common behavioral norms, and reduced judgment in practical social situations. The weighted scores across both verbal and performance subtests predominantly fall into the below-average range. Based on these findings, the patient demonstrates reduced cognitive abilities in several areas, which may affect his capacity to adequately assess his actions and make decisions; however, a formal conclusion regarding legal capacity would require a comprehensive evaluation and potential further legal assessment by the court.\n\n\nFollow-up and outcomes\nThroughout the patient’s hospital stay and subsequent follow-up, both clinician- and patient-assessed outcomes were closely monitored. The patient’s physical condition, including the surgical sites for the amputations and frostbite on the feet and toes, was regularly evaluated for signs of infection and healing progress. Psychiatric evaluations were conducted to manage the psychomotor agitation and paranoia, leading to necessary medication adjustments.\n\nThe patient was initially compliant with treatment using olanzapine and diazepam, which helped stabilize his psychiatric symptoms. However, he refused institutional treatment for substance abuse, thus minimizing its significance. Despite the resolution of psychotic symptoms, he did not gain complete insight into his condition. He was discharged on the 29th day of psychiatric hospitalization with an outpatient follow-up plan.\n\nFive months after the initial hospitalization, the patient underwent reconstructive penile surgery. He was highly motivated and involved in the planning of the surgery; he showed a strong desire for reconstruction and cooperated closely with the medical team. During his hospital stay, a psychiatrist assessed his mental state. The patient denied the use of any addictive substances, as proven by blood tests and reported no psychological issues. He stated that he had adhered to his medication regimen after discharge and had only recently discontinued antipsychotics. He also mentioned that he regularly attended psychiatric check-ups to regain his driver’s license. The patient showed no signs of acute psychopathology.\n\nGiven the patient’s refusal to undergo substance abuse treatment and psychiatric follow-up, a coordinated approach involving social services and outpatient psychiatric care was recommended to support his post-discharge transition. The patient was informed of the critical importance of adhering to the medical and psychiatric advice to prevent the recurrence of severe psychotic episodes and self-harm.\n\nThe available information suggests that abstinence began after the patient’s discharge into outpatient psychiatric care; however, the exact date and the duration of abstinence are not precisely documented. During this period, abstinence was monitored primarily through clinical examination, the patient’s own reports, and bedside saliva screening tests. There is no specific data regarding any blood test that may have been used; therefore, it is not possible to state which particular blood screening test was employed in this case.\n\nThe patient was offered psychosocial support by the local community mental health center team, which he declined, as well as recommended outpatient addiction treatment, which he also refused. Currently, he only attends appointments with an outpatient psychiatrist.",
    "summary": "This report describes the case of a 31-year-old male lumberjack with severe self-inflicted injuries, including the amputation of both auricles and the penis, under the influence of cannabinoids, mitragynine, and 7-hydroxymitragynine. Emergency surgery was performed, and psychiatric evaluation revealed substance-induced psychosis. The patient's motivation for reconstructive penile surgery led to abstinence from the substance use and cooperation with treatment. Five months after hospitalization, successful penile reconstruction was completed. The patient remained abstinent and was engaged in regular psychiatric follow-ups, showing no signs of acute psychopathology."
  },
  {
    "id": "multiclinsum_gs_en_119.txt",
    "fulltext": "A 10-year-old girl who suffered frequently from cyanosis and fatigue underwent echocardiography which revealed CCH with dextrocardia, severe pulmonary hypertension (SPAP = 75mmHg), ventricular septal defect (VSD, d = 13 mm), atrial septal defect (ASD, d = 8.1 mm), and patent ductus arteriosus (PDA, d = 13 mm). Electrocardiogram displayed the P-QRS-T wave group pattern of I lead inverted. Chest X-ray showed dextrocardia, situs inversus totalis, enlarged heart, and pulmonary artery protrusion.\n\nCT angiography done to confirm these diagnoses and reveal another important malformations - bronchial dysplasia and double-outlet right ventricle (DORV). Combined with CT 3D reconstruction, the right ventricular inflow tract had a cross relationship with the left ventricular inflow tract, confirming the diagnosis of a crisscross heart. Both aorta and pulmonary artery were seen walking side by side originated from the upper right ventricle, aorta on the left, pulmonary artery on the right, indicating a diagnosis of double-outlet right ventricle (DORV).Atrial trans was seen which superior vena cava and inferior vena cava returned to left atrium (anatomy right atrium), and pulmonary vein returned to right atrium (anatomy left atrium).There was no stenosis of the pulmonary valve outflow tract. The left and right pulmonary arteries were widened, the distal branches were twisted, and there was a right aortic arch. At the same time, there was also a sub-pulmonary VSD, ASD, and PDA, and the coronary arteries arised from the normal left and right aortic sinuses. Besides, we also found superior inferior vena cava and liver on the left, and the heart was on the right of the chest. The left main bronchus was long and narrow, the right main bronchus was short and thick, and the right main bronchus was divided into three branches, symmetrical with the left bronchus.",
    "summary": "A 10-year-old girl presented with recurrent cyanosis and fatigue, and echocardiography revealed a complex congenital heart condition involving CCH, dextrocardia, severe pulmonary hypertension, ventricular septal defect (VSD), atrial septal defect (ASD), and patent ductus arteriosus (PDA). Further CT angiography unveiled bronchial dysplasia and double-outlet right ventricle (DORV)."
  },
  {
    "id": "multiclinsum_gs_en_500.txt",
    "fulltext": "Male, born to a 28-year-old mother and a 34-year-old father. No consanguinity, no family history, second pregnancy, normal course. Serologies: negative for rubella, toxoplasma, human immunodeficiency virus and HBsAg. Low risk combined first trimester screening. Normal prenatal ultrasound. No known exposure to toxics and/or teratogens. Eutopic delivery at 40 weeks. Apgar: 9/10. Birth weight: 3,780 g (p50-90, Fenton charts). Length: 52 cm (p50-90). Head circumference: 37 cm (p90). Neonatal examination described as normal. Neonatal metabolic and auditory screenings without alterations.\n\nShe was monitored by neuropediatrics for psychomotor delay in her evolution: autonomous walking at 18 months and language delay. She attended an early care programme from the second year of life, with school supports (audition and language + therapeutic pedagogy) from the beginning of the infant education and curricular adaptation from primary school. Intellectual quotient at 6 years: 68. She currently attends functional habilitation. Other health problems: alternating decompensated exotropia pending surgery, obesity monitored by paediatric endocrinology and diagnosed with beta thalassemia minor.\n\nAssessed at clinical genetics consultation at 8.5 years: weight, 45 kg (p95; SD = 1.75); height, 138 cm (p77; SD = 0.77); body mass index, 23.63 (p96; SD = 1.85); and head circumference, 57 cm (p99; SD = 3.05). Phenotype with macrocephaly, truncal obesity with adipomastia, wide, broad forehead, sunken eyes, bulbous nose, slightly non-dysplastic ears, sharp chin, short and wide uvula, nasal voice, sharp distal phalanges of hands, lax flat feet and penis submerged in prepubic fat.\n\nGenetic study. Array SNP/CNV 750K (GeneChipÒ System 3000 platform, AffymetrixÒ, CytoScan Assay P/N 703038 Rev.5. Analysis with Chromosome Analysis Suite program, AffymetrixÒ v.3.3): a 586 kb deletion is detected in cytoband Xq21.1 arr[GRCh37]Xq21.1(79564583_80150138)x0. The deletion includes a single gene with known pathology associated, BRWD3. Array is performed later to the mother and sister, asymptomatic, both carriers of the deletion identified in the patient, not present in the maternal grandmother.\n",
    "summary": "Male with no family or perinatal history of interest with neurodevelopmental impairment: psychomotor retardation, language delay and cognitive impairment, macrocephaly (p > 99) and obesity. Facial dysmorphic phenotype: wide forehead, deep set eyes, bulbous nose, prominent auricles and sharp chin. Array CGH deletion of 586 kb in Xq21.1, including a single gene associated with the disease, BRWD3. Subsequently, the mother and sister, asymptomatic, were studied and both carry the deletion.\n"
  },
  {
    "id": "multiclinsum_gs_en_92.txt",
    "fulltext": "She is a 36-year-old woman with a single antecedent of anxiety-depressive syndrome, with the onset of episodic headaches, typically migrainous with visual aura at the age of 7 years. The patient was referred from another hospital where she had consulted 5 years ago for worsening of the frequency of migraine episodes. The pain had become daily/practically daily, was usually disabling, pulsatile and accompanied by intense photophobia. Her neurological examination and a magnetic resonance (MRI) of the skull were normal. She took non-steroidal anti-inflammatory drugs almost daily and triptans more than 15 days a month. She had failed with therapeutic doses of metoprolol, topiramate, zonisamide, amitriptyline, lamotrigine and botulinum toxin type A as a preventive treatment. She had been treated with erenumab (initially 70 and then 140 mg) and galcanezumab in her hospital. She had an apparent initial transient response with both antibodies, which was lost a few months later in both cases, so they were withdrawn.\n\nIn the first evaluation in our consultation, the patient had more than 20 days of pain per month, most of which were compatible with migraines with intense pain. We initiated treatment with valproic acid without a clear response (migraine crises persisted between 15 and 20 days per month), so we requested a special use of eptinezumab at a dose of 100 mg intravenously every three months. With this drug, the initial response was excellent in the first two months of treatment, in which a clear reduction in the number and intensity of crises and in the consumption of symptomatic medication was observed. However, this benefit was lost (for two consecutive quarters) in the third month after the infusion, which the patient interpreted as a failure of the treatment. We requested authorisation to administer eptinezumab at the end of the second month and, with this administration, the patient currently has a frequency of 3–5 days of headaches per month, which are less intense and respond well to conventional analgesia, allowing her to lead a normal personal and professional life.\n",
    "summary": "36-year-old woman with a diagnosis of migraine with aura since childhood and evolution to chronic migraine with daily headaches in the last 5 years associated with medication abuse and multiple failures of oral preventives, botulinum toxin and two antibodies against CGRP (erenumab and galcanezumab). After the initiation of eptinezumab quarterly, she presents a significant improvement in the number of headache days per month during the first 8 weeks, but experiences a clear deterioration at the end of dose in the third month during the first two cycles of treatment. Therefore, her administration is adjusted to every 8 weeks with an excellent control of the frequency of her migraine.\n"
  },
  {
    "id": "multiclinsum_gs_en_426.txt",
    "fulltext": "A 27-year-old Asian woman presented at the outpatient dermatology clinic with pronounced facial skin lesions that progressed in severity within days. Initially, she experienced mild erythema, which progressed to nodulocystic lesions. She had no previous history of acne or other dermatological disorders. However, a thorough examination of her medical history revealed that she had been consistently using a commercial skin-whitening cream for nearly 3 months preceding the onset of her acne. Further investigation revealed that the applied product contained elevated levels of mercury. Cutaneous examination revealed severe nodules and cysts against an erythematous background on both right and left cheeks and extended to the temples and neck. Laboratory tests revealed elevated levels of mercury in the blood and urine, confirming mercury toxicity. The patient was diagnosed with severe nodulocystic acne vulgaris secondary to the chronic use of mercury-containing skin-whitening cream. She was treated with isotretinoin 30 mg. In addition, prednisolone 50 mg was administered for 1 week and reduced to 25 mg the following week. At a detailed 3-month follow-up, the patient exhibited notable clinical improvement of the facial lesions. Long-term monitoring of patient outcomes included regular liver function tests and lipid profiles, as well as continued dermatological assessments.",
    "summary": "We report the case of a 27-year-old woman who developed severe nodulocystic acne due to chronic use of a mercury-containing skin-whitening cream. Treatment with isotretinoin and prednisolone led to significant improvement within 3 months."
  },
  {
    "id": "multiclinsum_gs_en_561.txt",
    "fulltext": "6-year-old boy referred for medical genetics consultation for intellectual disability, microcephaly, behavioural disorder and particular features.\n\nHe is the son of a mother with learning difficulties and subtle particular features (epicanthus, bulbous nose, hypoplastic nostrils, small mouth and microretrognatia). A maternal uncle with intellectual disability was evaluated in consultation, without associating other medical-surgical problems or significant morphological anomalies.\n\nThe patient's personal history was that the pregnancy was achieved naturally and was uneventful. No pathological ultrasound findings were detected. The delivery was by emergency cesarean section due to the risk of loss of fetal well-being, with Apgar 9/10. The somatometry at birth was: weight, 3,000 g (p16); length, 51 cm (p64); and head circumference, 33.5 cm (p16). In the perinatal period and the first months of life there were no incidents, with regular feeding, without swallowing or chewing problems.\n\nFollow-up started at 28 months by neuropediatrics for postnatal microcephaly, and mild psychomotor and language delay. The development index was 71 on the Baley scale at 30 months (equivalent to 22 months of development). There was greater impairment of the receptive language area. Evolutionary behavioural disorder was evident, and he was diagnosed with aggressive/obsessive hyperactivity disorder, with a good relationship with peers.\n\nHe is currently receiving mental health care and is being treated with risperidone and methylphenidate. He has had a favourable evolution and improvement after the start of treatment. He is enrolled in an ordinary school with support in hearing, language and speech therapy. He has not had crises or problems with sleep.\n\nOn physical examination, he had no neurologic focalities and microcephaly (head circumference p<1, -2.5 standard deviations), subtle particular features (triangular face, sparsely-medially-placed eyebrows, slanted eye fissures and long eyelashes, prominent auricles, prominent chin, bulbous nasal tip, and small mouth), mild brachydactyly, hypoplasia of distal phalanges, and deep-based nails.\n\nPossible associated anomalies were ruled out during follow-up (normal abdominal ultrasound and cardiac evaluation), hearing was normal and an EEG was performed, which showed no pathological findings.\n\nAt the genetic level, the molecular study of the X-fragile syndrome was normal and the 60 K comparative genomic hybridisation array showed a 14q24.3 duplication of uncertain significance of maternal origin, not present in the maternal uncle, classified after the segregation study as probably benign.\n\nA clinical exome was requested, which identified the maternal-line, likely pathogenic frameshift c.692delT (p.Leu231Trpfs*13) variant in the USP27X gene. The maternal uncle also carried the alteration.\n",
    "summary": "6-year-old boy with intellectual disability, language delay, behavioural disorder, microcephaly and particular features. Mother with learning difficulties and overlapping facial phenotype. A maternal uncle with isolated intellectual disability. Physical examination highlights a peculiar phenotype (triangular face, eye fissures and long eyelashes, less populous eyebrows medially, prominent auricles), mild brachydactyly and hypoplasia of distal phalanges. The clinical exome identified the likely pathogenic variant NM_001145073.3: c.692delT in the gene USP27X. The family segregation study was positive: mother and maternal uncle carriers, maternal aunt healthy non-carrier.\n"
  },
  {
    "id": "multiclinsum_gs_en_527.txt",
    "fulltext": "Patient information\nA 64-year-old male patient, with a prior history of SCC in the same anatomical area (vertex), presented to clinic with a persistent scalp lesion located on the vertex. His medical history was devoid of any significant conditions, including a family history of skin cancer.\n\nClinical findings\nUpon conducting a thorough clinical examination, there was an elevated, irregular shape scalp ulcer and was found to be immobile. Notably, the patient did not experience tenderness at the site of the lesion. An interesting feature was the mild yellow discoloration that was discernible in the affected area.\n\nDiagnostic assessment\nTo establish a comprehensive diagnosis, a series of imaging and diagnostic procedures were initiated. Ultrasound examination unveiled a distinct solid lesion measuring 25x23x13mm, located on the left side of the vertex scalp region. This was accompanied by a constellation of multiple bilateral cervical lymphadenopathies. The most significant lymphadenopathies observed included measurements of 18 mm in the right posterior group, 15.8 mm in right group IV, 26x17mm in the left submandibular region, and 31x20mm extending into the retroclavicular region. Each of these lymph nodes exhibited characteristics highly suggestive of malignancy.\n\nFurther radiological assessment through a head and neck CT scan corroborated the presence of the lesion, which was noted as an irregular, well-defined mass measuring 29x22mm. Importantly, this mass did not exhibit any signs of invasion into the surrounding anatomical structures. In addition to this, the scan also highlighted the presence of multiple bilateral cervical lymphadenopathies.\n\nSubsequent to the initial operation, an ultrasound examination uncovered additional pertinent findings. This included the identification of bilateral axillary and inguinal lymph nodes, among which the largest were noted to be 44x24mm in the left axilla and 59x28mm in the left inguinal area. Moreover, a few para-aortic lymph nodes were detected, with the most significant measuring 28x18mm. Notably, the patient’s spleen exhibited enlargement, measuring 12.5 cm.\n\nThe diagnostic evaluation was further refined through fine needle aspiration procedures. Notably, a sample obtained from the left cervical lymph node revealed benign lymphoid cells, while conversely, a sample from the left submandibular gland exhibited malignancy, strongly indicative of non-Hodgkin lymphoma.\n\nTherapeutic intervention\nIn response to these comprehensive diagnostic findings, a strategic therapeutic plan was formulated. The patient underwent a wide local excision of the scalp lesion. This surgical intervention was followed by a meticulous reconstruction process involving the application of an Orticochea (or pinwheel) flap to cover the excised area. To address the donor site, a graft of new skin was employed.\n\nSimultaneously, both the right and left supraclavicular lymph nodes were surgically excised and subsequently submitted for pathological examination within the same session. Histopathological examination of these specimens unveiled a moderately differentiated grade II invasive SCC, which was associated with lymph node involvement by SCC. Encouragingly, the margins of the scalp lesion were found to be entirely devoid of tumor cells.\n\nIn the postoperative phase, a secondary procedure was performed involving the excisional biopsy of the left axillary and left inguinal lymph nodes. These findings reaffirmed the presence of lymphoma, which was conclusively confirmed through immunostaining. Notably, positive immunostaining for CD20, CD10, CD3, and BCL2 provided definitive evidence of the lymphoma diagnosis.\n\nFollow-up\nFollowing the surgical interventions, the patient was promptly referred to an oncologist to initiate a comprehensive treatment plan. This included a combination of radiotherapy and chemotherapy to effectively manage the underlying malignancies and ensure the best possible outcome for the patient’s health. Rigorous follow-up and monitoring have been instituted to track the patient’s progress and response to therapy.",
    "summary": "A 64-year-old male with prior SCC presented with a new scalp lesion. Examination revealed an elevated, irregular, non-tender lesion with mild yellow discoloration. Imaging showed a scalp lesion, cervical lymphadenopathies, and a well-defined mass. Ultrasonography uncovered lymph node involvement and splenomegaly. Fine needle aspiration, biopsy, and immune stains of the lymph node confirmed NHL. Wide local excision of the scalp lesion, reconstruction, and lymph node biopsies were performed, confirming SCC and NHL. The patient received radiotherapy and chemotherapy."
  },
  {
    "id": "multiclinsum_gs_en_70.txt",
    "fulltext": "A 72-year-old woman presented with symptomatic anaemia to a regional hospital in North West province, South Africa, in June 2023. On clinical examination, she had massive splenomegaly but no lymphadenopathy. An FBC was performed on a Sysmex XN-1000 series and showed pancytopenia (haemoglobin 2.9 g/dL, platelet count 97 L × 109/L, neutrophils 0.93 × 109/L), with a leucocytosis of 58 × 109/L. The automated WBC differential count showed a lymphocytosis of 14.16 × 109/L and a marked monocytosis of 42.82 × 109/L. The PB smear was referred to the NHLS Universitas Academic Laboratory, South Africa, for pathologist review.\n\nA manual differential count and PB smear microscopy revealed almost no monocytes. However, abnormal lymphocytes were increased (78%). These cells were intermediate in size, with abundant pale blue cytoplasm and circumferential villi. Their nuclei were kidney-shaped with a ground-glass chromatin pattern and inconspicuous nucleoli.\n\nMultiparameter flow cytometry was performed on the FACSCanto™ II (Becton, Dickinson, and Company, Franklin Lakes, New Jersey, United States), and the data analysed on Infinicyt™ version 2.0 (Cytognos, Santa Marta de Tormes, Salamanca, Spain) software. Analysis revealed an abnormal population of large cells with moderate complexity and bright CD45 expression extending into the ‘monocyte window’. These cells expressed pan-B-cell markers, CD19, CD20, CD22, CD79b, and sIgM, with surface kappa light chain restriction. Villous markers (CD11c, CD25, CD103, CD123) and CD200 were positive. This immunophenotype is characteristic of HCL. There was no significant monocyte population.\n\nBecause monocytopenia, rather than monocytosis, is typically seen in HCL, an FBC and automated WBC differential was repeated on the Advia® 2120i (Siemens Healthineers, Erlangen, Germany) FBC analyser in our laboratory. The same blood sample subsequently revealed a monocytopenia of 0.93 × 109/L, with an increase in the lymphocyte count to 34.51 × 109/L. These counts correlated with the pathologist’s manual differential count and flow cytometry analysis. It was concluded that the Sysmex XN-1000 series spuriously counted the ‘hairy cells’ as monocytes, resulting in pseudomonocytosis.\n\nManagement and outcomes\nThe patient was referred to a tertiary hospital. Further workup of the case confirmed a diagnosis of HCL, with the detection of the BRAFV600E mutation and characteristic BM morphology. Unfortunately, the patient demised shortly after admission, and further details regarding treatment could not be obtained.",
    "summary": "Case presentation: A 72-year-old woman presented with symptomatic anaemia and massive splenomegaly to a regional hospital in North West province, South Africa, in June 2023. An FBC and differential count, performed on a Sysmex XN-series haematology analyser, revealed a monocytosis of 42.82 × 109/L. However, a manual differential count, peripheral blood microscopy, and multiparameter flow cytometry confirmed a monocytopenia with numerous 'hairy cells'.\n\nManagement and outcome: The patient was referred to a tertiary hospital where bone marrow morphology and a BRAFV600E mutation confirmed a diagnosis of HCL. Unfortunately, she demised shortly after admission."
  },
  {
    "id": "multiclinsum_gs_en_386.txt",
    "fulltext": "A 35-year-old female Ethiopian patient presented to Yekatitit 12 Hospital Medical College’s emergency department with complaints of shortness of breath at rest, orthopnoea, significant paroxysmal nocturnal dyspnoea, chest pain, a blood-tinged productive cough, and vomiting of ingested matter (2–3 episodes per day) for 2 weeks. She had progressive body swelling that started in the lower extremities and later involved the whole body, easy fatigability, a loss of appetite, a high-grade intermittent fever, and an epigastric burning sensation for the same duration for the same duration of the same week. The patient also experienced an unspecified amount of weight loss and fatigue for the past 2 months. Otherwise, she had no known comorbidities, no risky behavior, such as smoking or alcohol drinking, medications, or a family history of malignancy. She was married, had four children, and had no bad obstetrics history. Her occupation was farming, and she had been living in a rural area. She had never been admitted for a similar complaint.\n\nThe patient’s Glasgow Coma Scale (GCS) was 15 out of 15, and there were no memory, power, or tone abnormalities. The patient was in severe respiratory distress with oxygen saturation of 70% with atmospheric air, respiratory rate of 30–35 beats/minute, and pulse rate of 120 per minute. She had high-grade fever records up to the level of 39.5 0C and can maintain her blood pressure. The breast examination with ultrasound and mammography was reportedly normal. Lymphadenopathy was not detected in reachable areas.\n\nThe chest examination revealed signs of pleural effusion that were also revealed in the imaging and were analyzed. A chest computed tomography (CT) with contrast showed pericardial effusion and multifocal pneumonia. CT angiography showed a lower lobe segmental pulmonary arterial filling defect on both sides, which suggests pulmonary emboli and pleural effusion on both sides. The cytologic smears were reported with sheets of mesothelial cells, neutrophils, and scattered single clusters of large atypical cells with prominent nucleoli suggestive of malignant effusion. The plural fluid analysis had lymphocytic predominant fluid with normal glucose (82 mg/dl), protein (2.2 g/dl), and lactate dehydrogenase (LDH) of 592 mg/dl.\n\nJugular venous pressure was raised by muffled heart sounds. The echocardiography showed massive pericardial effusion with cardiac tamponade features, preserved ejection fraction (EF 65%), and tricuspid annular plane systolic excursion (TAPSE) greater than 18 mm. An electrocardiogram (ECG) revealed only sinus tachycardia and axis deviation. An immediate pericardiocentesis was done, a drain of about 250 ml of hemorrhagic fluid was removed, and the pericardial window was secured. Repeated echocardiography imaging revealed a size reduction. The cytology report from the pericardial fluid had numerous lymphocytes together with atypical malignant cells having prominent nucleoli suggestive of malignant effusion.\n\nOn the abdominal examination, she had positive signs of fluid collection with no ballotable organ. The abdominopelvic CT scan showed an increment in the size of the liver with multiple hypointense hepatic lesions suggestive of metastasis. The pelvic organs, including the ovaries and uterus, had no identified lesions. A core needle biopsy was performed on the liver lesion, and the results revealed secondary adenocarcinoma.\n\nA diagnosis of heart failure caused by malignant massive pericardial effusion secondary to disseminated adenocarcinoma and carcinoma of unknown primary origin involving the lung, pleura, pericardium, and gastrointestinal tract was made. The patient was diagnosed with left upper exterminate extensive deep vein, bilateral segmental pulmonary embolism possible owing to the disseminated CUP. The findings also showed superimposed multifocal pneumonia and mild anemia of chronic disease.\n\nThe initial complete blood cell count revealed leucocytosis with a white blood cell count of 24 × 103 per mL, neutrophil predominant (91%), red blood cell count of 3.7 × 106 per µL, mild normocytic anemia [hemoglobin (Hgb) 11.2 mg/dl], mean corpuscular volume (MCV) of 81.2 fl, and severe thrombocytopenia (66 × 103/µL). After antibiotic treatment for pneumonia, the total blood cell count returned to normal (except for Hgb). With normal bilirubin levels, aspartate aminotransferase (AST) increased by more than seven times (263 U/L), while Alanine transaminase (ALT) increased by more than nine times (332 U/L). Serum electrolytes (except for Na + with mild hyponatremia, 129 mEq/L) and renal function tests were normal. Albumin was low (2.12 g/dl). Lactate dehydrogenase (LDH) levels increased almost twofold from the baseline (592 U/L). The human immunodeficiency virus, hepatitis B, and hepatitis C viruses were not reactive. Blood and culture of pleural fluid had no growth. A carcinoembryonic antigen (CEA) increased over 400 times (1000 µg/L) of the baseline.\n\nThe patient was admitted to the general ward. A pericardial window and right-side chest tube insertion were done with a cardiothoracic surgeon along with a cardiologist (see the amount aspirated above). Intermittent therapeutic pleural aspiration was done for the malignant pleural effusion. Once the loading dose (60 mg) of frusemide produced sufficient urine output, this dose was maintained three times (TID) a day. This was then de-escalated, and she was discharged with an oral dose of 20 mg twice a day (BID). A standard dose of enoxaparin was started for pulmonary thromboembolism and left upper extremity acute extensive deep vein thrombosis. Enoxaparin at 40 mg subcutaneous BID was given during hospitalization, which was changed to 5 mg of oral warfarin daily during discharge because of financial issues. The multifocal pneumonia was treated with ceftazidime (1 gm intravenously TID) and vancomycin (1 gm intravenously BID) as per the national standard treatment protocol. The pain was controlled by a potent anti-pain medication (morphine 5 mg intravenously TID) and deescalated and discontinued. She was also on ulcer prophylaxis. The patient was discharged from the medical ward with significant improvement after 14 days of hospitalization and appointed to the oncology unit of the hospital. Thus, for cancer of unknown primary origin, she was given one cycle of chemotherapy (carboplatin/paclitaxel). She was lost on follow-up owing to financial issues, and the patient died at home within 4 months of discharge.",
    "summary": "A 35-year-old Black woman presented with shortness of breath at rest, orthopnea, paroxysmal nocturnal dyspnea, chest pain, a blood-tinged productive cough, and fever for 2 weeks. She also had progressive body swelling, easy fatigability, loss of appetite, and abdominal pain during the same week’s duration. Body imaging revealed large pleural and pericardial effusions, metastatic liver lesions, and bilateral pulmonary vascular segmental and subsegmental filling defects. Pericardial and pleural fluid cytology suggest malignant effusion. Liver lesions and core needle biopsy indicated adenocarcinoma of unknown origin, and the carcinoembryonic antigen level also increased significantly."
  },
  {
    "id": "multiclinsum_gs_en_197.txt",
    "fulltext": "65-year-old woman, native and resident of Mexico City, with a history of HIV infection of 20 years of diagnosis with undetectable viral load since 2020 and with a CD4 count of 1220 cells per milliliter in February 2022, hypothyroidism of 29 years, ischemic heart disease of 9 years of diagnosis, osteoporosis and dyslipidemia, under treatment and under medical control.\n\nHer dermatosis problem started 10 years ago, after a case of herpes zoster located in the lower right extremity and was complicated by a soft tissue infection, referred to as cellulitis. As a result of this event, the patient developed an ulcer, which required correction of the defect with 4 skin grafts at different surgical times by plastic surgery, with accompaniment by the wound clinic. During the follow-up and despite the measures taken, she did not achieve complete resolution and persisted with an ulcer associated with local pain, which was the reason for her referral to our service.\n\nThe physical examination showed a localized dermatosis in the lower right extremity, on the lateral face of the thigh, characterized by a flat neoformation on which an ulcer of 1.5 cm in diameter was located, with a clean bottom, with a sero-yellowish crust, raised edges, hyperpigmented and keratinous perilesional skin, an atrophic and hyperpigmented scar. The dermatosis was treated with a skin biopsy, with a histopathological report of verrucous carcinoma, which was concluded as a Marjolin ulcer associated with verrucous carcinoma in a patient with HIV. She was referred to the oncology hospital for radiotherapy treatment.\n",
    "summary": "65-year-old woman with a history of human immunodeficiency virus (HIV) infection, who presented with a warty carcinoma associated with a Marjolin's ulcer secondary to herpes zoster and soft tissue infection in the right leg, with a latency period of 10 years from the initial infectious process to the histopathological confirmation.\n"
  },
  {
    "id": "multiclinsum_gs_en_366.txt",
    "fulltext": "A middle-aged female with Crohn's disease presented with a sudden onset of fever, nonproductive cough, and diffuse abdominal pain for three days. The patient was febrile to 105°F, blood pressure of 114/59 mm Hg, heart rate of 91 beats/minute, and oxygen saturation of 88% on room air. Laboratory investigations were significant for leukocyte count of 9900/µL, erythrocyte sedimentation rate of 56 mm/h, C-reactive protein of 20.49 mg/dL, lactic acid of 2.0 mmol/L, procalcitonin 0.74 ng/mL, and D-dimer of 1923 ng/mL. A viral respiratory panel including COVID-19 was negative. Chest X-ray was initially unrevealing. However, computed abdomen/pelvis tomography revealed diffuse bilateral ground-glass opacities.\n\nOn the night of admission, the patient developed worsening respiratory distress. Chest radiography was repeated, showing evidence of diffuse airspace disease consistent with ARDS. Given the ongoing COVID pandemic, steroids and Remdesivir were started. Due to persistent oxygen desaturations, she was intubated, and antibiotics were broadened. Despite maximum lung-protective ventilatory-support-prone positioning, the patient remained hypoxemic and demonstrated respiratory acidosis. In progressive respiratory insufficiency with a FiO2 of 100% with shunting in her lungs and oxygen saturation of only 68% and increased vasopressor requirements, VV-ECMO was initiated on day three.\n\nA bronchoscopy was performed to determine the underlying etiology of her ARDS. Inspection of her airways showed markedly abnormal airways with multiple areas of erythema, ecchymosis, and endobronchial mucosal sloughing. Additional workup for infectious and autoimmune etiologies was negative. Following the initiation of VV-ECMO, she developed worsening kidney injury, and continuous venovenous hemofiltration (CVVH) was initiated.\n\nThe patient developed a leukemoid reaction with a leukocyte count of 73,400/µL, and ferritin level rose to 25,873 µg/L from an initial level of 12, raising suspicion for HLH. Subsequently, she was started on Anakinra due to a suspected inflammatory condition. Further workup for HLH was conducted. Peripheral smear and flow cytometry revealed a normal T-cell clone with 54% circulating lymphocytes. Quantitative immunoglobulins and lymphocyte subsets were ordered to evaluate the underlying malignancy. Polymerase chain reaction (PCR) identified T-cell rearrangement (TCR) gamma gene rearrangement, demonstrating an aggressive T-cell mature lymphoproliferative neoplasm that was CD30/ALK(-).\n\nThe patient's clinical condition improved on Anakinra and steroids and was successfully decannulated from VV-ECMO 13 days after implantation and extubated to a high-flow nasal cannula. For the remaining 3 weeks, she continued on high-dose steroids and etoposide. The patient was deemed stable for discharge 6 weeks following initial presentation, transitioning to oral steroid taper.",
    "summary": "A middle-aged female presented with dry cough and fever for three days. On presentation, the patient was febrile to 105°F and hypoxic to 88% on room air. Chest X-ray showed bilateral interstitial infiltrates. Laboratory investigations showed lymphopenia and elevated inflammatory markers. The viral panel, including coronavirus disease-2019 (COVID-19), influenza, and respiratory syncytial virus (RSV), was negative. Her respiratory status progressively worsened, requiring invasive mechanical ventilation for ARDS. Despite lung-protective ventilation, prone positioning, and the use of paralytic agents, the patient continued to remain hypoxic, necessitating extracorporeal membrane oxygenation (ECMO) support. The patient was started on antibiotics and high-dose steroid. Thereafter, she developed a leukemoid reaction, and the ferritin level started rising; raising suspicion for lymphophagocytosis. During this time, she also developed acute liver and kidney failure and required multiple vasopressors and renal replacement therapy. Eventually, a diagnosis of mature peripheral T-cell lymphoma was established. Subsequently, her respiratory status and multiorgan failure significantly improved, and ECMO was explanted after 2 weeks. She was started on etoposide and steroid, and eventually discharged after 6 weeks."
  },
  {
    "id": "multiclinsum_gs_en_477.txt",
    "fulltext": "A 60-year-old man collapsed in the sauna facility of a capsule hotel, a budget accommodation facility with small sleeping units, where he had resided for the past two years. The patient reported a one-week history of poor appetite, diarrhea, and low-grade fever, accompanied by progressively worsening dyspnea over the three days prior to admission. His medical history and medications were unknown due to a lack of family contacts and severe dyspnea that prevented a detailed history taking.\n\nOn admission, the patient presented with tachycardia, tachypnea, and hypoxemia. His vital signs were as follows: blood pressure 128/85 mmHg, heart rate 120 beats per minute, respiratory rate 40 breaths per minute, oxygen saturation 88% on a 15L non-rebreather mask, and body temperature 37.8°C, consistent with low-grade fever. Physical examination revealed rapid, shallow breathing using accessory respiratory muscles. His Glasgow Coma Scale score was E4V5M6.\n\nInitial laboratory investigations revealed severe metabolic acidosis with respiratory compensation, as evidenced by an arterial blood gas analysis showing a pH of 7.067, partial pressure of carbon dioxide (pCO₂) of 63.1 mmHg, partial pressure of oxygen (pO₂) of 126 mmHg, bicarbonate (HCO₃⁻) of 17.3 mmol/L, and lactate of 11 mmol/L. Laboratory results also indicated severe renal dysfunction with a blood urea nitrogen (BUN) of 147.2 mg/dL and creatinine of 8.82 mg/dL. Aspartate aminotransferase (AST) was elevated to 268 U/L and alanine aminotransferase (ALT) to 108 U/L, along with lactate dehydrogenase (LDH) at 1910 U/L and creatine kinase (CK) at 1552 U/L. Marked inflammation was evident, with a white blood cell (WBC) count of 64 × 10⁹/L and a C-reactive protein (CRP) level of 17.13 mg/dL. The patient also had thrombocytopenia, with a platelet (PLT) count of 8.6 × 10⁹/L (see Table 1 for full laboratory results). Tests for HIV, COVID-19, and urine Legionella antigen were negative. A chest CT scan revealed bilateral consolidations with cavitary lesions, predominantly in the left lung.\n\nSputum samples obtained via bronchoalveolar lavage revealed both Gram-positive cocci and Gram-negative rods. The patient was diagnosed with severe pneumonia and lung abscess caused by a polymicrobial infection. He was intubated upon ICU admission. Empiric antibiotics, including vancomycin, piperacillin-tazobactam, and azithromycin, were initiated. Hydrocortisone 200 mg/day was also administered. The initial PaO₂/FiO₂ ratio was 110 on mechanical ventilation, consistent with moderate ARDS. Due to worsening hypoxia, neuromuscular blockade was started and continued for 48 hours, and prone positioning was initiated. Due to worsening renal dysfunction, renal replacement therapy was initiated. A permissive hypercapnia strategy allowed a pH as low as 7.15.\n\nBy the third day, his PaO₂/FiO₂ ratio had rapidly declined to 65, showing further deterioration. Inhaled nitric oxide therapy was initiated but did not result in significant improvement. Consequently, venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated on the evening of day three.\n\nSputum cultures yielded only Moraxella catarrhalis, which was discordant with the initial Gram stain, suggesting polymicrobial infection. The culture results were inconsistent with the initial Gram stain findings. Considering this discrepancy and the patient's residence in a capsule hotel, TB was suspected as the underlying cause of his refractory pneumonia and ARDS. On day four of admission, acid-fast bacilli testing was strongly positive (>10 acid-fast bacilli per oil immersion field), and polymerase chain reaction detected Mycobacterium tuberculosis, confirming the diagnosis of pulmonary TB. Anti-TB therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol was initiated. Methylprednisolone 1 g was administered for three days to address TB-associated ARDS. A daily bronchoscopy was performed to manage sputum clearance.\n\nBetween days 9 and 11, the patient’s clinical condition improved, as evidenced by radiographic resolution of pulmonary infiltrates and an increase in respiratory system compliance to 40 mL/cmH₂O, enabling successful weaning from VV-ECMO. Subsequently, a tracheostomy was performed five days later to facilitate prolonged ventilatory support.\n\nTwo days after the tracheostomy, drug-induced liver injury necessitated adjustment of anti-TB therapy to ethambutol, streptomycin, and levofloxacin. Cycloserine was added three days later. The patient remained ventilator-dependent and was transferred to a designated TB hospital 29 days after admission. Since multiple healthcare workers were exposed to TB before its confirmation, an exposure screening program was implemented. This included medical evaluation, chest radiography, and interferon-gamma release assay testing without identifying active or latent TB infections among the staff.",
    "summary": "We report a case of a 60-year-old man who developed severe respiratory failure after collapsing in a sauna facility. Initially diagnosed with severe community-acquired pneumonia and acute respiratory distress syndrome (ARDS), his condition deteriorated despite standard treatment, necessitating venovenous extracorporeal membrane oxygenation (VV-ECMO). Acid-fast bacilli testing confirmed pulmonary tuberculosis (TB) on day 4, prompting the initiation of anti-TB therapy. Following clinical improvement, the patient was successfully weaned from VV-ECMO and transferred to a specialized TB hospital for ongoing care."
  },
  {
    "id": "multiclinsum_gs_en_28.txt",
    "fulltext": "A 23-year-old male, with a history of LL who had been RFT, came to the emergency department with a chief complaint of painful red bumps accompanied by purulent blisters on both arms, hands, legs, and feet. He also complained of fever, joint, and body ache, rendering him to not be able to move properly. The patient had been diagnosed with leprosy in the past 17 months before admission and had finished the multibacillary leprosy treatment course with MDT multibacillary (MDT-MB). He had a history of ENL without pustules for seven months before admission and was treated with prednisone. A 40 mg prednisone was initially given, and the dose was tapered according to the World Health Organization (WHO) guideline. However, the lesions consistently recurred when prednisone was tapered at 10 mg daily, and did not experience complete remission for six months. The first pustules were discovered a month before admission. Skin biopsy was conducted for both histopathology examination and drug resistance test. Histopathology examination from pustular lesion revealed thinning of the epidermis with a massive number of foam cells deposition in the dermis. There was no RpoB and FolP gene mutation, indicating no rifampicin and dapsone resistance. He was diagnosed with pustular ENL and received 40 mg a day prednisone, but there was no improvement despite five weeks of treatment. Instead, the ENL worsened as pustules kept appearing, accompanied by systemic symptoms such as fever, severe arthralgia, and myalgia. Because of the severity of the symptoms, he came to the emergency department afterward and was hospitalized.\n\nThe patient admitted that he was in psychological distress due to his condition. Physical examination showed pendulous earlobes, moon face, and gynecomastia. There were pustules on the center of erythematous nodules on the extremities, erythematous nodules, and shallow ulcers. Neurological examination revealed that both ulnar nerves were enlarged and rubbery, without tenderness. There was hypesthesia of the skin lesions on both arms, hands, legs, and feet, without gloves and stockings anesthesia. On slit-skin smear, mean bacterial index (BI) and morphological index (MI) were 6+ and 0, respectively. Direct microscopic examination of the pus with Ziehl-Neelsen (ZN) staining revealed acid-fast bacilli (AFB), and Gram staining revealed no bacteria. Upon hospitalization, the patient was initially treated with 60 mg prednisone once daily. After three days of prednisone administration, no clinical improvement was observed. Therefore, we substitute the prednisone with intravenous dexamethasone 10 mg once daily. Despite the administration of intravenous dexamethasone, new pustules still appeared. Therefore, oral minocycline 100 mg once daily was administered in addition to the intravenous dexamethasone on the seventh day of hospitalization. After a day of minocycline administration, no new pustule was observed. The patient was discharged on the ninth day of hospitalization, and treatment was continued with prednisone 60 mg once daily and minocycline 100 mg once daily.\n\nAt a 7-day follow-up after hospitalization in the outpatient clinic, the patient showed a significant improvement as the arthralgia and myalgia almost entirely subsided, and no new skin lesion was identified. The minocycline dose was sustained for four weeks, while the prednisone was able to be tapered without any recurring lesions. There were no adverse effects such as gastrointestinal disorders and skin discoloration during minocycline and prednisone treatment. As the pustules no longer recurred, the minocycline was discontinued while the prednisone was continued at 30 mg a day and tapered according to WHO guideline.",
    "summary": "We report a case of pustular ENL in a 23-year-old male who had been released from treatment (RFT) of lepromatous leprosy (LL). The patient had been on prednisone for six months as treatment for ENL. The condition recurred when prednisone was tapered to 10 mg daily. Eventually, pustules developed on the erythematous nodules, and the lesions did not improve despite seven weeks of treatment with 40-60 mg prednisone. Later, 100 mg minocycline once daily was given in addition to 60 mg prednisone once daily and improvement was rapidly observed on the ninth day after minocycline administration. This condition was sustained for four weeks with prednisone tapering, and no side effects were reported during the treatment."
  },
  {
    "id": "multiclinsum_gs_en_299.txt",
    "fulltext": "Presentation and initial treatment\n\nA 67-year-old woman presented to the Institute of Cardiology, Warsaw, Poland, in June 2016 with a three-week history of increasing heart failure. The patient had New York Heart Association (NYHA) Functional Class IV symptoms that included dyspnea, weakness, and weight gain. The patient had a history of chronic heart failure due to dilated cardiomyopathy. She had a left ventricular ejection fraction (LVEF) of 25% and severe mitral regurgitation. In 2015, she was diagnosed with paroxysmal atrial fibrillation and hypothyroidism. She had been previously treated using the Mitralign percutaneous annuloplasty system (Mitralign Inc., Tewksbury MA, USA) for mitral regurgitation. She had also previously been treated with a cardiac resynchronization therapy device (CRT-D). However, she suffered recurrent pulmonary edema with episodes of pulmonary hypertension and required intubation and ventilation. The patient was admitted to the Intensive Care Cardiac Therapy Clinic for immediate medical treatment. An IABP with catheter access through a femoral artery was initially used. At this stage, because she had severe pulmonary hypertension, this was considered to be a contraindication for heart transplantation. During 115 days of hospital stay, the patient suffered from immobility associated with the siting of the IABP catheter.\n\nIn December 2016, following several unsuccessful attempts to remove the femoral artery IABP catheter, a decision was made to change the IABP access from the femoral artery to the external iliac artery. Following re-siting the IABP catheter, the aim was to combine optimal pharmacological management with active and passive physical rehabilitation.\n\nA four-stage approach using the external iliac artery for IABP catheter placement\n\nAn innovative technique has recently been developed at our institution to address the problems resulting from long-term femoral IABP placement. The patient was informed about this new procedure and signed written informed consent for this treatment. The left external iliac artery was used for IABP catheter insertion and included an 8 mm diameter Gelsoft prosthetic conduit (Vascutek, Inchinnan, Scotland, UK). A bevelled 8 mm Dacron graft was anastomosed end-to-side to the artery with a 5-0 polypropylene suture. The catheter was subcutaneously removed from the left retroperitoneal space to the right lower quadrant of the abdomen. No complications occurred during the procedure.\n\nThe procedure developed at our institution included four main stages. Stage 1 began with a longitudinal lower left quadrant incision from the lower rib arch to the superior portion of the inguinal ligament. The skin, subcutaneous tissue, and muscles were incised to the peritoneal membrane to expose the external iliac artery. Using retractors, the intra-abdominal organs were moved medially to expose the iliac arteries. A side-to-end anastomosis was performed between the external iliac artery and the prosthetic graft. Stage 2 of the procedure involved a 1 cm incision in the right sight of the abdomen, 5–6 cm from the umbilicus, and 2 cm below it. A tunnel was created in the subcutaneous plane from the right side of the abdomen to the left side. Stage 3 of the procedure included advancing the proximal part of the IABP catheter from the right side of the abdomen through the subcutaneous tunnel to the left side. The catheter was placed in the descending thoracic aorta through the prosthetic graft, iliac artery, and aorta. The catheter was tied and sealed at the connection site with the graft using a prolene 2-0 suture. Stage 4 of the procedure included the closure of the retroperitoneal wound. The use of the vascular conduit allowed relative ease of removal of the IABP from a small incision in the lower left quadrant of the abdomen, which was closed with two stitches.\n\n\nPatient outcome and follow-up\n\nFollowing the IABP procedure, the patient was allowed to sit, stand, and ambulate with assistance and no neurological complications occurred. There were no episodes of sepsis-related to the insertion site. Following transiliac IABP, the patient had reduced serum levels of creatinine and total bilirubin. The patient had no limb ischemia during IABP counter-pulsation. The improvements noted during physiotherapy included walking for 290 meters during a six-minute walk test. The patient had significant improvement in cardiac function with reduced pulmonary hypertension and reduced pulmonary vascular resistance. By 195 days after changing the IABP access, the patient underwent successful cardiac transplantation.",
    "summary": "Patient: Female, 67-year-old\n\nFinal Diagnosis: Heart failure\n\nSymptoms: Chest pain • dyspnoea • poor exercise tolerance\n\nMedication: —\n\nClinical Procedure: Intraoartic baloon pump insertion – new technique\n\nSpecialty: Cardiac surgery\n\nCase Report:\nA 67-year-old woman presented with a history of heart failure. She had New York Heart Association (NYHA) Functional Class IV symptoms. The patient had a history of chronic heart failure due to dilated cardiomyopathy with a left ventricular ejection fraction of 25%, severe mitral regurgitation, paroxysmal atrial fibrillation, and hypothyroidism. Immediate pharmacological treatment began, and an IABP catheter was initially inserted using femoral artery access. During 115 days of hospital treatment, several unsuccessful attempts were made to remove the IABP catheter. Due to prolonged patient immobility, the IABP catheter access was changed from the femoral artery to the external iliac artery. A prosthetic Dacron graft and a subcutaneous channel were used. Optimal pharmacotherapy commenced, and the patient underwent rehabilitation and mobilization with significant improvement in cardiac function. At 195 days after changing the IABP catheter access, the patient underwent successful heart transplantation."
  },
  {
    "id": "multiclinsum_gs_en_467.txt",
    "fulltext": "64-year-old male with no medical history who lived with pets (dogs). He consulted for a holocranial headache, a week-old right homonymous hemianopsia associated with a generalized tonic-clonic seizure episode, without fever. A single brain CT scan was performed, which showed a lesion at the cortico/subcortical level accompanied by edema. Subsequently, an MRI of the brain was performed, in which a heterogeneous lesion with restriction in said sequence and correlative in ADC was observed, with a peripheral hypointense halo associated with extensive vasogenic edema that generated a mass effect with partial collapse of the right lateral ventricle and corpus callosum and a non-significant deviation of the midline to the left, which measured 67x36x26 mm. A complete excision of an encapsulated lesion with purulent content was performed through transcortical access, initiating antibiotic therapy with meropenem/vancomycin until isolation in culture of A. aphrophilus, completing treatment with ceftriaxone for 21 days. During his hospital stay, an ultrasound of the total abdomen, fundus of the eye and transesophageal echocardiogram was performed without evidence of other sites of infection. He evolved favorably, allowing his discharge from the hospital.\n",
    "summary": "A 64-year-old male patient with no relevant history was admitted to the emergency department with a headache, hemianopsia of one week's duration and subsequent tonic-clonic seizures. Imaging studies and a brain lesion culture led to the diagnosis of a cerebral abscess caused by A. aphrophilus.\n"
  },
  {
    "id": "multiclinsum_gs_en_437.txt",
    "fulltext": "A 63-year-old male Hispanic patient presented to hospital as an emergency with sudden onset of severe respiratory distress, palpitations, and profuse sweating. He was in his usual state of health and could feely ambulate with independent activities of daily living until 30 minutes before arrival to emergency room. He had a 20-year history of hypertension, a 15-year history of diabetes mellitus, coronary artery disease requiring insertion of a coronary artery stent five years previously, a ten-year history of New York Heart Association (NYHA) Class II heart failure with a reduced ejection fraction (EF) of 35%, chronic kidney disease (CKD) stage 3B. On admission to hospital, his medications included carvedilol (25 mg twice daily), lisinopril (20 mg daily), spironolactone (25 mg daily), furosemide (20 mg daily), glargine insulin (20 units at bedtime), insulin lispro injection (7 units three times daily), atorvastatin (40 mg daily), and aspirin (81 mg daily), with no known drug allergies.\n\nOn examination, his blood pressure was 205/110 mmHg, his respiration rate was 29 breaths/min, his heart rate was 118 beats/min, pulse oximetry was 82% (in room air), and his temperature was 36.2°C. His weight was 72 kg and his height was 68 inches, resulting in a body mass index (BMI) 24.13 kg/m2. On physical examination, the patient was in severe respiratory distress, he was sweating, and unable to speak clearly. His jugular venous pressure was elevated, as shown by jugular vein distention (3+). On chest auscultation, profuse bilateral crackles were present in all pulmonary fields. Cardiac auscultation was remarkable for a gallop with a regular rate along and a systolic murmur 3/6 heard at the left midclavicular line, at the level of the fifth intercostal space. The point of maximal cardiac impulse was displaced to the left (at the anterior mid-axillary line) and no abdominal distention or ascites was noted, with lower limb pitting edema (1+) up to the level of the mid-calf.\n\nThe patient was placed in the cardiopulmonary resuscitation (CPR) area where blood gases on air were measured, and laboratory tests were ordered. The patient was treated with 100% oxygen using a non-rebreather mask and positioned at 90°, resulting in improvement pulse oximetry, which increased up to 90%. An electrocardiogram (ECG) showed sinus tachycardia, lateral lead ST depression (of 1 mV), left axis deviation and left ventricle hypertrophy. A portable chest X-ray was obtained which was remarkable for an enlarged cardiac silhouette, stag’s antler sign of upper lobe pulmonary venous diversion (cephalization), and Kerley B-lines, indicating interstitial edema.\n\nAlthough laboratory tests were ordered, because the patient was critically ill, and further management could not be delayed, initial treatment was guided based on the clinical findings, clinical history, the ECG, arterial blood gases, and X-ray findings. In view of the findings of the initial investigations and the absence of fever, pneumonia was excluded and a diagnosis of hypertensive cardiogenic pulmonary edema was made. Intravenous (IV) nitroglycerin treatment was commenced, starting at 30 mcg/min and increased by 15 mcg/min every 3 minutes, with continuous pulse oximetry and monitoring of vital signs every 3 minutes. After 18 minutes, nitroglycerin was titrated up to 120 mcg/min and his blood pressure decreased to 148/82 mmHg, his systolic blood pressure reduced by 29%, his diastolic blood reduced by 25%, and his heart rate decreased to 87 beats per minute. A rapid clinical improvement was made and the patient was able to communicate in complete sentences and was able to breathe without the use of accessory muscles. Pulse oximetry showed an oxygen saturation >97%, and oxygen supplementation continued with the use of a nasal cannula at 3 L/min and the patient’s pulse oximetry measurement was >96%.\n\nAfter 25 minutes, the patient was treated with enalapril (2.5 mg IV) combined with furosemide (20 mg IV). Nitroglycerin was decreased at a rate of 10 mcg/min every 5 minutes until it was discontinued, followed with an oral dose of isosorbide dinitrate (30 mg). After complete clinical stabilization, the laboratories results showed a white blood cell (WBC) count of 11.43×109/uL, hemoglobin of 10.9 g/dl, hematocrit of 31.8%, platelets level of 74×109/L, sodium of 144 mmol/L, potassium of 3.9 mmol/L, chloride of 107 mmol/L, carbon dioxide (CO2) of 25 mmol/L, blood urea nitrogen (BUN) of 27 mg/dL, creatinine of 1.4 mg/dL, brain natriuretic peptide (BNP) of 3,452 pg/ml, and troponin I <0.05 ng/ml. Blood gas measurements on air included pH of 7.381, pCO2 of 44.8 mmHg, pO2 of 57 mmHg, HCO3 of 25.8 mmol/L, and oxygen saturation of 84%.\n\nThe patient was evaluated for the presence of possible underlying pulmonary embolism (PE) using the Wells risk stratification criteria for PE, and stratified as low-risk, with further evaluation with a D-dimer level of 340 ng/ml, which was interpreted as negative. Evaluation for hyperthyroidism showed a normal ultrasensitive plasma thyroid stimulating hormone assay (usTSH) measurement of 2.56 μU/mL and free thyroxine (T4) of 6.87 μU/mL.\n\nThe patient was admitted to the internal medicine hospital ward with a diagnosis of hypertensive cardiogenic pulmonary edema and discharge home 48 hours later. On discharge from hospital, his medications included furosemide (40 mg daily), carvedilol (12.5 mg twice a day), sacubitril/valsartan (24 mg/26 mg twice a day), spironolactone (25 mg daily) and isosorbide mononitrate (60 mg daily). The patient underwent weekly follow-up by his cardiologist who optimized the medication therapy. No emergency room visits or hospitalization were reported, at least for the next 60 days.",
    "summary": "Patient: Male, 63\n\nFinal Diagnosis: Hypertensive cardiovenic pulmonary edema\n\nSymptoms: Shortness of breath\n\nMedication: —\n\nClinical Procedure: —\n\nSpecialty: General and Internal Medicine\n\nA 63-year-old Hispanic male with a medical history of hypertension, coronary artery disease, heart failure with a reduced ejection fraction of 35%, chronic kidney disease (CKD) and diabetes mellitus, presented as an emergency with acute, severe dyspnea. The patient was initially managed with 100% oxygen supplementation and intravenous (IV) high-dose nitroglycerin (30 mcg/min), which was titrated every 3 minutes, increasing by 15 mcg/min until a dose of 120 mcg/min was reached. After 18 minutes of aggressive therapy, the patient’s condition improved and he no longer required mechanical ventilation."
  },
  {
    "id": "multiclinsum_gs_en_4.txt",
    "fulltext": "A 67-year-old man presented to our center with a history of gait instability with right lateral thrust and urinary incontinence of three weeks' evolution. Notable antecedents included type 2 diabetes under treatment with oral metformin and arterial hypertension; possible excessive consumption of alcohol in the past. At the time of admission, the examination highlighted the impossibility of maintaining bipedalism, with a fall backwards and to the right; as well as difficulty in postural control in sedentary position. The examination of motor balance in extremities and cranial nerves was normal. At the cognitive level, the temporal disorientation, difficulty in calculation and the impairment of delayed memory were notable.\n\nA head CT scan performed in the emergency department showed a tetraventricular dilation with transudation. A subsequent MRI scan performed 48 hours after admission showed the same hydrocephalus, with no contrast-enhancing lesions and areas of gliosis affecting the middle and lower cerebellar peduncles and vermis.\n\nThe usual preoperative study was performed at admission with no significant findings in the chest radiograph or in the analytical study with blood count, basic biochemistry and coagulation.\n\nIn view of these imaging findings, endoscopic treatment of hydrocephalus was decided, which was performed 72 hours later, with intraoperative collection of cerebrospinal fluid (CSF). Endoscopic fenestration of the floor of the third ventricle was performed. It is worth noting that the opening pressure of the CSF was 22 mm Hg measured when the procedure was performed. The immediate postoperative course was without incident. The analytical and microbiological studies of peripheral blood showed no data of note. In the CSF study, pleocytosis was demonstrated with 335 cells/µL (normal range, RN: 0-5), predominantly monomorphonuclear (71%), with glucorrache of 47 mg/dL (RN: 40-80, with simultaneous glycemia of 96 mg/dL) and proteinorrache of 189 mg/dL (RN: 15-60). In the culture of CSF, growth of Cryptococcus neoformans was detected.\n\nThis microbiological diagnosis was completed with a chest and abdominal CT scan, with no findings of involvement in other locations. Screening for immunosuppression was performed, including HIV, HBV and HCV serologies, which were negative, with lymphocyte counts of 2,250/mm3 (RN: 1,300-4,000) and IgG immunoglobulin counts of 1,000 mg/dL (RN: 650-1,600), IgM of 200 mg/dL (RN: 54-300) and IgA of 180 mg/dL (RN: 40-350). Glycosylated haemoglobin values: 5% (RN: <5.7%) and liver function were also normal; albumin: 5 g/dL (RN: 3.4-5.4), alkaline phosphatase: 100 IU/L (RN: 44 to 147), alkaline transaminase (ALT): 50 IU/L (RN:5-60), aspartate aminotransferase (AST): 33 IU/L (RN: 10-34), gamma-glutamyl transaminase (GGT): 45 IU/L (RN: 5-80) and total bilirubin: 1 mg/dL (RN: 0.1-1.2).\n\nIn view of the findings of C. neoformans infection, and as our center did not have flucytosine, intravenous treatment with liposomal amphotericin B (5 mg/kg/day) and fluconazole (800 mg/day) was initiated for two weeks. After that time, a lumbar puncture was performed to study the CSF, with normalization of the biochemical parameters and of the opening pressure, and absence of C. neoformans observed. Intravenous treatment with oral fluconazole (800 mg/day) was continued for eight more weeks.\n\nThe patient's evolution was favorable, with progressive neurological recovery. In the first week after surgery, the patient's walking and instability improved, and the rest of the neurological symptoms improved after finishing the antifungal treatment. The MRI control performed two weeks later verified the resolution of the hydrocephalus.\n",
    "summary": "We present the case of a 67-year-old man who presented with a subacute gait disturbance and urinary incontinence. Neurologic examination revealed an inability to stand and a deterioration of memory. Cranial imaging showed obstructive hydrocephalus with areas of gliosis in the cerebellar peduncles. Endoscopic treatment of the hydrocephalus was performed, and cerebrospinal fluid samples were taken that showed growth of Cryptococcus neoformans. The patient improved with endoscopic treatment and after completing ten weeks of intravenous antifungal therapy with liposomal amphotericin B and fluconazole.\n"
  },
  {
    "id": "multiclinsum_gs_en_190.txt",
    "fulltext": "43-year-old woman with a history of hypertension with treatment with losartan, two cesareans and bilateral tubal occlusion. She was admitted to our hospital and reported pain of 24 hours of evolution, colicky type in hypogastrium and irradiation to the left iliac fossa, as well as nausea and vomiting on two occasions. Semiliquid evacuations were added initially and later ceased and gas was not passed. On physical examination, the patient presented abdominal pain, as well as distension, especially towards the left flank. There was presence of tympanism in the mesogastrium and left flank. Peristalsis was present, minimal, abolished in the left flank and mesogastrium. Peritoneal irritation was absent. A nasogastric tube was placed with minimal gastric output and no improvement in symptomatology. Laboratory studies demonstrated: 9700 leukocytes with 87% neutrophils, creatinine of 0.7 mg/dL, urea of 22 mg/dL and C reactive protein of 5.0 mg/L. Simple abdominal radiography showed significant dilation of the left side of the colon, with hydroaereous levels. The tomography shows the dilation of the left side of the colon, with an image that simulates a coffee bean in the coronal section.\n\nIn view of these clinical and imaging findings, emergency laparotomy was performed on the basis of suspected sigmoid volvulus or complicated adhesive syndrome. During surgery, a cecum flexed forward and to the left was observed, with no retroperitoneal fixation. The flexion point was produced by an adhesive band placed on the ascending colon. The adhesive band was released and adequate continuity to the distal colon was confirmed. Ischemia, necrosis or perforation of the cecum was not observed. Appendicectomy was performed with decompression of the cecum through the appendicular base and subsequent ligation of the appendix. Cecopexy was performed towards the right iliac fossa wall. After surgery, the patient's clinical condition improved and she had normal presentations. The patient continued to be monitored correctly in the surgical outpatient department and remained asymptomatic.\n",
    "summary": "43-year-old female presented to the emergency department with a history of intestinal obstruction. A plain abdominal X-ray was performed which identified a dilated colon with a coffee bean-like image. A laparotomy was performed and a scissor-like volvulus was identified with no vascular compromise. A volvulus was discolsed and decompressed through appendectomy and cecopexy. The patient recovered without incident following the surgical procedure and was discharged with appropriate outpatient follow-up.\n"
  },
  {
    "id": "multiclinsum_gs_en_1.txt",
    "fulltext": "A 52-year-old female patient from Wolkiet (Northwest Ethiopia) was apparently healthy two years ago but then started experiencing irritability, heat intolerance and diaphoresis. She had an anterior neck swelling of 30 years’ duration. For this, she was evaluated at Haider referral hospital (North Ethiopia), diagnosed with a toxic multinodular goiter and managed with propylthiouracil 100 mg orally (po) three times per day. Six months following initiation of the medication, her symptoms improved, and she was offered surgical treatment, which she refused. Four months prior to her current presentation, she developed generalized body fatigue which worsened during activities like climbing stairs, combing her hair and standing from a squatting position. Concomitantly, she noticed violaceous rash over both hands and neck, which later involved the anterior part of her bilateral thighs and shoulders, hair loss and facial puffiness, but no morning stiffness. One week preceding her current visit, she had difficulty swallowing food, and was unable to support her head. On physical examination, she was acutely sick looking, conscious and oriented. Vital signs were all in normal ranges (blood pressure [BP] = 110/80 mmHg; pulse rate [PR] = 88 beats/minute; respiratory rate [RR] = 24 breaths/minute; temperature [Toc] = 36.7°C; Sa02 = 94% while breathing in room air). She had pink conjunctivae and non-icteric sclera. The anterior neck mass measured 4 by 5 cm, and was non-tender, mobile, multi-nodular, hard in consistency, not attached to overlying skin and showed no palpable lymphadenopathy. The chest was resonant on percussion note and clear on auscultation. Heart sounds were well heard, and there was no murmur or gallop. Abdominal examination revealed no enlarged organ or any sign of fluid collection and she had no visible deformity or limitation of movement on locomotor examination. On integumentary examination, there was an erythematous hyper-pigmented lesion on her face with periorbital edema (heliotrope rashes); confluent violaceous and erythematous macular rashes on the knuckles of the hands (Gottron’s sign) and macular rashes on the forearms with a salt and pepper appearance; and violaceous macular rashes on the neck line (V-shaped rashes), shoulder and back (shawl’s sign) (E) and upper thighs, laterally (holster sign). Additionally, she had a hypopigmented area on her nails, hands, anterior chest and bilateral thigh. On neurologic examination, she was alert and oriented to time, place and person, and cranial nerves were all intact. She had difficulty holding objects against gravity and standing from a squatting position. Sensory examination was normal and meningeal irritation signs were absent. Her laboratory test results showed that she had moderate anemia (hemoglobin = 10.9g/dl, MCV = 78.0 Fl, and RDW: 13.5%), with normal other blood cell lines and erythrocyte sedimentation rate. Liver enzyme was mildly elevated (SGOT/AST: 52.97IU/L SGPT/ALT: 52.99IU/L), and serum albumin was low (2.6g/dl) with a normal bilirubin level. Renal function tests and serum electrolytes were normal. Thyroid function tests were within normal range. Urine analysis and serology test results were unremarkable. Serum creatine kinase before treatment was mildly elevated = 232u/l (normal range =20 – 198). The results of serology tests, such as the ANA, RF and anti-HIV antibody were non-revealing. Another immunological panel was not done due to limited clinical set up.\n\nThyroid FNAC smears showed cellular aspirate composed of moderately pleomorphic round to polygonal cells admixed with scant colloid suggestive of thyroid follicular neoplasm. Thyroid gland biopsy was not possible since excision is required. Thyroid ultrasound showed multiple hyper-echoic masses on the left side of the thyroid measuring 4.5×2.4 cm, with calcification and multiple ipsilateral neck lymphadenopathy, the largest measuring 1.2 cm on the short axis dimension suggestive of thyroid malignancy. Chest x-ray was normal. Muscle biopsy showed increased nuclear internalization, scattered lymphocyte infiltration and atrophy, which was suggestive of inflammatory myopathy.\n\nThe diagnosis of thyroid neoplasm-associated dermatomyositis was considered based on ACR-EULAR classification criteria and the patient was put on prednisolone 40mg daily, methotrexate 7.5 mg po weekly, folic acid 5 mg po daily and cotrimoxazole 960 mg po 3 times per week. Broad spectrum sunscreen and liquid paraffin (moisturizer) were applied on a daily basis. The patient was advised on regular exercise, avoidance of direct sunlight exposure and was linked to chronic follow-up clinic. After 2 weeks of steroid treatment, the patient showed remarkable improvement in muscle strength, and the steroid dose was tapered every week thereafter. After 2 months of treatment, she showed dermatological improvement and her physical exercise endurance was also significantly better.",
    "summary": "A 52-year-old known female patient with a toxic multi-nodular goiter presented with insidious onset of itchy erythematous rash on her neck and bilateral hands and progressive muscle weakness of 4 months' duration. Associated with this, she had photosensitivity, and periorbital edema of 2 months' duration. On physical examination, she had an anterior neck mass, proximal muscle weakness, periorbital edema, and violaceous skin rash on her bilateral arms, shoulders and neck. Thyroid function tests were normal, creatinine kinase was elevated, and muscle biopsy revealed inflammatory myositis. Ultrasound of the anterior neck mass and analysis of fine needle aspiration suggested thyroid cancer."
  },
  {
    "id": "multiclinsum_gs_en_93.txt",
    "fulltext": "A 32-year-old male presented with complaints of right wrist pain and swelling along with open fracture of the right both bone leg, following a road traffic accident. Primary splintage was given to the lower limb and on examination of the wrist there was significant swelling which was confined to right wrist. He was unable to actively flex or extend his wrist and complained of pain on passive movement of the wrist. Radiographs revealed volar scaphoid dislocation with increase in scapho-lunate space (Terry Thomas sign) and increase in scapholunate angle to 97° [Normal scapholunate angle varies between 30° and 60°].\n\n\nTreatment and follow up\nThe patient underwent primary debridement and external fixation for the right both bone leg fracture and single stage fixation of the wrist under regional anesthesia in supine position in the same sitting. A dorsal approach was performed to access the radiocarpal joint, the scapholunate ligament was found to torn and scapholunate diastasis was also visualized. The scaphoid was found to be unstable and hence fixed with one 2 mm K-wire to the lunate and scapholunate ligament was repaired using 1 suture anchor. Carpel alignment was achieved and the reduction was confirmed under c-arm guidance and splintage was provided using below elbow scaphoid slab.\n\nImmediate postoperative radiographs were satisfactory and the scapholunate angle was found to be 58° postoperatively. Patient's wrist was immobilized for 4 weeks with POP slab. 4 weeks post-surgery splintage and K-wire was removed and physiotherapy was started. After 6 month follow up patient complained of no pain and returned to work without any limitations. The clinical outcomes were assessed according to the modified Mayo wrist score score, which was found to be excellent. The outcome was established using the DASH (Disabilities of the Arm, Shoulder, and Hand) and PRWE score (Patient-Rated Wrist Evaluation), which was found to be 13 and 16 respectively. The Flexion/Extension/Pronation/Supination of the injured right wrist was 80°/80°/90°/90° respectively, which was comparable to the contralateral side. Grip strength of the affected side was 60 kg compared with 70 kg on the contralateral side. After a close follow up of 12 months patient had achieved complete range of motion and no complaints. The follow up radiographs at 12 months did not show any avascular necrosis or diastasis. ",
    "summary": "We present a case of 20-year-old male with an isolated scaphoid dislocation and scapholunate ligament injury of the wrist, diagnosed and repaired in an acute setting with k wires and suture anchor augmentation. At 1 year follow up patient complained of no pain and returned to work without any limitations, with no signs of avascular necrosis of the scaphoid on imaging."
  },
  {
    "id": "multiclinsum_gs_en_69.txt",
    "fulltext": "The patient, a 50 kg Iranian male with a height of 138 cm, arrived at our emergency department presenting with a significant bulge on the left side of his neck, accompanied by dysphagia, fever, and limited range of motion on the affected side. These symptoms had escalated rapidly over the two weeks preceding his referral. His medical history was largely unremarkable, with no notable allergic reactions, use of immunosuppressant, previous surgeries, alcohol abuse, or smoking. However, he did have a history of prior hospitalization due to recurrent tonsillitis.\n\nPresent illness\nThe patient presented in a state of good health prior to the onset of left-sided neck bulging, which was accompanied by recurrent fever, dysphagia, and restricted range of motion over a duration of 14 days. A physical examination performed in the emergency department of our Ear, Nose, and Throat Surgery unit identified a notable bulge, approximately 10 × 6 × 8 cm in size, located in the left oral cavity, particularly in the peritonsillar region. Additionally, the intraoral assessment revealed an unusual blue-to-purple structure resembling an abscess. Given the strong suspicion of a peritonsillar abscess, an incision was made in the peritonsillar area; however, this procedure unexpectedly led to considerable arterial hemorrhage. This necessitated an immediate emergency transfer of the patient to the vascular surgery unit at Namazi Hospital, following the application of pressure gauze packs to control the hemorrhage and performing intubation.\n\nRecovery timeline and follow-up\nUpon arrival at the vascular surgery unit, a thorough evaluation was performed to reduce the risk of hypovolemia and hemorrhagic shock. The patient underwent an emergency computed tomography angiography (CTA) of the cervical region with intravenous contrast, which revealed significant findings. Notably, there was considerable luminal narrowing in the mid-portion of the left internal carotid artery (ICA), demonstrating over 90 % stenosis. This was accompanied by a large heterogeneous hematoma measuring approximately 90 × 70 × 50 mm, located in the left parapharyngeal and carotid spaces, which exerted substantial pressure on the upper airways and contributed to the luminal narrowing. Additionally, an aneurysmal dilation measuring 10 × 6 mm was identified on the medial aspect of the left ICA at the site of the stenosis. The common carotid arteries (CCA), external carotid arteries (ECA), and vertebral arteries (VA) on both sides exhibited normal caliber and course, with no evidence of narrowing or obliteration. Multiple lymph nodes of varying sizes were observed on the left side of the neck, with the largest measuring up to 16 × 10 mm in the left trans-jugular chain zone II. The anterior cerebral arteries (ACA), middle cerebral arteries (MCA), posterior cerebral arteries (PCA), vertebrobasilar arteries, and anterior communicating artery (ACOM) on both sides displayed a normal course without signs of narrowing or aneurysmal dilation. However, the left posterior communicating artery (PCOM) was noted to be hypoplastic. Importantly, there were no indications of filling defects or arteriovenous malformations in the aforementioned vessels.\n\nFollowing the diagnosis of a ruptured aneurysm of the left internal carotid artery (ICA), the patient underwent an angioplasty procedure. During this procedure, a 6 French catheter was introduced via the superficial femoral artery to access the left ICA. One day later, a vascular surgical intervention was performed to evacuate the hematoma that had developed in the oral cavity as a consequence of a prior incision made for a misdiagnosed peritonsillar abscess, utilizing a Hemovac drainage system.\n\nPostoperative recovery\nFollowing the removal of the femoral catheter after angioplasty, the vascular surgery team conducted color Doppler sonography on the affected lower extremity due to the presence of a bulge in the medial thigh. The sonographic examination revealed an intimal flap measuring approximately 13 × 5 mm in the common femoral artery, suggestive of a potential dissection, as well as two pseudoaneurysms measuring 50 × 22 mm and 24 × 14 mm, likely associated with the catheterization procedure. The team decided to pursue conservative management with close monitoring, given that the pseudoaneurysms were small and asymptomatic.\nThe patient was admitted to the pediatric intensive care unit (PICU) and remained hospitalized for a duration of five days. Throughout this period, a multidisciplinary team, which included a pediatric neurosurgeon, an infectious disease specialist, a pediatric neurologist, a pediatric surgeon, and a pediatric psychiatrist, conducted a comprehensive assessment of the patient. A computed tomography (CT) scan of the brain was performed, which effectively ruled out ischemic and hemorrhagic strokes, as well as subdural and epidural hematomas, and confirmed the absence of brain cortex herniation.\n\nNeurological recovery timeline\nDay 1 post-surgery, the patient demonstrated mild cognitive impairments, dysarthria characterized by slurred speech, and a deviation of the tongue towards the left side. These findings are consistent with transient ischemic changes resulting from internal carotid artery (ICA) stenosis.\nOn the third day following the surgical procedure, the patient exhibited notable improvement in neurological symptoms. Specifically, the clarity of the patient's speech increased, and there was a significant resolution of tongue deviation. A pediatric neurologist conducted an assessment and observed no focal deficits during the physical examination.\nDay 5 post-surgery, the patient was transferred from the Pediatric Intensive Care Unit (PICU) to the general pediatric ward. At this point, all neurological symptoms had resolved spontaneously, and the patient demonstrated effective communication without any signs of dysarthria.\n\nVascular recovery timeline\nOn the first day following the surgical procedure, the femoral pseudoaneurysms were identified and managed using conservative treatment methods.\nOn the third day following the surgical procedure, a repeat Doppler ultrasound indicated no increase in the size of the pseudoaneurysms, and the patient continued to exhibit hemodynamic stability. Anticoagulation therapy was commenced to mitigate the risk of thromboembolic complications.\nOn the fifth day following the surgical procedure, the patient demonstrated the ability to ambulate without difficulty. Follow-up imaging revealed that the femoral pseudoaneurysms exhibited signs of spontaneous thrombosis.\n\nOutpatient follow-up care\nOne Month Post-Discharge: A follow-up CT angiography of the neck revealed no residual stenosis or aneurysmal dilation in the left internal carotid artery (ICA). The patient reported no recurrence of symptoms and was authorized to resume normal activities.",
    "summary": "We report a case of a 14-year-old male presenting with a rapidly enlarging left-sided neck bulge, dysphagia, and fever persisting for two weeks. Initial examination suggested a peritonsillar abscess, but surgical drainage resulted in arterial bleeding. Imaging revealed over 90 % stenosis of the left ICA with an associated aneurysm. The patient underwent angioplasty and hematoma evacuation, followed by a multidisciplinary approach to manage complications, including femoral pseudoaneurysms."
  },
  {
    "id": "multiclinsum_gs_en_6.txt",
    "fulltext": "69-year-old woman with a history of essential thrombocythemia (ET) JAK-2 (+) t (9;22) (-) diagnosed in 2008, on treatment with hydroxyurea and acetylsalicylic acid. Her father, an Italian, had a polyneuropathy of undetermined etiology that began in adulthood. In 2011, she presented with distal numbness and paresthesia, associated with neuropathic pain in both lower limbs (LLB), without autonomic compromise or loss of strength. At the same time, she presented with a bilateral decrease in visual acuity (VA) that was not painful and slowly progressive. On physical examination, she was emaciated, with a decrease in VA (0.3 and 0.3) and a fundus with bilateral vitreitis. Mental and cranial nerve examination was normal, strength was preserved but with a decrease in distal osteotendinous reflexes in the LLB and multimodal hypoesthesia in all four limbs in glove and sock, with no signs of autonomic compromise. Initial laboratory studies showed a hemoglobin of 11.7 g/dL, a mean corpuscular volume of 106.9 fL, platelets of 1,056,000 mm3 and a white blood cell count of 15 mm/h, with normal renal, hepatic, thyroid and coagulation function. Electromyography (EMG) showed a sensory-motor, axonal and demyelinating polyneuropathy. She was treated with pregabalin and vitamin B12.\n\nIn 2014, an ophthalmologic ultrasound documented bilateral occlusive vasculopathy with symmetrical papilar hyperfluorescence in relation to vitreous occupation, with a negative infectious study. The vitreous biopsy identified deposits of amyloid substance (congo red positive), which was complemented with a superficial peroneal nerve biopsy. The electrocardiogram and echocardiography (with measurement of longitudinal strain) ruled out cardiac involvement. Gastrointestinal and renal involvement were also ruled out. In a control with haematology (2016), an increase in the Kappa/Lambda index (K/L; 2.55 mg/L) was documented, which led to suspicion of light chain amyloidosis (AL), indicating a chemotherapy with melphalan and dexamethasone without response.\n\nIn 2019, the multidisciplinary amyloidosis study group of the Hospital del Salvador considered a diagnosis of ATTRv. A new EMG showed a severe polyneuropathic sensory-motor, axonal and demyelinating compromise, with signs of active axonal degeneration (not present in 2011), and the quantitative thermal somatosensory analysis identified a severe dysfunction of small diameter afferent fibers (A-delta and C), of polyneuropathic distribution. Finally, the TTR gene sequencing study confirmed the pathogenic Val50Met mutation, compatible with polyneuropathic ATTRv.\n",
    "summary": "We present the case of a 69-year-old woman who presented with a predominantly sensory polyneuropathy associated with distal neuropathic pain and bilateral vitritis. Her father's Italian background with polyneuropathy of unspecified etiology was of note. A vitreous biopsy identified deposits of amyloid (congo red positive). These were also confirmed in a superficial biopsy of the peroneal nerve. During the etiologic study of her polyneuropathy, an increased Kappa/Lambda index of 2.55 mg/L was noted. Therefore, light chain amyloidosis was suspected and chemotherapeutic treatment was indicated with no favorable response. After 10 years of progressive neurological and ophthalmological involvement, a genetic study confirmed the first case of late-onset Val50Met transthyretin hereditary amyloidosis with polyneuropathy in Chile.\n"
  },
  {
    "id": "multiclinsum_gs_en_340.txt",
    "fulltext": "19-year-old male patient, no known family history as the patient is adopted.\n\nAt 6 months of age, he was brought to an emergency department with a 48-hour history of diarrhea accompanied by vomiting of gastric contents. The patient was severely dehydrated on admission.\n\nInitial laboratory studies indicated a hydroelectrolytic imbalance, hyperglycemia, ketonuria (++++) and severe metabolic acidosis. Treatment was initiated for diabetic ketoacidosis as the main diagnostic suspicion. Also, due to respiratory distress, advanced airway management was necessary, so the patient remained in the intensive care unit for 11 days. Subsequently, treatment for ketoacidosis was discontinued during his stay, due to the suspicion of organic acidemia and not of diabetic ketoacidosis as the main cause of his clinical condition. The patient has not had new episodes of hyperglycemia since then, only indicating that he continued with severe metabolic acidosis. Bicarbonate replacements were performed until he showed improvement, which allowed the patient to be discharged to his home, although the cause of the metabolic acidosis of elevated anion gap could not be determined on that occasion.\n\nAt 12 months of age, the patient developed a second episode, with a diagnosis of laryngotracheitis as the reason for admission to the emergency department, with similar biochemical characteristics to the initial episode, with the exception of serum glucose, which was within normal parameters.\n\nLaboratory studies at admission showed the following results: serum glucose 79 mg/dL; serum creatinine 0.2 mg/dL; serum calcium 8.7 mg/dL; serum phosphorus 4.2 mg/dL; serum chloride 100 mEq/L; serum sodium 135 mEq/L; serum potassium 1.9 mEq/L; serum magnesium 1.1 mEq/L; venous blood gas pH: 7.0; pCO2 27.1; pO2 52; serum bicarbonate 7.9 mEq/L.\n\nThe patient was discharged for clinical improvement on that occasion, but the persistence of ketonuria (++++). Because of this, the approach of metabolic acidosis of elevated anion gap was initiated, with suspicion of inborn error of metabolism.\n\nUrinary organic acids were studied by gas chromatography and mass spectrometry. The results showed a marked elevation of ketone bodies (acetoacetate, 3 beta-hydroxybutyrate), which, together with the patient's clinical presentation, was highly suggestive of succinyl-CoA acetoacetate transferase (SCOT) deficiency.\n\nEvolution\nAfter diagnosis, maintenance therapy was initiated with a high-carbohydrate, low-protein (1.06 grams/kilogram of body weight) and low-fat diet including 30 g of cornstarch, a modified amino acid compound (Ketonex-2R), equivalent to 90 g, and 2 g of sodium bicarbonate.\n\nThe patient had 3 more episodes of mild-moderate anion gap metabolic acidosis, the last at 18 years of age, with no new episodes since.\n\nHis last laboratory results were as follows: venous blood gas pH 7.4; serum bicarbonate 25.9 mEq/L; normal levels of ammonia and lactate; with discrete positive (+) ketone bodies in urine and clinically asymptomatic, which demonstrated that the patient had an adequate response to treatment, so we inferred an absence of permanent ketosis.\n",
    "summary": "A case of a patient with SCOT deficiency, with a first atypical episode accompanied by hyperglycemia, with 4 subsequent episodes with classic manifestations of the disease, who presented a biochemical pattern of permanent ketonuria with marked elevation of ketone bodies (acetoacetate, 3 beta-hydroxybutyrate) in a study of urinary organic acids by gas chromatography and mass spectrometry, together with a clinical picture that granted the diagnosis. Maintenance therapy was initiated with a characteristic feeding plan; an adequate response to treatment was demonstrated, and an absence of permanent ketosis was inferred.\n"
  },
  {
    "id": "multiclinsum_gs_en_308.txt",
    "fulltext": "A 63-year-old woman was referred to the Athens Vision Eye Institute Cornea Clinic for management of severe mucous membrane pemphigoid in both eyes. Medical history was significant for diabetes mellitus and a positive skin biopsy for pemphigoid 1.5 years prior to presentation. The patient was being managed with methylprednisolone 16 mg per os once a day. Over the 6 months prior to presentation, significant redness developed in both eyes along with a persistent epithelial defect in the left eye.\n\nUpon examination of the right eye, best-corrected visual acuity was 20/80 and IOP was 20 mmHg by Goldmann applanation tonometry. For the left eye, best-corrected visual acuity was light perception and IOP readings were unreliable. Slit lamp examination was significant for entropion and trichiasis, extensive symblepharon formation and forniceal foreshortening in both eyes as well as ankyloblepharon in the left eye. Severe conjunctival injection and ocular surface dryness was present in both eyes, while the cornea of the left eye was completely conjunctivalized.\n\nA cataract (2+ nuclear sclerosis) was also seen in the right eye. Dilated fundus examination of the right eye revealed macular drusen and cupping of the right optic nerve with a cup to disc ratio of 0.5. We were unable to obtain reliable results on static automated perimetry despite several attempts. The conjunctivalized surface of the left eye impeded examination of the fundus and, for this reason, a B-scan ultrasound was performed, which did not reveal any abnormalities.\n\nGiven the severe ocular surface inflammation and the monocular status of the patient, aggressive treatment was initiated to preserve vision in the right eye. Monthly intravenous cyclophosphamide (25 mg/kg) infusions were administered for 6 months along with a slow oral steroid taper and topical preservative-free dexamethasone drops. The patient was subsequently transitioned to oral mycophenolate mofetil 2 g daily. At the 8 month follow up visit the ocular surface was white and quiet but the cataract had matured significantly with a nuclear sclerotic and a posterior subcapsular component. Vision in the right eye had dropped to 20/200 and IOP had increased to 35 mmHg. Despite cessation of oral and topical steroids and maximum medical therapy with oral acetazolamide 250 mg 3 times daily, topical preservative-free dorzolamide/timolol, brimonidine and latanoprost eye drops, IOP remained high at 28 mmHg.\n\nDecision was made to proceed with clear cornea cataract surgery combined with ab interno goniotomy using the Kahook Dual Blade (phaco-KDB) in the patient’s right eye. Because of the significant forniceal foreshortening and the ankyloblepharon a pediatric lid speculum was used during the procedure and an assistant was manually retracting the patient’s lower lid as needed during otherwise standard clear cornea phacoemulsification via a 2.6 mm main incision. Following insertion of a single piece intraocular lens (Acrysoft IQ SN60WF 24.0 D, Alcon Laboratories, Fort Worth, TX, USA) and before removal of the cohesive viscoelastic the head of the patient and the head of the operating microscope were rotated, a Swan Jacob direct goniolens was applied on the cornea and 3–4 clock hours of pigmented trabecular meshwork were removed with the Kahook dual blade. Reflux of blood from collector channels into the anterior chamber was observed and the majority of the viscoelastic was removed with the irrigation aspiration handpiece. Postoperatively the patient was started on preservative-free topical dexamethasone eye drops, topical moxifloxacin and nepafenac.\n\n\nResults\nOn the first post-operative day, the IOP was 14 mmHg and there was no layering hyphema in the anterior chamber. The patient’s corneal surface appeared very dry and within a few days a corneal epithelial defect developed, which was managed with a bandage contact lens and use of serum tears 30% and resolved by the 6th post-operative week. Intraocular pressure was 12 mmHg at 3 months post-operatively without any topical glaucoma medications and has remained in the 12–14 mm Hg range over a total follow up of 3.5 years. The patient’s visual acuity in the right eye at the last follow up visit was 20/40.",
    "summary": "A 63-year-old woman with a history of severe MMP presented with exacerbation of the disease in both eyes. Vision was 20/80 in the right eye and light perception in the left eye. Symblepharon formation, trichiasis and forniceal foreshortening were present in the right eye, while the cornea of the left eye was completely conjunctivalized. Following aggressive systemic immunosuppressive therapy with corticosteroids and cyclophosphamide, the disease was brought under control. However, the patient developed a mature cataract and high intraocular pressure (IOP) of 28 mmHg on maximal medical therapy. Due to the high risk of ocular MMP exacerbation with glaucoma filtration surgery, the decision was made to proceed with cataract extraction combined with ab interno goniotomy with the Kahook Dual Blade.\n\nResults: There were no intraoperative complications. The IOP has remained in the 12-14 mmHg range without any topical glaucoma medications over a total follow up of 3.5 years."
  },
  {
    "id": "multiclinsum_gs_en_187.txt",
    "fulltext": "The patient presented signed the Free and Informed Consent Form and the other ethical principles were complied with, respecting the Resolution 466/12 of the National Council of Ethics in Research. This case report was approved by the Ethics Committee in Research of the Federal University of São Paulo (UNIFESP), under opinion number 4.455.365.\n\nThe 66-year-old male patient presented to the otorhinolaryngology consultation with a complaint of dysphagia type gagging to solids and nasal reflux of food for 1 year. He had a car accident 13 years ago and has diabetes mellitus. Video-endoscopy of swallowing (VED) was performed, and a bulge of the posterior wall of the hypopharynx was visualized in the structural evaluation, with saliva residue on the lesion. In the functional evaluation, after offering solid food, restriction to retroflection of the epiglottis, limitation of laryngeal elevation and nasal reflux of food was observed, with a large amount of food residue above the lesion, in the posterior wall of the pharynx. In the test of postural maneuvers, there was a worsening of dysphagia to cervical extension and better clearance to flexion of the head. Computed tomography (CT) of cervical spine, requested for evaluation of the nature of the lesion, evidenced the presence of cervical anterior osteophytes between the C3 and C6 vertebrae, the largest with a anteroposterior length of 12 millimeters (mm), narrowing the air column at the level of the oropharynx and hypopharynx. Other causes of dysphagia were excluded and the patient was treated with swallowing therapy and omeprazole, directed to pharyngeal reflux. 6 sessions of individualized weekly swallowing therapy were performed, with the objective of compensating the swallowing mechanism in the face of a mechanical obstacle in the pharyngeal region. The main aspects worked were: modification of the texture of the diet, avoiding solid and dry food; swallowing postural maneuvers, tested during the VED, especially the chin tuck (“head down” or “head flexion”), which increases the space of the vallecula (“open the vallecula”) and improves the pharyngeal transfer pressure of the food; and exercises to strengthen the tongue, to overcome the mechanical barrier of the oropharynx during the expulsion of food. It was also recommended, if necessary, to alternate the offer of solid food with liquid. The patient was instructed to repeat the tongue exercises at home, 2 to 3 times a day. After the initial sessions, the patient presented a satisfactory response, maintaining quarterly monitoring in the first year and semi-annual monitoring from the second year. He was referred for orthopedic evaluation to discuss surgical feasibility, and conservative treatment was chosen due to good compensation with clinical measures. He has been followed up for 2 years, maintaining efficient swallowing, without incidence of complications related to dysphagia. It was decided to maintain periodic reassessments, at least once a year, to detect early possible new imbalance of swallowing homeostasis related to the gradual decline of functions in the context of presbyphagia or the emergence of a new aggressive factor.\n",
    "summary": "A 66-year-old male patient with a history of gagging type dysphagia to solids and nasal food reflux for 1 year was reported. Video endoscopy of swallowing demonstrated posterior pharyngeal wall bulge and, with the offer of solid food, restriction to epiglottic retroflexion, nasal food reflux and large amount of food residue on the lesion. Computed tomography of cervical spine identified the presence of anterior cervical osteophytes between C3 and C6 vertebrae, the largest with an anteroposterior length of 12 mm, narrowing the air column at the level of the oropharynx and hypopharynx. The patient was adequately treated with swallowing therapy.\n"
  },
  {
    "id": "multiclinsum_gs_en_356.txt",
    "fulltext": "40-year-old woman with a history of mood disorder and increased stress in the last year. She was admitted to our center after a syncope associated with palpitations. During the examination, she reported retrosternal chest pain without irradiation in the three days prior to the consultation, associated with dizziness and significant distress.\n\nEnter the emergency department hemodynamically stable, the electrocardiogram (ECG) in sinus rhythm interspersed with non-sustained wide complex tachycardia. Propanolol and amiodaron are administered in intravenous bolus. It presents torsion of points and posterior ventricular fibrillation that is defibrillated with 200 Joules at 20 seconds of the start, coming out to sinus tachycardia, vigil, connected. Emergency ultrasound shows segmental alterations. Enter the hemodynamic department, coronary angiography with epicardial coronary arteries without angiographic lesions. Ventriculography shows medioventricular hypokinesia with depressed ejection fraction in moderate degree 35%. Left ventricular end-diastolic pressure 26 mmHg. The values of NT-ProBNP and Troponin T after electrical defibrillation were 2478 pg/mL and 36.1 ng/L, respectively.\n\nECG at admission QTc prolonged 490 ms, negative T waves in V1 to V3, DI and aVL.\n\nCardio-resonance showed marked alteration of segmental motility associated with edema, without late enhancement, suggestive of a mid-ventricular variety of stress cardiomyopathy. Mild systolic dysfunction and minimal left ventricular dilatation6.\n\nDuring the first 24 hours the patient persists with salves of polymorphic ventricular tachycardias (TV), without new episodes of syncope. She then evolves with a decrease in QTc without new episodes of TV. ECG prior to discharge in RS, QTc 430 ms, isobifasic T in V2.\n\nShe is discharged 7 days after admission with low dose bisoprolol and enalapril.\n\nEcho at one month discharge showed no segmental abnormalities, normal size cavity, wall thickness and mass index in normal ranges. Ejection fraction (EFI) within normal limits, EFI 55%.\n\nFollow-up at six months the patient has remained asymptomatic, with no new episodes of chest pain or palpitations.\n",
    "summary": "In this manuscript, we report a case of a 40-year-old female patient presenting with syncope that progressed to torsades de pointes and then ventricular fibrillation. Coronary angiography did not show coronary lesions. Ventriculography, transthoracic echocardiography and cardiac MRI were compatible with mid-ventricular Takotsubo cardiomyopathy. The ECG showed a long QTc interval with inverted T wave. During the first 48 hours, she had multiple episodes of non-sustained polymorphic ventricular tachycardia. The patient progressed with a decrease in QTc interval and regression of the segmental alterations. At the six-month follow-up, the patient was asymptomatic, with no new episodes.\n"
  },
  {
    "id": "multiclinsum_gs_en_50.txt",
    "fulltext": "A 25-year-old female presented to the emergency department with thermalgia in the left palm accompanied by upper limb tingling, and generalized asthenia accompany low-grade fever that started 3 days prior to presentation. Originally, orthopedic physician who diagnosed her as peripheral nerve compression syndrome and treated her with supportive measures(ibuprofen and aescuven forte). On the following day, her left palm developed extremely itchy and burning pain in her left palm accompanied by significant scattered pulsation, including palm, interphalangeal, and fingertip areas, especially where there is a noticeable sense of vascular pulsation at the fingertip which seriously affects normal life and work. Therefore, she immediately presented to the emergency department to exclude drug allergies or poisoning reactions due to her allergic constitution.\n\nUpon examination, there were no obvious abnormalities in vital signs. Her left upper limb skin showed no abnormalities such as erythema or rash, and the stinging sensation disappeared. However, integumentary examination revealed visible scattered erythema and clustered blisters on the palmar surface, finger surface, and distal of the index finger in the left hand, with thick blister walls, clear blister fluid, and basal erythema. Those with large blisters are like soybean, while those with small blisters are like millet grain meanwhile itching and burning pain gradually worsen.\n\nInspection results showed that there are no significant abnormalities in the complete blood count test are normal as well as routine urinalysis (‐), liver and kidney function tests (‐), blood glucose (‐), human immunodeficiency virus (‐). Her symptoms were ruled out as drug-related issues in the emergency department, and a professional dermatologist was invited to provide consultation support. The dermatologist gave a preliminary diagnosis was hand eczema thus recommended applying triamcinolone acetonide econazole cream to the affected area, once in the morning and once in the evening. And take loratadine orally once a day, 1 tablet at a time (10 mg).\n\nAfter 2 days, there was no improvement in symptoms in the left hand, and clustered blisters became more prominent and gradually fused. Dermatologists found that the clinical characteristics of herpes zoster were more pronounced and verified by local biopsy on the lesion. At the same time, the doctor suggested that she has to take medication such as acyclovir tablets for treatment, while the patient refused and sought for the Traditional Chinese Medicine treatment to relieve her pain and anxiety as soon as possible. Therefore, she sought further treatment in the acupuncture and moxibustion department.\n\nThe patient was first assessed by the acupuncture and moxibustion doctor before treatment, including subjective symptoms evaluated by visual analog scale such as itching, pain and vascular pulsation, as well as objective symptoms by Eczema Area and Severity Index scores such as the size of erythema and the number of papules.\n\nAccording to the patient’s description, the patient’s left hand had the highest pain score of 7.5 points, itching score of 8.5 points, and blood vessel pulsation score of 5 points. After understanding the specific situation of this patient, we gave her treatment with TFM. The specific operation process is as follows. First, prepare a traditional Chinese medicine incense stick. Then, the doctor pinches one end of the incense stick with his right thumb and index finger, exposing one end about 1 cm for ignition. Finally, shake off the burning flame, and when it forms a bead shaped spark, quickly press the bead shaped charcoal spark head directly onto the blister. Once pressed, immediately leave which is called one zhuang. Generally, large blisters should be treated 5 to 7 zhuang, and small rash spots should be treated 2 to 3 zhuang. Treatment should be given once a day, with 10 times serving as a course of treatment.\n\nTherefore, she received TFM treatment once a day in the acupuncture and moxibustion department, and assessed the changes of symptoms before and after treatment every 2 days, and made records. On the 4th day of TFM treatment, she told that the burning sensation and itching in her palms had significantly decreased, and the pulsatility of her finger blood vessels had basically disappeared, with the visual analog scale scores significantly decreased. After 6th treatments, the tissue fluid inside the blister is gradually absorbed, and the skin covering the blister has separated from the bottom of the palm skin. After sixth treatments, the skin covering the blisters has peeled off from the bottom of the palm skin. Meanwhile, the top of the large blisters gradually turns yellow, scabs and hardens, and the peripheral redness and halo of all blisters increase. At this point, all subjective discomfort has basically disappeared. Four more TFM treatments were given, as a result, the patient’s herpes gradually falls off, and pink new skin appears at the base of the herpes, slightly shallower than the surrounding normal skin without any discomfort. We shown off the symptom changes during her entire TMF treatment period based on her symptom rating. No adverse events occurred throughout the entire treatment period. After a course of treatment, the patient received a follow-up from the doctor who treated her with TFM. Currently, there are no discomfort symptoms and returned to normal in her left hand, and took photos to gave feedback.",
    "summary": "Patient concerns: A 25-year-old woman experienced left palm pain accompanied by upper limb stabbing pain, general weakness, and low-grade fever after staying up late. At first, she was diagnosed with peripheral nerve compression and hand eczema, and received relevant symptomatic treatment, but her condition did not improve. Diagnosed with herpes zoster on the hand after skin biopsy, treated with thread fragrant moxibustion (TFM).\n\nDiagnoses: The HHZ diagnosis was established based on clinical appearance and dermatological findings eventually.\n\nInterventions: The intervention project was TFM treatment once a day in the acupuncture and moxibustion department, and the whole treatment period lasted for 10 days.\n\nOutcomes: After 3 more TFM treatments were given, the burning sensation and itching in her palms as well as the pulsatility of the finger blood vessels had significantly reduction, the visual analog scale scores significantly decreased. After 10 treatments, the patient's herpes gradually falls off, revealing pink new skin without any discomfort."
  },
  {
    "id": "multiclinsum_gs_en_252.txt",
    "fulltext": "48-year-old man, with no relevant antecedents, presented secondary trauma to a high-energy vehicular collision. He was transferred to the emergency department of the nearest hospital and, due to progressive deterioration of consciousness, was intubated, connected to a ventilator and transferred to the base hospital in his region. The severity index of the trauma was: Injury Severity Score (ISS) of 38, Revised Trauma Score Triage (RTS-T) of 10 and Trauma Injury Severity Score (TRISS) of 23.\n\nThe tomographic study showed multiple bilateral rib fractures with slight displacement, fracture of the sternum manubrium not displaced, right pleural and pericardial occupation, fracture of the spinous process (T1), liver laceration, mild hemoperitoneum and frontal hematoma, with no evidence of intracranial injury. A right pleurotomy was performed, with an initial debit of 1,100 cc of blood and he was transferred to the Intensive Care Unit (ICU). A left pleurotomy was performed due to the finding of a left pneumothorax in radiographic follow-up.\n\nShe progressed with increasing requirements for oxygen and vasoactive drugs. Laboratory tests showed acidosis, thrombocytopenia, coagulopathy and acute renal failure. The chest radiograph showed bilateral diffuse infiltrates and velamentous clouding of both costo-frenic angles. On the third day after the trauma she presented the following ventilatory parameters: tidal volume 380 ml, compliance 23 ml/cmH2O, PEEP 10 cmH2O, respiratory rate of 32 per minute, paO2 53.4 mmHg, paCO246.1 mmHg, oxygenation index 33, inspired fraction of oxygen (FIO2) 80%; paO2/FIO2 of 66 and Murray score of 35. She was ventilated in prone position, without improvement of oxygenation. Due to catastrophic respiratory failure, a decision was made to connect her to veno-venous ECMO in the ECMO-Ministry of Health commission.\n\nECMO was requested for transport to our center. It was connected to the ICU by percutaneous cannulation via the right femoral vein (23 FR) and the right jugular vein (17 FR), with a flow rate of up to 4.5 L/min. It was then transferred to the surgical ICU of our hospital, where it was kept anticoagulated with non-fractionated heparin.\n\nOn the first day of connection, an increase in paO2/FIO2 was observed to 176. CT showed extensive bilateral pulmonary contusion foci with suggestive images of areas of left pulmonary infarction.\n\nHe evolved without the need for vasoactive drugs on the 3rd day of ECMO connection. After an evident radiographic and gasometric improvement (paO2/FIO2 consistently greater than 200), the flow of fresh gases in the ECMO circuit was discontinued on the 10th day for evaluation of the exchange capacity with a ventilator alone. Due to good evolution, he was disconnected from ECMO on the 12th day. Weaning was initiated prior to tracheostomy, achieving disconnection of mechanical ventilation on the 16th day. Pleurostomy was removed on the 17th day. He was transferred to the hospital of origin on the 22nd day, and was discharged on the 32nd day.\n",
    "summary": "A 48-year-old man, with no relevant history, after a high-energy vehicle collision admitted with severe TTS. He evolved with respiratory failure that required intubation and connection to mechanical ventilation (MV). He persisted with high ventilatory requirements, requiring rescue ECMO and transfer to our center. He evolved with gasometric and ventilatory improvement that allowed disconnection on the ten day. There were no bleeding or thrombotic complications during ECMO.\n"
  },
  {
    "id": "multiclinsum_gs_en_281.txt",
    "fulltext": "A 35-year-old woman with recent use of a JAK inhibitor for rheumatoid arthritis presented with a two-week history of fever, cervical adenopathy, and facial erythema. On admission, she was found to have anemia, hypoalbuminemia, proteinuria, and severe acute renal injury. SLE was diagnosed, and parvovirus B19 DNA was detected in serum samples. A renal biopsy revealed GC without any typical features of lupus nephritis. The patient was treated with prednisone and showed marked improvement in anemia and renal function after a few weeks. In this case, the patient with SLE had GC possibly caused by parvovirus B19 infection associated with the homozygous G1 genotype of apolipoprotein 1 (APOL1), which has been described as a major risk factor for this glomerulopathy. Whether SLE had a causal relationship to the glomerular disease or was a concomitant cause is unclear. Treatment may be challenging in this context, since no antiviral medications are effective and immunosuppression has no discernible benefits, although the use of steroids was effective in treating the renal manifestations in this case.\n",
    "summary": "A 35-year-old black woman presented to our hospital two weeks ago with fever, night sweats, facial erythema, and painful oral ulcers. She denied joint or respiratory symptoms. Physical examination revealed normal vital signs, pallor, tender cervical adenopathy, and no hepatosplenomegaly.\n\nEighteen months earlier, she had been diagnosed with rheumatoid arthritis by another medical service, with asymmetric polyarthritis of the hands, ankles, and knees associated with an hour of morning stiffness. Prednisone and methotrexate were initiated, but the latter was discontinued a few months later due to nausea and vomiting, and tofacitinib (JAK inhibitor) was prescribed. Tofacitinib was administered for about 6 months and discontinued 2 months before hospitalization due to financial issues. She was then maintained on low-dose prednisone.\n\nLaboratory tests collected at admission revealed serum creatinine (Cr) of 3.74 mg/dL, urea 108 mg/dL, hemoglobin (Hb) 10.9 g/dL, leukocytes 2,620/mm3, platelets 137,000/mm3, total bilirubin 0.21 mg/dL, AST 191 U/L, ALT 110 U/L, ferritin 5,628 ng/mL, DHL 777 U/L, albumin 1.9 g/dL, and normal levels of complement. Baseline serum creatinine was not available. Urinalysis revealed 222,000 leukocytes/mL, 110,000 red blood cells/mL, and 10.3 g/L protein. Further testing during the investigation showed negative IgG and IgM for toxoplasmosis, HIV, HTLV, syphilis, hepatitis B and C; a homogeneous pattern of FAN > 1:1280, anti-dsDNA > 1:320, and anti-ENA and rheumatoid factor negative. Ultrasound revealed normal-sized kidneys with diffuse and increased echogenicity. The typical panel of autoantibodies with a compatible clinical presentation supported the diagnosis of SLE. As this was a patient who had never had a documented renal exacerbation and with atypical signs of lupus activity such as adenopathy, painful oral ulcers, and elevated liver enzymes, investigation of other causes of acute lymphadenopathy and glomerulopathy was initiated while a 3-day course of 1 g intravenous methylprednisolone was initiated.\n\nIn the following days, the patient developed progressive anaemia (Hb 9.0 g/dL on day 2 and 7.7 g/dL on day 7) and progressive renal insufficiency. Intermittent haemodialysis was initiated on day 6, and a renal biopsy was performed. The examination showed 11 glomeruli, all with degenerated and hypertrophic podocytes. One glomerulus showed segmental collapse of the capillary walls. The renal interstitium showed dilated tubules filled with hyaline cylinders, mild fibrosis and tubular atrophy. Immunofluorescence microscopy demonstrated segmental and irregular deposits of IgM (++/4+) and C3 (traces). In electron microscopy, discrete mesangial deposits and sparse subepithelial deposits associated with retraction and tortuosity of the capillary wall were observed.\n\nFurther investigation of viral agents resulted in negative serology for EBV, CMV IgG positive and CMV IgM serology and serum PCR negative for CMV. However, IgM and IgG serology as well as serum PCR for parvovirus B19 were positive. APOL1 gene sequencing was performed, revealing a homozygous G1 genotype.\n\nPrednisone treatment was initiated at 1 mg/kg (70 mg/day) with clinical and laboratory improvement in the following days. The last dialysis was performed on the eighth day after admission to hospital, and Cr has been decreasing since then (4.2, 3.1 and 2.4 mg/dL on days 10, 13 and 15, respectively). The urinary protein creatinine (UPC) in a single urine sample on day 9 was 2.31 g/g. After discharge, at her first outpatient appointment (18 days after admission), she had a Cr of 1.09 mg/dL. A gradual reduction of prednisone was initiated and after 3 months the dose was 30 mg/day. Thereafter, laboratory tests revealed a Cr of 0.69 mg/dL, albumin of 4.3 g/dL, haemoglobin of 16.2 g/dL, a UPC of 1.24 g/g and a 24-hour urine protein of 0.93 g.\n"
  },
  {
    "id": "multiclinsum_gs_en_257.txt",
    "fulltext": "39-year-old woman with a history of CKD stage 5 on thrice-weekly dialysis 10 years ago, HPS and arterial hypertension. She consults at the surgery polyclinic for the need of total thyroidectomy in the context of long-standing non-toxic multinodular goiter.\n\nThe physical examination highlights increased facial volume with bilateral growth of the maxilla and mandible, a tumour of the hard palate and floor of the mouth, increased interdental space and loss of the nasal commissure with widening of the nostrils, which determine a leonine face.\n\nThe patient reported a painless and progressive increase in facial volume over the past year, associated with dysphagia, hoarseness, rhinolalia and respiratory difficulty in the last 2 months. A head and neck computed axial tomography (CAT) was performed without contrast, which showed bone widening of the cranial vault, base of the skull and facial mass, predominantly in the mandibular and maxillary bones, with the presence of tunnel-like images compatible with uremic bone leontiasis. Preoperative examinations were requested, which are described in Table 1, where a PTH of 4557 pg/ml, a calcemia of 10.6 mg/dl and a phosphemia of 5.5 mg/dl stand out.\n\nTotal thyroidectomy was planned and subtotal parathyroidectomy was decided in the context of a poorly managed LOU and HPS despite dialysis and pharmacological treatment. The patient was admitted for elective surgery and, in the context of a difficult airway, nasal intubation was decided using fibrobronchoscopy. However, after two unsuccessful attempts, it was decided to perform vigil orotracheal intubation with a fibrobronchoscope, achieving the installation of the endotracheal tube and subsequent sedation of the patient. Total thyroidectomy and subtotal parathyroidectomy were performed without incident. In the early postoperative period, she was transferred to the surgical intermediate service where she received scheduled haemodialysis and postoperative care, and she evolved satisfactorily without presenting complications such as hypocalcaemia. During the first day of the postoperative period, a decrease in PTH to 120 pg/mL was noted, without evidence of hyperkalaemia, a hungry bone effect or other biochemical complications. The patient decided to continue management and subsequent monitoring in another centre.\n",
    "summary": "39-year-old woman with a history of chronic renal failure on hemodialysis, arterial hypertension and HPS. She was admitted for elective total thyroidectomy in the context of a non-toxic multinodular goiter. On physical examination, she had a painless increase in volume of the bilateral maxillary and mandibular bones, loss of the nasal commissure and widening of the nostrils, which gave a leonine face. Preoperative examinations showed a PTH of 4557 pg/ml, so a head and neck CT scan was requested, which showed tunnel-like images in the bones of the base of the skull and facial mass, consistent with a goiter. Total thyroidectomy with subtotal parathyroidectomy was performed, with a reduction in PTH levels on the first postoperative day.\n"
  },
  {
    "id": "multiclinsum_gs_en_173.txt",
    "fulltext": "On August 4, 2023, a 47-year-old male patient was admitted to the hospital with symptoms of nausea, emesis, and abdominal bloating that had persisted for 3 days. The patient had been diagnosed with uremia for 13 years and underwent kidney transplantation two months prior. Post-transplant, he was taking prednisone (20 mg orally once daily), tacrolimus (3 mg orally every 12 hours), and mycophenolate mofetil (0.5 g orally every 12 hours) as anti-rejection treatment as per doctor’s instructions, but he had not received any prophylaxis for Pneumocystis jiroveci pneumonia (PJP). In February 2021, he traveled to Guangdong, an area previously reported to have cases of strongyloidiasis. After returning home, he reported no discomfort. However, in April 2021, his eosinophilia increased to 2.53×109/L and returned to normal over six months without treatment. The patient reports no additional medical history, medication use, or surgical interventions, and there are no relevant family medical history entries requiring mention.\n\nUpon admission, the patient exhibited stable vital signs, characterized by distinct coarse breath sounds in both lungs, slight tenderness in the upper left quadrant of the abdomen, and 7–8 bowel sounds per minute. No other positive signs were observed. The blood test showed the following: Complete blood count: white blood cell count was 5.34×109/L, hemoglobin was 91 g/L, lymphocyte count was 0.18×109/L, eosinophil count was 0.29×109/L; Procalcitonin level was 0.63 ng/mL; Renal function: Serum creatinine level was 283.4 μmol/L; No significant abnormalities were observed in liver function. The abdominal X-ray, conducted in both the standing and supine positions on August 4, indicated a partial accumulation of intestinal gas, with no other abnormalities detected. That same day, a chest computed tomography (CT) revealed widespread nodular opacities and patchy areas of increased density in both lungs. Given the patient’s recent kidney transplantation and concurrent lung infection, the original medication was halted, and switched to Methylprednisolone (60 mg intravenously once daily) for anti-rejection, and Caspofungin (initial dose of 70 mg intravenously, followed by a maintenance dose of 50 mg daily) combined with Cefoperazone/Sulbactam (1.5 g intravenously every 12 hours) for anti-infection treatment was administered. Simultaneously, Omeprazole was used for gastric protection, and the patient’s gastrointestinal symptoms were alleviated on the same day.\n\nHowever, on the night of August 4, the patient developed a cough, hemoptysis, but no symptoms such as chest pain, chest tightness, difficulty breathing, or fever. On August 5, the patient still had hemoptysis and developed symptoms of dyspnea and an elevated respiratory rate. Arterial blood gas (ABG) analysis showed a pH of 7.35, PaO2 at 71 mmHg, PCO2 at 29 mmHg, an oxygenation index of 192, and FiO2 at 37%, suggestive of respiratory failure. Consequently, non-invasive mechanical ventilation was initiated, employing Continuous Positive Airway Pressure (CPAP) mode. Combining the patient’s chest CT and medical history, it was considered that the patient could be suffering from PJP, thus sulfamethoxazole-trimethoprim (1.92g intravenously every 6 hours) for PJP was added to the treatment.\n\nOn August 7, sputum metagenomics next-generation sequencing (mNGS) revealed Escherichia coli with 40,668 sequence reads, Klebsiella pneumoniae with 3373 sequence reads, and Strongyloides stercoralis with 271,732 sequence reads. Simultaneously, Strongyloides stercoralis was seen in the sputum smear. Considering the patient’s chest CT more with Strongyloides stercoralis infection than with typical bacterial infection, and noting that neither white blood cell count nor procalcitonin levels showed significant elevation, it is believed that the primary concern is a Strongyloides stercoralis infection. Since Ivermectin was unavailable in the region, the patient was immediately given Albendazole (0.4g orally every 12 hours) for treatment, and the sulfamethoxazole-trimethoprim (0.96g orally once daily) dosage was adjusted to a preventive one. However, on the night of August 7th, the patient’s respiratory function deteriorated rapidly, with the oxygenation index dropping to 65. In order to administer effective oxygen therapy, the patient underwent tracheal intubation and invasive mechanical ventilation. After tracheal intubation, approximately 60 mL of bloody secretions were aspirated from the airway. We immediately performed a fiberoptic bronchoscopy and found a large amount of bloody secretions in the right bronchus, and partial blood clot blocking the bronchial lumen in the right lower lobe, suggesting active bleeding in the patient’s airway.\n\nAfter successfully achieving hemostasis (a process involving the infusion of vasopressin and tranexamic acid, and the local instillation of a mixture of ice saline and adrenaline into the bleeding site under bronchoscopic guidance), the bronchial lumen was then cleared, with approximately 40 mL of bloody secretions removed. The hemoglobin level decreased from 75 g/L to 57 g/L. To address the anemia, 600 mL of red blood cells were transfused, and no fresh blood was observed flowing out on the same day.\n\nHowever, on August 8th, approximately 60mL of bloody secretions were again aspirated from the patient’s airway. While supported by endotracheal mechanical ventilation (FIO2: 100%), the patient exhibited oxygen saturation levels fluctuating between 70% and 85%. Additionally, the patient’s heart rate fluctuated between 95 and 110 beats per minute, with a systolic blood pressure ranging from 80 to 100 mmHg and a diastolic blood pressure from 50 to 70 mmHg. These vital signs were observed while the patient was receiving norepinephrine at 1.5 µg/kg/min, epinephrine at 1 µg/kg/min, and metaraminol at 3 µg/kg/min. We suggested to the patient’s family that Extracorporeal Membrane Oxygenation (ECMO) treatment could be implemented. Due to financial constraints, the patient’s family declined further treatment, electing to proceed with same-day discharge. Unfortunately, follow-up data revealed that the patient experienced a rapid deterioration in health, leading to his demise at home on the day of discharge.",
    "summary": "A 47-year-old male, regularly taking immunosuppressants post-kidney transplant, visited our hospital with symptoms of abdominal bloating, nausea, and emesis persisting for three days. After hospitalization, he developed a cough, hemoptysis, and respiratory failure. Sputum analysis confirmed an infestation with Strongyloides stercoralis. Despite receiving albendazole therapy and bronchoscopic management for bronchial hemorrhage, the patient ultimately died due to acute respiratory and circulatory collapse triggered by severe airway bleeding."
  },
  {
    "id": "multiclinsum_gs_en_556.txt",
    "fulltext": "A 38 year old woman was admitted in the surgical ward November 2022 with the chief complain of progressive abdominal swelling which was associated with mild abdominal pain, and early satiety for five months. She had no systemic symptoms such as weight loss, constipation, diarrhea, craving for salty foods, easy fatigability or headache.\nOn examination, she appeared well-nourished but had gross abdominal distension, mild pale, afebrile with sclera tinge of jaundice.\nAbdominal palpation revealed a large, non-tender, intra-abdominal mass occupying the entire lower abdomen and extending into the upper abdomen with no signs of peritoneal irritation or organomegaly.\nBlood tests showed White cell count (5.7 × 109/l), Haemoglobin (9.8 g/dl), Bilirubin (103 mg/dl) with normal platelet counts (393 × 109/l. Liver enzymes, AST (24.0 U/l, ALT (21.0 U/l), albumin 42.7 g/l. Serum creatinine (53 μmol/l) and ESR (80 mm/h). All other blood tests were normal. An abdominal ultrasound revealed a complex abdominal cyst, both kidneys were normal in size and normal echotexture, the liver appeared normal. Contrast CT abdomen and pelvis – axial and coronal views, demonstrate a large thin-walled right suprarenal cyst (blue arrows) measuring approximately 23.5 cm (AP) x 20.3 cm (T) x 32.2 cm (CC) in size with a volume of 8 l. The large cyst displaces the right kidney (red arrows) inferomedial across the midline and exerts pressure effect on the liver, gall bladder, pancreas and small bowels. It extends into the right iliac fossa. Since there was a tinge of sclera jaundiced, but the mass was separately from the liver, pancreas, biliary trees and the right kidney. Given the size of the cyst and its compressive effects, surgical intervention was planned. An open surgical approach was chosen.\n\nThe patient underwent laparotomy. Under general anaesthesia, an abdominal extended midline incision was made, after opening abdominal wall layers, a huge retroperitoneal cyst was identified, that was occupying the entire part of an abdominal cavity.\n\nThe cyst was opened to get access for fluid suctioning as demonstrated in cystectomy was successfully done, about 8 l of brown-coloured fluid was sucked out from the mass. Cystic wall and fluid samples were sent for histology.\n\nThe patient had an uneventful recovery and was discharged on postoperative day 7. Follow-up at 6 and 12 months showed no recurrence or complications. Cytological examination of the sample reported presence of amorphous material, there was no evidence of malignancy. Histological results, the cystic wall was reported to have adrenal tissue without atypia, there was cystic wall infiltration by mononuclear inflammatory cells. The inner surface of the wall was not lined by recognizable specific cells. Regarding the intraoperative clinical findings where by the origin of the cyst was uncertained, the findings were more suggestive of a giant idiopathic retroperitoneal cyst.\n\n",
    "summary": "A 38-year-old female presented with progressive abdominal distension. Imaging revealed a giant retroperitoneal cyst. Due to limited resources, an open laparotomy was performed, and a 33 cm cyst containing 8 l of clear fluid was completely excised. Histopathology confirmed a giant idiopathic retroperitoneal cyst."
  },
  {
    "id": "multiclinsum_gs_en_452.txt",
    "fulltext": "A 3-year-old boy with an Ommaya reservoir in his right ventricle presented to our hospital with a fever. The reservoir was used to prevent hydrocephalus after a ventriculoperitoneal (VP) shunt removal placed after a grade 3 intraventricular hemorrhage. He also had a right subclavian portal catheter placed 2 years previously due to Hirschsprung disease (entire colon type). He had a history of catheter-related methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. He was mechanically ventilated through a tracheostomy because of congenital central hypoventilation syndrome. On examination, he had a fever of 38.8°C and erythema around the Ommaya reservoir. Hematology showed a white blood cell count of 9260 cells/mL with 50% neutrophils. Cerebrospinal fluid (CSF) from the Ommaya reservoir showed a leukocyte count of 6 cells/mL (40% neutrophils and 60% lymphocytes) and Gram-positive bacilli on Gram stain. Empiric intravenous treatment was initiated with 300 mg/kg/day of cefotaxime for Ommaya reservoir infection.\n\nAfter 3 days of cefotaxime treatment, his fever persisted. Therefore, considering the patient’s history of catheter-associated MRSA bacteremia, two sets of blood cultures were drawn, one from a peripheral site and another from the indwelling vascular catheter. A second CSF sample from the Ommaya reservoir was obtained, and antibiotic treatment was switched from cefotaxime to vancomycin (20 mg/kg/day) and meropenem (120 mg/kg/day). The CSF from the Ommaya reservoir showed the following features: glucose concentration, 55 mg/dL with blood glucose of 101 mg/dL; protein concentration, 40 mg/dL; and leukocyte count, 194/mL (81% neutrophils and 19% lymphocytes). Three days later, C. striatum was identified in CSF cultures. Antibiotic susceptibility testing (BD Phoenix automated microbiology systems) revealed that the strain was susceptible to penicillin, amino benzylpenicillin, cefotaxime, cefepime, sulbactam/ampicillin, imipenem/cilastatin, meropenem, erythromycin, clindamycin, levofloxacin, and vancomycin and was resistant to sulfamethoxazole/trimethoprim.\n\nThus, vancomycin and meropenem were de-escalated to 400 mg/kg/day of ampicillin.\n\nAmpicillin treatment was continued for 2 weeks. A CSF culture obtained on day 6 of ampicillin treatment was negative for C. striatum; thus, the Ommaya reservoir was removed and replaced by external ventricular drainage. However, cultures of the removed Ommaya reservoir, and CSF samples grew C. striatum, which was susceptible to meropenem and vancomycin and resistant to the other antibiotics tested. Vancomycin was initiated to treat this new C. striatum meningitis strain, and after 8 days of treatment, the CSF culture from lumbar puncture was negative for C. striatum. External ventricular drainage was removed after confirmation that the ventricular enlargement had not progressed.\n\nThe patient was discharged from the hospital after confirming that there was no residual infection or ventricular enlargement.",
    "summary": "A 3-year-old boy with an Ommaya reservoir in the right ventricle and a medical history of grade 3 intraventricular hemorrhage, Hirschsprung disease, catheter-related methicillin-resistant Staphylococcus aureus bacteremia, and congenital central hypoventilation syndrome was hospitalized for Ommaya reservoir infection with C. striatum. He was treated with ampicillin, to which the initial isolate was susceptible. C. striatum may have acquired multiple-drug resistance during the antibiotic treatment due to biofilm production. The Ommaya reservoir was replaced by external ventricular drainage. Cultures of the removed Ommaya reservoir, and cerebrospinal fluid samples grew C. striatum, which was susceptible to meropenem and vancomycin and resistant to other antibiotics. The antibiotic was switched to vancomycin to treat this new multidrug-resistant strain. After 8 days of vancomycin treatment, the cerebrospinal fluid culture obtained by a lumbar puncture was negative for C. striatum."
  },
  {
    "id": "multiclinsum_gs_en_415.txt",
    "fulltext": "A 76-year-old Japanese male visited to our department with a chief complaint of left scrotal swelling. The patient had been aware of the scrotal swelling for 4 years, and there was no evidence of enlargement. The left scrotal mass was soft and elastic without pain, and skin color was normal. Ultrasound examination revealed a 10 cm multilocular cystic mass with a solid component in part; however, apparent left testis could not be detected. T2-weighted images (T2WI) of the mass via magnetic resonance imaging (MRI) also showed a multilocular cystic pattern with different degrees of hyperintensities in each cyst. The solid component was observed as a hypointense area. Diffusion-weighted imaging (DWI) showed no significant decreasing apparent diffusion coefficient (ADC) value in the solid area. The results of laboratory examination including alpha-fetoprotein (AFP), human chorionic gonadotropin beta-subunit (βHCG), and lactate dehydrogenase were within normal limits. We performed puncture of the cystic area, and the aspirated brown fluid was analyzed cytologically. Although there was no apparent evidence of malignancy in cytology, malignant potential was not ruled out completely. Since the patient consented to complete resection, transinguinal radical orchiectomy was performed. There were no specific findings including adhesion to surrounding tissue or intraoperative complications, and the patient recovered without any postoperative event. In addition, neither apparent recurrence nor metastasis was observed at 7 years after surgery.\n\nThe surgically resected specimen revealed a 10 cm multilocular cystic tumor with solid component. The solid area was tan-brown in color without hemorrhage or necrosis. Histologically, tumor cells proliferate in sheets, containing scant cytoplasm and oval- or round-shaped hyperchromatic nuclei with nuclear grooving. Cysts lined with flat cells were observed, and other cystic architectures lined with cuboidal or columnar epithelium were found. Small nests of tumor cells with clear cytoplasm were seen. In addition, tumor cells with eosinophilic cytoplasm similar with those of Leydig cells were seen in part. No apparent invasion into albuginea was found. Populations of the tumor cells were classified into three groups as follows: tumor cells with scanty cytoplasm and grooved nuclei (adult-type granulosa cell tumor-like appearance), tumor cells with eosinophilic cytoplasm (Leydig cell tumor-like appearance), and tumor cells with clear to slightly eosinophilic cytoplasm (Sertoli cell tumor-like appearance). Results of immunohistochemical staining are summarized in Table 2. All subtypes of tumor cells were positive for alpha-inhibin, calretinin, CD99, melan A, and vimentin, whereas all were negative for EmA. Tumor cells with scanty cytoplasm and grooved nuclei were positive for CD56, which is consistent with adult-type granulosa cell tumor component. In addition, tumor cells with eosinophilic cytoplasm were positive for synaptophysin, suggesting a Leydig cell tumor component. Distinct nuclear staining of beta-catenin was observed in tumor cells with clear to slightly eosinophilic cytoplasm, which suggested a Sertoli cell tumor component. Based on these pathological findings, the patient was diagnosed with mixed sex cord stromal tumor consisting of adult-type granulose cell tumor, Leydig cell tumor, and Sertoli cell tumor components.",
    "summary": "A 76-year-old Japanese male visited our hospital complaining of left scrotal swelling. Magnetic resonance imaging of the mass showed a multilocular cystic pattern with different degrees of intensities in each cyst. The solid component was observed in part showing hypointensity on the T2-weighted image. Although there was no apparent evidence of malignancy in cytology of punctured fluid of the cystic tumor, malignant potential was not ruled out completely. Therefore, transinguinal radical orchiectomy was performed, and the tumor was diagnosed as mixed sex cord stromal tumor consisting of adult-type granulosa cell tumor, Leydig cell tumor and Sertoli cell tumor components. The patient recovered without any postoperative event. In addition, neither apparent recurrence nor metastasis was observed at 7 years after surgery."
  },
  {
    "id": "multiclinsum_gs_en_135.txt",
    "fulltext": "19-year-old male with multiple consultations for a three-month history characterised by fatigue, abdominal pain in the right hypochondrium, of a dull character, moderate intensity and intermittent, associated with a holocranial oppressive headache and dark urine.\n\nHe was seen in the emergency department and had a blood pressure of 117/65 mmHg, heart rate of 62 beats per minute, respiratory rate of 12 breaths per minute, temperature of 36.4 °C, weight of 60 kg, urine output of 0.6 ml/kg/hour in the last 6 hours, mild jaundice and diffuse abdominal pain without signs of peritoneal irritation or hypovolemia.\n\nHe was admitted for study and treatment for suspected thrombotic thrombocytopaenic purpura (TTP, PLASMIC score 4 points). He received 2,000 ml of 0.9% saline solution in the first 24 hours with an increase in the urine flow rate to 1.3 ml/kg/hour, plasmapheresis (PLEX) and dexamethasone 20 mg/day intravenous (IV).\n\nThe initial study did not identify schistocytes in the smear, the Coombs test was negative and no haptoglobin measurement was available. Asymptomatic severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) was detected.\n\nBloodstream infection (BSI), Lactate dehydrogenase (LDH), Plasmapheresis (PLEX), Erythrocyte sedimentation rate (ESR), + 2 months prior to admission, *24 hours after completion of the third PLEX.\n\nThe remaining study was negative or normal for: ADAMTS 13 (activity 140%, reference >40%, vWF metalloproteinase activity not available), vitamin B12 (265 pg/ml, reference 197–771 pg/ml), cocaine, HIV Elisa, HBsAg, anti-HCV antibodies (AC), IgM and IgG for Epstein Barr and Cytomegalovirus, C3 (92 mg/dl, reference 90-180 mg/dl), C4 (32 mg/dl, reference 10-40 mg/dl), antinuclear AC, anti-DNA ds AC, lupus anticoagulant, anti-cardiolipin AC, anti β2-glycoprotein AC, light chains in blood, blood and urine electrophoresis and immunofixation.\n\nComputed tomography of the chest, abdomen and pelvis with contrast ruled out thrombosis, neoplasia, visceromegaly and lymphadenopathy.\n\nRenal biopsy showed extensive evidence of acute tubular damage associated with abundant hemosiderin pigment. The myelogram showed a plasma cell count of 4%, with no other series affected, and the bone marrow biopsy showed severe hypocellularity with no marrow infiltration.\n\nThe flow cytometry and immunophenotype for HPN were consistent and identified clonality in erythrocytes (56.12%) and granulocytes (84.31%). A study with fluorescein-labelled proaerolysin was not available.\n\nThe follow-up study ruled out PTT with PLEX discontinued on day 3. Dexamethasone 20 mg/day IV was administered for 6 days, then prednisone 60 mg/day orally. She recovered with a rise in platelet count.\n\nOn day 18 of hospitalization, he developed a bloodstream infection (BSI) associated with a catheter for S. aureus multisensible treated 14 days with Cefazolina 2 g every 8 hours IV. During this period he presented anaemia and thrombocytopenia, without requiring transfusion of blood products.\n\nFollowing this episode, anticoagulation was initiated with oral rivaroxaban 15 mg every 12 hours, prednisone was adjusted to 40 mg/day orally, oral iron and folic acid were supplemented, and hepatitis B, pneumococcal, meningococcal and influenza vaccines were administered.\n\nHe has evolved with complete recovery of pancytopenia and ARF. He is currently asymptomatic, receiving oral anticoagulant treatment, without corticosteroids and awaiting to start complement inhibitor requested since the hospitalization.\n",
    "summary": "We present the case of a 19-year-old man with multiple emergency room visits for fatigue, abdominal pain, and intermittent dark urine. On admission, pancytopenia with elements suggestive of hemolysis and acute renal injury was noted. Thrombotic thrombocytopaenic purpura was suspected and was treated with dexamethasone and plasma exchange. The complementary study ruled out this suspicion and plasma exchange was discontinued. The renal biopsy revealed acute renal injury compatible with paroxysmal nocturnal haemoglobinuria (PNH) and the bone marrow biopsy excluded medullar infiltration. The diagnosis of PNH was confirmed by flow cytometry. He was treated with prednisone, anticoagulation, iron supplementation, and folic acid. He had a favorable clinical and laboratory response.\n"
  },
  {
    "id": "multiclinsum_gs_en_550.txt",
    "fulltext": "A middle‐aged woman underwent a routine mammogram in 2018, revealing a consolidation in the left breast. A quadrantectomy was performed, and histopathology showed inflammatory infiltrates with foamy histiocytes but no malignancy. The patient remained asymptomatic until 2021, when she developed fever unresponsive to antibiotics. Imaging identified a basal consolidation in the right lung, and a surgical biopsy revealed granulomatous inflammation and foamy histiocytes. A similar consolidation appeared in the left lung months later, leading to a bronchoscopy with transbronchial biopsy, confirming a similar histologic pattern. Laboratory tests showed significant inflammation (C‐reactive protein > 80 mg/L, fibrinogen > 800 mg/dL) but negative autoantibodies, including antineutrophil cytoplasmic antibodies (ANCAs).\n\nThe patient was initially treated with prednisone (50 mg/day), leading to temporary symptom relief. A concurrent thyroid ultrasound identified a 23‐mm hypoechoic nodule, and fine‐needle aspiration confirmed granulomatous inflammation with histiocytic clusters. The presence of foamy histiocytes across multiple organs prompted consideration of Erdheim–Chester disease (ECD), supported by positive CD68 staining. However, the absence of the BRAF V600E mutation made her ineligible for targeted therapy. Instead, pegylated alpha‐interferon was initiated, but within a few months, the patient developed new symptoms, including polyarthralgia, persistent fever, and purpuric lesions. A skin biopsy showed leukocytoclastic vasculitis, initially attributed to interferon‐induced drug reaction, which led to therapy discontinuation. Treatment with cyclosporine (200 mg/day) and methotrexate (15 mg/wk) was started, aiming at targeting possible pathogenic mechanisms underlying granulomatous lesions. By 2023, the patient experienced persistent inflammation and ongoing systemic symptoms, such as fever and fatigue, while autoimmune tests remained negative. In the following months, she developed epistaxis and haemoptysis. A high‐resolution computed tomography (CT) scan showed multiple pseudonodular consolidations in her lungs, and a new biopsy confirmed granulomatous inflammation. Given the evolving clinical picture, ANCA testing was repeated, revealing high PR3‐ANCA titer (67 IU/mL; positive threshold > 3 IU/mL). These findings led to a revised diagnosis of mass‐forming GPA.\n\nDifferential diagnosis\nThe presence of foamy histiocytes was a key diagnostic challenge because these cells can be observed in ECD, Rosai–Dorfman disease, Langerhans cell histiocytosis, Whipple disease, and certain mycobacterial infections. Extensive microbiological testing was negative, and histopathological review ruled out ECD, leading to an interim diagnosis of “granulomatous disease not otherwise specified.” Re‐evaluation of the initial breast biopsy confirmed chronic inflammation with necrotizing granulomas and foamy histiocytes. Additional histochemical analysis excluded Langerhans cell histiocytosis (negative CD1a and S100 staining) and malakoplakia (absence of Michaelis–Gutmann bodies). Given persistent systemic inflammation, emerging pulmonary nodules, and ear–nose–throat involvement, repeat ANCA testing confirmed PR3‐ANCA positivity, solidifying the diagnosis of GPA.\n\nManagement and outcome\nRituximab induction therapy (two doses of 1 g each, two weeks apart) was initiated, followed by maintenance per MAINRITSAN protocol.  Cyclosporine was discontinued, methotrexate was continued, and steroids were tapered off within a year. The patient achieved clinical remission with sustained resolution of symptoms, declining ANCA titer and normalization of markers of inflammation at the last follow‐up in 2024.",
    "summary": "A middle-aged woman presented with a granulomatous breast lesion in 2018. By 2021, antibiotic-resistant pneumonia led to the discovery of granulomatous inflammation in the lung and thyroid. Initially misdiagnosed as Erdheim-Chester disease (ECD), she was treated with interferon without success. Histopathology later ruled out ECD, suggesting an unspecified granulomatous disease, with granulomatosis with polyangiitis (GPA) initially excluded due to negative antineutrophil cytoplasmic antibodies (ANCAs) and foamy histiocytes. In 2023, repeated lung biopsy and PR3-ANCA positivity led to a revised diagnosis of mass-forming GPA. Rituximab therapy resulted in remission."
  },
  {
    "id": "multiclinsum_gs_en_53.txt",
    "fulltext": "59-year-old man with a history of high blood pressure and active smoking. Consultation in the Primary Care Emergency Service for a 45-minute picture of oppressive chest pain radiating to the epigastrium and back associated with neurovegetative symptoms, paresis and paresthesia of the lower extremities (EEII). The ECG shows elevation of the ST segment in the anterior and inferior wall. The infarction network is activated and is referred to a hospital with a haemodynamic service for primary angioplasty, entering the ward 3 hours after the picture began.\n\n6Fr radial sheath puncture was performed. Coronary catheters were advanced and injected into the ostium of the right coronary artery (RCA). The aortogram showed a suggestive image of a compressive hematoma and possible aortic dissection. Computed tomographic angiography (CT angiography) of the aorta was performed and showed a flap of dissection in the ascending aorta, consistent with a Stanford classification type A aortic dissection with intramural hematoma extending to the RCA and left coronary trunk (LCT) to the anterior descending artery (ADA). Aortic root replacement was performed with a 18 mm Dacron tube plus a single bridge with the saphenous vein reversed to the RCA.\n\nIn the immediate post-operative examinations, total CK of 310 U/L (normal value VN: 0-308 U/L) and CK MB of 52 U/L (VN: 0-25 U/L) were noted. He had a complex evolution with polytransfusion and high requirements of vasoactive drugs (VAD), with evidence of cardiac tamponade, requiring a surgical re-examination in which the drain was removed, the dose of the VAD was reduced until it was discontinued and extubation was achieved. The neurological evaluation confirmed a medullar syndrome with motor disorder of the type flaccid paraplegia of the lower limbs with neurogenic bladder and intestinal disorder. The nuclear magnetic resonance of the cervical and dorsal column concluded extensive medullar injury from T7 to the medullar cone. After 31 days of hospitalization, he was transferred to a rehabilitation hospital from which he was discharged. He is currently a cardiovascular asymptomatic patient, retired due to disability.\n",
    "summary": "We present the case of a 59-year-old man who presented with chest pain and an electrocardiogram with inferior and anterior ST segment elevation, referred to primary angioplasty and in the angiographic study, ostial compromise of coronary arteries was identified, aortic dissection was suspected, confirmed by computed tomography of the aorta, where an ascending aortic dissection with compromise of both coronary ostia was evident and was treated surgically.\n"
  },
  {
    "id": "multiclinsum_gs_en_409.txt",
    "fulltext": "A 28-year-old Asian woman was admitted to the hospital for the treatment of “a pelvic mass for 10 months” on November 11, 2018. The patient usually had regular menstruation, moderate menstrual volume, dysmenorrhea, and a G1P0L0A1. Gynecological examination: The rear of the uterus was approximately 8 cm in diameter with poor activity and tenderness, but no other abnormalities were noted. The patient had no obvious cause of abdominal pain during the first 10 months prior to admission. Ultrasound examination revealed a heterogeneous mass on the upper right side of the uterus with a diameter of approximately 4 cm, nodule of the greater omentum with a diameter of approximately 2 cm, and serum CA125 level of 416 mU/mL. Is it diagnosed as “endometriosis? Inflammatory Pelvic Masses”. Anti-infective rehydration therapy was administered and the patient was discharged with pain relief. Two weeks after discharge, the patient’s CA125 level decreased to 106 mU/mL and returned to normal after 6 weeks. However, the pelvic mass gradually increased. Re-examination of pelvic ultrasound performed showed a 7.7 cm × 7.4 cm × 8.2 cm mixed echoic mass on the right side of the uterus with clear boundary, fine punctate echo in the cyst, and abdominal and pelvic effusion. Contrast-enhanced ultrasonography showed that the cyst wall of the pelvic mass was significantly enhanced, malignancy was suspected, and surgical treatment was recommended. On November 14, 2018, the patient underwent transabdominal pelvic and intestinal adhesion release, omental, bilateral ovarian, peritoneal multipoint, and multiple adenomyomas, and hysteroplasty. During the operation, approximately 600 mL of hemorrhagic ascites were aspirated. Upon exploration, a gray-red mass with a diameter of approximately 8 cm was observed on the surface of the greater omentum, which was soft and resembled rotten meat. Diffuse “moss like” brown cellulose deposits were found on the surface of the uterus, bilateral adnexa, abdominal wall, intestinal tract, lateral groove of the rectum, and anterior wall of the rectum. The lesions were not completely cleared and some areas were electrocoagulated. Pathological examination of the resected specimen showed retinal tissue endometriosis with vasodilation, blisters, scattered and focal lymphocytic infiltration, bilateral ovarian cystic follicles, peritoneal fibers inside adipose tissue necrosis, fibroblast proliferation, increased foam cell infiltration, and uterine adenomyoma. Ascites pathology showed many red blood cells, a small number of small lymphocytes and neutrophils, and no tumor cells. Postoperatively, the patient recovered smoothly, and was treated with gonadotropin-releasing hormone agonist (GnRH-α). Leuprorelin was started once a month for 6 months, followed by oral dienogest (DNG) for 3 years, after which the medication was stopped for 3 months. The patient conceived naturally and had normal pregnancy. A baby boy weighing 3300 g was delivered via vaginal discharge at 39 + 3 weeks of gestation. Both the mothers and babies were healthy, with no recurrence or adverse reactions during follow-up.",
    "summary": "Patient concerns: A 28-year-old female came to our hospital for treatment because of the discovery of a pelvic mass for 10 months. After admission, the patient underwent surgical treatment and was discharged within 1 week. She received medical treatment for 3 years after discharge. After medication withdrawal, the patient became pregnant and gave birth to a child without recurrence during the follow-up.\n\nDiagnoses: Initial diagnosis on first admission were \"'Pelvic inflammatory mass?' and 'endometriosis?'.\" After 10 months, the patient was readmitted to the hospital because of gradual enlargement of the mass, and was diagnosed with endometriosis.\n\nInterventions: The patient was treated with anti-infective rehydration therapy for the first time, and the patient was surgically treated for the second time, followed by gonadotropin-releasing hormone agonist (GnRH-α) and dienogest (DNG) treatment after surgery.\n\nOutcomes: After 6 cycles of GnRH-α treatment and 3 years of DNG treatment, a son was successfully born after discontinuation of the medication, and so far, there has been no recurrence or adverse reactions during the follow-up period."
  },
  {
    "id": "multiclinsum_gs_en_295.txt",
    "fulltext": "A 59-year-old G4P4 postmenopausal woman had undergone renal transplantation in 2007. Her comorbidities included obesity (body mass index: 33.9 kg/m2), hypertension, and type 2 diabetes mellitus. Additionally, she had a history of two-vessel coronary artery disease, severe mitral regurgitation (MR), and moderate tricuspid regurgitation (TR), for which she had received surgical treatment. She was regularly taking aspirin, candesartan, carvedilol, everolimus (as of 2011), methylprednisolone, cyclosporine, and mycophenolate sodium. Her gynecological history included a thickened endometrium (0.89 cm), which was noted in 2012, but she denied postmenopausal bleeding. During a routine cancer screening in 2016, elevated level of serum CA-125 (258.0 U/mL; reference range: ≤35 U/mL) was identified, and subsequently confirmed by serial measurements. The endometrial thickness had increased to 1.34 cm and hysteroscopy revealed an endometrial tumor, which was successfully removed by transcervical resection. Pathological examination revealed a high-grade USC, which was immunologically positive for p53, p16, and estrogen/progesterone receptors.\n\nPreoperative echocardiography revealed mild MR and TR, with a left ventricular ejection fraction (LVEF) of 48% (New York Heart Association [NYHA] functional class II. Several episodes of transient hypotension (blood pressure: 64/40 mmHg) were observed intraoperatively. Total hysterectomy with bilateral salpingo-oophorectomy was performed. Final pathology revealed no residual tumor. However, cytology of the ascitic fluid revealed clusters of malignant cells. TP53 p.C277F and BUC1B p.R550* were later detected in a genetic test with copy number loss of MRE11A, ATM, CHEK1, BLM, TP53, FLCN, and NF1.\n\nAfter the surgery, the patient was transferred to the intensive care unit (ICU), where she developed lethargy, dyspnea with shallow breathing (15–17/min), and oliguria. On the second postoperative day, she was febrile (38.3 °C) and her central venous pressure (CVP) was 26 mmHg. Laboratory analyses showed mild normocytic anemia (hemoglobin: 11.4 g/dL), increased serum creatinine (1.73 mg/dL), hypercapnia, and pyuria. Chest X-ray revealed pulmonary edema. Electrocardiogram revealed atrial fibrillation with rapid ventricular response and occasional premature ventricular contractions. Global hypokinesia with LVEF of 41% was evident on echocardiography; the blood pressure dropped to 80/50 mmHg and the patient was diagnosed with cardiogenic shock.\n\nIn view of the complex history, a multidisciplinary approach was implemented for her care. The cardiac surgeon prescribed norepinephrine and amiodarone for hypotension and tachycardia. Antibiotic therapy with meropenem and teicoplanin was started according to the nephrologist's suggestion, whereas oliguria and elevated CVP were treated with furosemide (40 mg/day). Bi-level positive airway pressure followed by oxygen via nasal cannula (3 L/min) was used to treat dyspnea. In the following days, the blood pressure improved and norepinephrine was tapered off. Serum creatinine gradually returned to normal values.\n\nAfter a week, the acute cardiogenic shock had resolved and the patient was transferred to the gynecological ward. During her stay, fluid overload, persistent dyspnea, and pedal edema were observed. A cardiologist was consulted for the decompensated heart failure with pulmonary edema. Follow-up echocardiography revealed biventricular systolic failure (LVEF = 31%), moderate MR and TR, and pulmonary hypertension (estimated systolic pulmonary artery pressure = 111 mmHg). Therefore, the dosage of furosemide was increased to 80 mg/day, and candesartan and spironolactone were added. Water and salt restriction was strictly enforced. Thereafter, a favorable response was noted in terms of gradual resolution of pedal edema and dyspnea along with increased urine output. Postoperatively, the patient lost 6 kg in body weight and was discharged 48 days later. Home oxygenation was required to prevent oxygen desaturation. A follow-up chest X-ray performed a month after she was discharged confirmed improvement of pulmonary edema. Based on the genetic tests, everolimus, an immunosuppressant, was also used as anticancer therapy for her copy number loss of FLCN and NF1. Letrozole was prescribed for the positive estrogen and progesterone receptors.",
    "summary": "An asymptomatic 59-year-old woman who had undergone renal transplantation presented with elevated serum CA-125 levels. Cancer screening revealed uterine serous carcinoma, for which she underwent total hysterectomy and bilateral salpingo-oophorectomy. Unfortunately, the postoperative course was complicated by cardiogenic shock and decompensated heart failure. The complexities of the cardiac problems and renal transplantation required a multidisciplinary approach involving different specialists. She was successfully discharged 48 days after the surgery."
  },
  {
    "id": "multiclinsum_gs_en_379.txt",
    "fulltext": "32-year-old male with a history of HIV infection on antiretroviral therapy (undetectable viral load and CD4 count of 454 cells/mm3) and smoking and drug use (marijuana, ecstasy and ketamine). He presented to our sexual health unit with a 2-week history of mucous urethral discharge with little local burning, associated with an erythematous indurated ulcer in the balanopreputial sulcus 1.5 cm in diameter, painful and exudative. On physical examination, he had a 2 cm left inguinal lymph node, sensitive to palpation, soft, not adherent to deep tissue and not associated with inflammatory skin signs. He had no fever or other associated symptoms. In the directed history, he reported 20 male sexual partners in the last year, with insertive and receptive oral and anal sex, with occasional use of condoms. He had no history of travel outside Chile. Four weeks before the onset of symptoms, he had had a risky sexual contact without condom with a partner contacted through a mobile phone application. With the presumptive diagnosis of a primary syphilis and urethral infection under study, blood and urethral discharge samples were taken for microbiological study. Because of the high-risk sexual behaviour, an anorectal swab was also taken for Gram staining and culture. According to the current regulations in Chile, three doses of 2.4 million IU of benzathine penicillin were administered intramuscularly at weekly intervals, in addition to 250 mg of intramuscular ceftriaxone and 1 g of oral azithromycin, both for once. The laboratory study confirmed the diagnosis of syphilis, with a VDRL (venereal disease research laboratory) reactive with a 1:2 dilution and MHA-TP (microhaemagglutination assay for antibody to Treponema pallidum) reactive. Gram staining and urethral discharge cultures (blood agar and Thayer Martin) were negative. The anorectal swab showed few Gram-negative diplococci in Gram staining, with abundant development of N. meningitidis and commensal microbiota in the current culture. The bacterial identification was performed through MALDI-TOF MS spectrometry. The patient had a favourable evolution, with no urethral discharge and with regression of the genital ulcer lesion and inguinal lymph node at two weeks of follow-up. Gram staining and control cultures of urethral, pharyngeal and anorectal discharge were negative. The recent sexual contact was referred for study and treatment. However, he was asymptomatic and the pharyngeal, anorectal and urethral cultures were negative.\n",
    "summary": "We present the case of a MSM with HIV infection who presented with a urethritis and primary syphilis, in which N. meningitidis was isolated in an anorectal sample. He was treated empirically with ceftriaxone and azithromycin, and a post-treatment culture was negative.\n"
  },
  {
    "id": "multiclinsum_gs_en_247.txt",
    "fulltext": "The patient was a female, 73 years old, admitted to hospital owing to dizziness and fatigue with shortness of breath for 3 hours. Three hours before admission, the patient began to show symptoms including dizziness, fatigue, shortness of breath, vomiting stomach contents once, acid reflux, and heartburn. The patient was exposed to indoor stove heating during the onset, with poor ventilation. The other occupants of the same room showed identical symptoms and attended the emergency department of the hospital. This patient had a history of hypertension for 12 years with systolic blood pressure up to 170 mmHg and no specified diastolic pressure record. The patient routinely takes Norvasc to control her blood pressure when it is 130/80 mmHg. The patient has had diabetes for 14 years. Metformin is regularly used for treatment. Before-meal blood glucose was controlled at 7 mmol/L, and postprandial blood glucose was not monitored. Physical examination: blood pressure 120/80 mmHg, conscious, precise speech, shortness of breath, respiratory frequency at 30 beats per minute, pupils equal and equally reactive to light, rough breath sounds in bilateral lungs, audible wet and dry rales, heart rate 110 beats/minute, arrhythmia, class 4 limb muscle strength, normal muscle tone. Emergent examination showed carboxyhemoglobin 17%, electrocardiogram with the wild range ST-segment depression, emergent cardiac troponin I (CTNI) 4.75 ng/mL, creatine kinase MB (CKMB) 1494 ng/mL, monitored oxygen saturation 90%. After giving oxygen via oxygen mask (oxygen flow 10L/min), emergent blood analysis showed: lactic acid 8.7 mmol/L, pH 7.196, partial pressure of carbon dioxide 34.6 mmHg, partial pressure of oxygen 82.4 mmHg, oxygen saturation 93.5%, actual bicarbonate 13.5 mmol/L, blood glucose 22.89 mmol/L, urine ketone bodies (–). Chest radiography suggested pulmonary edema. According to the above characteristics, the patient was diagnosed with acute carbon monoxide poisoning (ACOP), acute coronary syndrome, acute left heart failure, lactic acidosis, high-risk grade 3 hypertension, and type II diabetes. The patient was admitted as an inpatient for further treatment.\n\nAfter admission, the re-examination results showed that myocardial enzymes CKMB and CTNI were becoming progressively elevated. Twenty-four hours after the onset, CTNI had increased to 69.42 ng/mL, and brain natriuretic peptide had reached 1113 pg/mL. The echocardiography results indicated segmental wall motion abnormalities (reduced amplitude of motion of lower left ventricular wall, and posterior wall basal and apical segments), reduced left ventricular function, and ejection fraction 50%. The patient was diagnosed with NSTEMI and acute left heart failure. She was treated with a high concentration of oxygen, an inhibitor of platelet aggregation (aspirin plus clopidogrel), an anticoagulant (low molecular weight heparin), an antimicrobial (ceftizoxime), an expectorant (mucosolvan), diuresis (furosemide and spironolactone), and myocardial support (Metoprolol). On the second day after the onset, the wheezing symptoms began to be relieved, and troponin I decreased to 39 ng/mL with a continuous decrease afterward. After 8 days, the CTNI had decreased to 0.2 ng/mL, and symptoms of wheezing, dizziness, and fatigue were relieved. The patient was transferred to the department of cardiology to undergo coronary arteriography. The result indicated that the coronary blood supply was right dominant. The right canal opening had developed normally, as had the left coronary opening. The left main coronary artery showed 50% localized stenosis, and the thrombolysis in myocardial infarction (TIMI) blood flow was grade III. In the near-middle segment of the left anterior descending artery, 80% diffuse stenosis was observed, and the TIMI flow was grade III. A 90% stenosis was seen in the opening-near segment of the diagonal branch 1, with grade III flow in the TIMI. The obtuse marginal branch I showed 90% localized stenosis with a TIMI grade III . An 80% localized stenosis was observed at the right main coronary artery opening, and 70% diffuse stenosis was observed in the proximal right coronary artery. A 70% to 95% diffuse stenosis was seen in the right and middle right coronary arteries, with a grade III TIMI. The conclusion from angiography was: Coronary heart disease in the left main artery + 3 branch lesions (afflicting the left anterior descending artery + left circumflex + right coronary artery).\n\nDuring the surgical operation, the right coronary artery was treated and 3 stents were implanted. The rest of the blood vessels were not treated temporarily. On the 10th day after onset of the condition, echocardiography was performed, which showed that cardiac function was improved. Mild segmental wall motion abnormality was observed on echocardiography. After 14 days, the patient had recovered well and was discharged without chest tightness, chest pain, dizziness, headache, or unresponsiveness.",
    "summary": "Patient concerns:\nA 73-year-old woman complained of dizziness and fatigue with shortness of breath after carbon monoxide intoxication.\n\nDiagnoses:\nThis patient had a clear history of carbon monoxide poisoning, acute respiratory distress, bilateral lung dry and moist rale, chest X-ray showed bilateral pulmonary edema, Electrocardiograph indicated general depression of the ST segment of the leads in the chest, cardiac troponin I (CTNI) increased progressively, cardiac ultrasonography indicated abnormal ventricular wall movement, coronary angiography suggested left main trunk and 3-vessel lesions, suggesting diagnosis acute carbon monoxide poisoning, acute coronary syndrome, acute left heart failure.\n\nInterventions:\nShe was treated with a high concentration of oxygen, an inhibitor of platelet aggregation (aspirin plus clopidogrel), an anticoagulant (low molecular weight heparin), an antimicrobial (ceftizoxime), an expectorant (mucosolvan), diuresis (furosemide and spironolactone), and myocardial support (Metoprolol). Coronary angiography and stent placement were performed 8 days later.\n\nOutcome:\nOn the 10th day after onset of the condition, echocardiography was performed, which showed that cardiac function was improved. Mild segmental wall motion abnormality was observed on echocardiography. After 14 days, the patient had recovered well and was discharged without chest tightness, chest pain, dizziness, headache, or unresponsiveness."
  },
  {
    "id": "multiclinsum_gs_en_290.txt",
    "fulltext": "A 61-year-old female patient with a history of acute pulmonary thromboembolism secondary to a right pelvic deep vein thrombosis episode four years earlier presented. Chronic thromboembolic pulmonary hypertension (CTEPH) was diagnosed during follow-up and she was treated with oral anticoagulation with vitamin K antagonists (VKA).\n\nIn the diagnostic approach, a pulmonary angiogram was performed in which bilateral peripheral thrombi were documented with a predominance in the right main branch with extension to the upper, middle and lower lobar branches, causing linear and segmental and subsegmental defects, as well as total occlusion of the left anterior, medial and posterior segmental branches. The pulmonary artery was observed dilated to 40 mm in diameter. A transthoracic echocardiogram was performed in which the dilated right ventricle (RV) was observed (basal 43 mm, middle third 51 mm and length 84 mm). Longitudinal systolic function (systolic excursion of the tricuspid annulus plane of 15 mm, speed of the tricuspid annulus S wave of 7.8 cm/s and circumferential (18% shortening fraction of the RV) reduced. Estimated pulmonary artery systolic pressure of 96 mmHg and flattening of the interventricular septum.\n\nTo complete the stratification, a right and left cardiac catheterization was performed with the following measurements: pulmonary artery systolic pressure (PAPs) 105 mmHg, pulmonary artery diastolic pressure (PAPd) 44 mmHg, pulmonary artery mean pressure (PAPm) 64 mmHg, pulmonary vascular resistance (RVP) 13.7 UW/1,096 dyn, D2VI 11 mmHg. Selective pulmonary angiography was performed, which showed filling defects in both main branches of the pulmonary artery, as well as subocclusive lesions in the left and right subsegmental arteries that were amenable to surgical treatment.\n\nThe case was discussed with the surgical team and the patient was proposed as a candidate for surgical treatment.\n\nBoth pulmonary thromboendarterectomies were performed in a planned fashion with a total time of cardiopulmonary bypass of 149 minutes and two hypothermic arrest times of 17 and 15 minutes. The pulmonary artery and its main branches and lobar branches were examined and thromboendarterectomy was performed.\n\nShe was transferred to the intensive cardiovascular care unit after surgery, where she was hypotensive with evidence of systemic hypoperfusion and mechanical ventilation with an inspired oxygen fraction (O2) of 100% to achieve an oxygen saturation (O2) of 90%. The hemodynamic profile by pulmonary floating catheter in cardiogenic shock (cardiac output [CO] of 1.97 l/min, IC of 1.13 l/min/m2, PAPs of 95 mmHg, PAPd of 54 mmHg, PAPm of 65 mmHg, PVC of 10 mmHg, IS of 14.1 ml/m2, SVR of 1191 dyn), was initiated with inotropic (levosimendan) and dual vasopressor (norepinephrine and vasopressin) therapy, which was titrated to the maximum therapeutic dose. Despite the therapy used, six hours after surgery the patient was still in cardiogenic shock and refractory hypoxaemia despite having high mechanical ventilation parameters, including FiO2 of 100%. Diffuse bilateral radiopaque infiltrates were observed on the chest radiograph. Based on the evidence consistent with pulmonary reperfusion syndrome with PaO2/O2 of 80, it was decided to escalate the treatment and support was added with an extracorporeal membrane oxygenation (ECMO) by right femoral vein cannulation, through which the extraction cannula was advanced to the inferior caval-atrial junction and a return cannula was advanced to the superior caval-atrial junction. Once circulatory support was established, the flow was titrated to 3 l/min.\n\nCirculatory support was provided with adequate evolution, with haemodynamic stabilisation, and the amines and inotropics were removed in the first 12 hours, as well as the pulmonary congestion was reduced and extubation was achieved in the first 48 hours. As for the biventricular function, with progressive improvement (until achieving LVEF of 40%, integral time speed 16 cm, lateral mitral speed «s» 9 cm/s and right ventricular shortening fraction of 35%), without complications related to ECMO, the therapy was successfully suspended after six days, and the radiography of control after withdrawal of ECMO with a reduction in the pattern of bilateral infiltrates.\n\nHe was then transferred to the cardiology floor, where a new pulmonary angiogram was performed, reporting no new pulmonary thromboembolic event, so oral anticoagulation was initiated with acenocoumarol, reaching an international normalized ratio of 2.5. He was discharged home without complications.\n",
    "summary": "We present the case of a 61-year-old patient with a history of acute pulmonary thromboembolism secondary to deep vein thrombosis of the right pelvic limb who was diagnosed with HPTC during follow-up and was admitted on a scheduled basis for surgical treatment with bilateral TEAP, however, during the immediate post-surgical period she presented cardiogenic shock and refractory hypoxemia secondary to pulmonary reperfusion syndrome, for which she required circulatory support with veno-venous ECMO for six days, with resolution of the pulmonary condition and clinical improvement.\n"
  },
  {
    "id": "multiclinsum_gs_en_416.txt",
    "fulltext": "62-year-old male with a history of diabetes mellitus with poor metabolic control and hypertension. About 15 days before the consultation he presented isolated febrile episodes that then became daily and 24 hours before his consultation he presented neck stiffness and altered consciousness. On admission he was febrile, confused and disoriented in time and space. On physical examination he presented neck stiffness with positive Kernig and Brudzinski signs. In the laboratory examinations there was a glycaemia of 584 mg/dL, haematocrit 36.8%, leukocyte count 19,600 ml/uL, platelet count 74,000/µL, creatinemia 1.94 ml/dL, total bilirubin 0.9 mg/dL and transaminases within normal parameters. A brain axial tomography was performed that did not show abscesses or other lesions. The abdominal tomography showed a collection in the segments V and VIII of the liver. A lumbar puncture was performed, from which a purulent CSF was obtained. It was not possible to perform cell counting of the sample, but Gram staining showed abundant leukocytes and Gram negative bacilli. The liquid presented proteinorraquia of 3480 mg/dL and glucorraquia of 34 mg/dL for a plasma glycaemia of 584 mg/dL. A test was requested by immunochromatography for HIV that was negative. The patient initiated antimicrobial treatment with ceftriaxone and ampicillin. After 72 hours, given the findings, treatment continued with 2g of ceftriaxone every 12 hours. In addition, he received 3 days of dexamethasone. Both in the blood and urine cultures and in the cerebrospinal fluid K. pneumoniae was identified (by biochemical tests) sensitive to ampicillin-sulbactam, ceftriaxone, amikacin, gentamicin and ciprofloxacin, with only resistance to ampicillin (intrinsic resistance). The antibiogram was performed by diffusion (Kirby Bauer method) in Mueller Hinton agar using the cut-off points of the Clinical and Laboratory Standards Institute (CLSI) 2023 for the interpretation of the category of the antibiotics reported. Gram staining and culture of this abscess were also negative, since it was performed when the patient had been on antibiotic treatment for 5 days. An ophthalmological evaluation was performed, ruling out endophthalmitis. After 72 hours the patient persisted with intense dorsal pain and stiff neck, which prevented him from moving and sitting. In the neurological examination, brachio-crural right paresis was evident, without sensory disorders. A new lumbar puncture was performed that presented hyperproteinorraquia, hypoglycorraquia and in the culture K. pneumoniae was isolated again, with the same profile of antibiotic sensitivity. In addition, a new abdominal tomography showed resolution of the hepatic collection. A new resonance of the brain was performed that ruled out the presence of collections, as well as ischemic lesions. The resonance of the spine showed an increase in the signal in the central region of the spinal cord (from D2 to D7) compatible with myelitis, associated with diffuse meningeal enhancement at the dorsal level and post-contrast enhancement of the filum terminale, of isolated roots of the cauda equina and of the sacro-coccygeal. In the electromyogram, radicular compromise was evident at the metamere L4 to S1 level on the right side with a slight denervating activity and probable degeneration, secondary to the popliteal sciatic nerve. Given the evolution, the findings in the resonance and in the electromyogram and the presumptive diagnosis of hypertrophic pachymeningitis post infection, it was decided to initiate treatment with methylprednisolone 1g for 5 consecutive days. He completed 28 days of antibiotic treatment with ceftriaxone and, after the treatment with methylprednisolone, he evolved favourably. At the time of discharge from the hospital, the right hemiparesis was in improvement with a mild motor deficit.\n",
    "summary": "A 62-year-old man with a history of diabetes mellitus was admitted to our center with meningeal syndrome. Gram-negative bacilli were isolated in blood cultures and cerebrospinal fluid (CSF) 24 hours after admission. They were later identified as Klebsiella pneumoniae. The presence of a hepatic abscess was identified by computed tomography. Despite early antibiotic treatment, the patient developed dorsal pain that prevented him from moving and right hemiparesis. An MRI of the spine identified increased signal in the central region of the spinal cord consistent with myelitis, for which he received treatment with methylprednisolone 1 g/day for 5 consecutive days. The patient developed favourably.\n"
  },
  {
    "id": "multiclinsum_gs_en_335.txt",
    "fulltext": "A 20-year-old man began to experience cough, chest pain, and mild exertional dyspnea. He was admitted to the hospital at 23 years of age with respiratory failure. He had been successfully treated for acute lymphoblastic leukemia (ALL) at 3 years of age, with chemotherapy that included a cumulative dose of cyclophosphamide of 15.6 g/m2. His ALL relapsed six years later, when he was 9-years-old, and he was the treated again with cyclophosphamide and underwent a second and complete remission. During chemotherapy for ALL, he did not experience pulmonary adverse events, including pneumonia, and chest X-ray at the time of cessation of chemotherapy at 11 years of age was normal. He was never treated with radiotherapy. Unfortunately, he was lost to follow-up for several years, until he presented to our hospital at the age of 20 years, due to a one-week history of non-productive cough.\n\nOn this most recent hospital admission, at the age of 23 years, he was in respiratory failure, and chest imaging showed pleural thickening and platythorax, or flattening of the chest with a reduction in the anteroposterior (AP) diameter, was prominent. His respiratory rate was 52/min with 75% SpO2. No respiratory infections were identified. Chest computed tomography (CT) showed diffuse infiltrates and bilateral pleural thickening. His pulmonary vital capacity was 0.56 L (13.3%) of the predicted value. No physical findings, blood tests, or family history suggested the presence of collagen or autoimmune diseases. Non-invasive positive pressure ventilation (PPV) with oxygen was commenced for respiratory failure. He developed severe dyspnea with New York Heart Association (NYHA) class IV heart failure, secondary to pulmonary fibrosis, which gradually worsened.\n\nAt 25 years of age, he died of cardiopulmonary failure, five years after the onset of respiratory symptoms. Permission for an autopsy was not obtained. It was assumed that his platythorax, or reduced AP diameter of the chest, might have been secondary to pulmonary hypoplasia with pulmonary fibrosis because the diaphragm in his chest X-ray films had been elevated. He had previously received a moderate dose of cyclophosphamide (cumulative dose, 15.6 g/m2) for the treatment of ALL. Finally, based on the clinical course and exclusion of other diseases, a clinical diagnosis was made of cyclophosphamide-related late-onset pulmonary fibrosis resulting in platythorax, or reduced AP diameter of the chest.",
    "summary": "Patient: Male, 26\n\nFinal Diagnosis: Cyclophosphamide-induced pulmonary fibrosis\n\nSymptoms: Platythorax • progressive cardiopulmonary failure\n\nMedication: Cyclophosphamide\n\nClinical Procedure: Supportive care\n\nA 20-year-old man began to experience cough, chest pain, and mild exertional dyspnea. He was admitted to the hospital at 23 years of age with respiratory failure. Chest imaging showed pleural thickening and platythorax. He had been successfully treated for acute lymphoblastic leukemia (ALL), at 3 years of age, with chemotherapy that included a cumulative dose of cyclophosphamide of 15.6 g/m2. His ALL relapsed six years later and he was the treated again with cyclophosphamide and underwent a second and complete remission. A clinical diagnosis of late-onset cyclophosphamide-induced lung disease with progressive platythorax was made on the basis of his clinical history and on imaging findings of the ratio of the AP to lateral chest wall diameter when compared with age-matched controls. Despite continued remission of his ALL, he died of progressive cardiopulmonary failure at 25 years of age."
  },
  {
    "id": "multiclinsum_gs_en_535.txt",
    "fulltext": "78-year-old male patient with a history of coronary artery disease, benign prostatic hyperplasia under medical management, diverticulosis, and severe cholangitis presented two months prior to current consultation, which was managed with a bile duct drainage by endoscopic retrograde cholangiography and the installation of a single biliary prosthesis without incident. Emergency consultation with a 24-hour history of migratory epigastric abdominal pain in the right iliac fossa associated with hyporexia and a compromised general condition. On admission, the physical examination highlighted the presence of McBurney and Rovsing signs. Laboratory tests showed elevated inflammatory parameters, with leukocytosis and left shift. Complementary imaging was performed, with a contrast-enhanced computed tomography of the abdomen and pelvis, which showed acute appendicitis, suggesting a secondary cause of obstruction of the appendicular duct by a biliary prosthesis. The patient was evaluated by the team of coloproctology and therapeutic endoscopy, who determined the endoscopic resolution of the condition after a colon preparation, antibiotic hydration, and analgesia. Colonoscopy was performed without incident the next day, reaching the cecum without incident and identifying a migrated biliary prosthesis passing through the appendicular hole. The prosthesis appeared occluded by debris. It was successfully removed with a loop.\n\nThe patient is in good general condition, with resolution of abdominal pain, afebrile, with transit to gases and decrease of inflammatory parameters in control at 48 h of the procedure. Hospital discharge is performed two days after the procedure. Controlled at two weeks, without symptoms, discharge is decided.\n",
    "summary": "We present a case of a 78-year-old patient who presented with acute appendicitis in the emergency department. Computed tomography of the abdomen and pelvis showed acute appendicitis secondary to an obstruction of the appendicular orifice by a migrated biliary stent. Successful management was achieved by removal of the stent by colonoscopy, allowing the patient to be discharged 72 hours after admission.\n"
  },
  {
    "id": "multiclinsum_gs_en_420.txt",
    "fulltext": "A 69-year-old female patient complained of progressive vision loss. Her parents were first cousins. She had been diagnosed with retinitis pigmentosa 27 years previously. The patient had been a smoker for 15 years. She had a past medical history of hyperlipidemia and hypothyroidism.\n\nUpon a comprehensive ophthalmic evaluation, the patient was found to have a best corrected visual acuity (BCVA) of counting fingers at 5’ and 3’ in the right and left eyes, respectively. Retinoscopy showed a refraction of –1.00 + 0.50×70 and –2.00 + 1.00×5 in the right and left eyes, respectively. The patient had pale optic discs with extensive deep atrophy of the central macula, epithelial pigment hyperplasia, and other areas of multifocal atrophy in the right eye. In addition, the patient had macular atrophy in the left eye. In the patient’s fundus autofluorescence (FAF) imaging, there was evidence of central hypoautofluorescence of the macula, with diffuse outward centrifugal extension from its center to its periphery.\n\nMacular optical coherence tomography (OCT) determined that the average macular thickness was 191 µM and 193 µM in the right and left eyes, respectively. Macular volume was 6.9 mm3 and 7.0 mm3 in the right and left eyes, respectively. No macular edema, cysts, or subretinal fluid was found in either eye.\n\nA visual field test revealed that the patient had mean deviations of –23.75 dB and –24.56 dB in the right and left eyes, respectively. Pattern standard deviations were +3.69 dB and +4.69 dB in the right and left eyes, respectively. The results of a full-field electroretinogram (ERG) showed a normal rod response and decreased cone response, bilaterally. For these reasons, a clinical diagnosis of STGD1 disease was made.\n\nA single pathogenic homozygous intronic variant c.5714+5G>A of the ABCA4 gene was found upon sequencing and deletion/duplication analysis using next-generation sequencing (Invitae Corporation, San Francisco, California). She had six additional variants of uncertain significance (VUS) at the CACNA1F, EYS, KCNV2, KLHL7, MKKS, and USH2A genes.",
    "summary": "A 69-year-old female patient presented to the clinic complaining of progressive vision loss. The ophthalmic evaluation was remarkable for a best corrected visual acuity of counting fingers at 5' in the right eye and 3' in the left eye. Imaging revealed deep extensive atrophy of the central macula, epithelial pigment hyperplasia, and other areas of multifocal atrophy in the right eye. Furthermore, fundus autofluorescence imaging of the macula showed central hypoautofluorescence with bilateral expansion to the periphery in both eyes. A full-field electroretinogram showed a normal rod response, with decreased cone response, bilaterally. Genetic testing was positive for a homozygous intronic mutation in the ABCA4 gene of the variant c.5714+5G>A."
  },
  {
    "id": "multiclinsum_gs_en_548.txt",
    "fulltext": "25-year-old female patient admitted to the Central Emergency Room of the Institution with a history of abdominal cramp-like pain of 48 hours duration, of high intensity, of sudden onset, following a large intake of cooked corn, located in the right half of the abdomen, not irradiated, associated with repeated episodes of nausea and vomiting of the alimentary type. The patient reported a history of abdominal pain of similar characteristics but of lower intensity during the 4 weeks prior to the consultation, which partially subsided with diet, gastroprotective medication and oral anti-spasmodics. She reported a positive catharsis 24 hours prior to the consultation and no elimination of gases in the last 12 hours.\n\nThe patient had a history of surgery including an appendectomy 10 years ago and a cesarean section 2 years ago. She had no medical history and no regular medication.\n\nOn physical examination, the patient was afebrile, normophygmic and normotensive. The abdomen was distended, symmetrical, painful to the generalized palpation, with defense at the level of the right iliac fossa, without peritoneal reaction and increased frequency and intensity of hydroaereous noises. Rectal examination and gynecological examination without particularities.\n\nThe requested complementary examinations demonstrated leukocytosis (15,000/uL) and increased PCR (1.8 mg/dL), with renal, hepatic, ionogram, amylase, and urinary sediment within normal limits. B-HCG negative.\n\nThe simple radiological examination of the abdomen demonstrated an occlusive pattern with multiple hydroaereous levels, distension of small intestine loops and absence of air in the colonic frame. The abdominal-pelvic tomographic scan with double contrast demonstrated the presence of a heterogeneous mass with contrasted reinforcement of 4 cm in diameter, located at the ileocecal level, associated with proximal distension of small intestine loops.\n\nThe patient underwent a laparoscopy which showed the presence of a tumour lesion, with a regular surface, approximately 4 cm in diameter, located at the level of the ileocecal valve and multiple locoregional small-sized adenopathies. There was no evidence of secondary lesions or intestinal perforation. It was decided to proceed with a conventional right hemicolectomy with end-to-side transverse ileal anastomosis and protective loop ileostomy.\n\nNo complications were reported during the immediate postoperative period and the patient was discharged on the 5th day postoperatively after normal intestinal function and a functioning ileostomy were observed.\n\nThe histopathological examination of the surgical piece demonstrated the presence of a hardened mass of 3 x 1 x 1 cm located at the level of the ileocecal valve, with marked stenosis of the same, seated on cecal mucosa formed by a proliferation of well-differentiated smooth muscle cells and with a low mitotic index, associated with 25 mesocolon ganglion formations with sinusoidal hyperplasia without signs of secondary disease. The immuno-histochemical analysis of the piece revealed Actin (+), CD117 (-), Ki67 1%, findings consistent with benign leiomyoma of the cecum.\n\nThe patient underwent a laparoscopy which showed the presence of a tumour lesion, with a regular surface, approximately 4 cm in diameter, located at the level of the ileocecal valve and multiple locoregional small-sized adenopathies. There was no evidence of secondary lesions or intestinal perforation. It was decided to proceed with a conventional right hemicolectomy with end-to-side transverse ileal anastomosis and protective loop ileostomy.\n",
    "summary": "We present the case of a 25-year-old woman who presented to the institution's Central Emergency Room with abdominal cramping pain of 48 hours' duration associated with vomiting and abdominal distension. A video-laparoscopic surgical approach was decided upon, in which an abdominal mass was identified at the level of the ileocecal valve. A conventional right hemicolectomy with proximal loop ileostomy was performed with good postoperative evolution. The histopathological examination of the resected piece revealed a benign leiomyoma of the cecum.\n\nResults: The patient resolved her acute abdominal condition without complications and was discharged on the 5th postoperative day.\n"
  },
  {
    "id": "multiclinsum_gs_en_161.txt",
    "fulltext": "A 27-year-old female patient, without notable medical history, was diagnosed with Graves’ disease (GD) in December 2020. The diagnosis was confirmed based on suggestive clinical signs including chronic fatigue accompanied by paroxysmal palpitations persisting for approximately 2 months. Physical examination revealed sinus tachycardia with a heart rate of 102 beats per minute, associated with exophthalmos. Biological investigations demonstrated markedly reduced Thyroid Stimulating Hormone (TSH) levels and elevated Free Thyroxine 4 (FT4) levels in laboratory tests (TSH = 0.002 mU/L, FT4 = 30.08 pmol/L). She was subsequently admitted to the endocrinology department of La Rabta Hospital in Tunis. The pre-therapeutic assessment, including liver function tests, revealed no abnormalities. Thus, she was put on propranolol and methimazole at a daily dose of 120 and 20 mg, respectively. Thirteen days post-initiation of treatment, she manifested severe pruritus along with cutaneous-mucosal jaundice. Hepatic assessment revealed cytolysis (Aspartate Transaminase (AST) = 95 U/L, Alanine Transaminase (ALT) = 117 U/L), cholestasis (Gamma-glutamyl Transpeptidase (GGT) = 103 U/L, Alkaline Phosphatase (ALP) = 759 U/L), and predominantly conjugated hyperbilirubinemia (total bilirubin/direct bilirubin = 412/400 μmol/L). Methimazole was consequently discontinued, and the patient was initiated on ursodeoxycholic acid (UDCA) at a dosage of 13 mg/kg/day, along with oral corticosteroid therapy using prednisone at a dosage of 1 mg/kg/day. She was, then, referred to the Gastroenterology Department “B” at La Rabta Hospital in Tunis for further care. The clinical course was characterized by a marked reduction in pruritus and jaundice, accompanied by a regression of cytolysis in laboratory parameters and a gradual exacerbation of cholestasis. A follow-up thyroid assessment revealed a slight increase in TSH levels alongside a decrease in FT4 levels, which remain above the laboratory’s biological reference ranges (TSH = 0.01 mU/L, FT4 = 25 pmol/L). A comprehensive etiological assessment, including viral serologies, immunological profiling, and biliary magnetic resonance imaging (Bili-MRI), yielded negative results. An associated seronegative primary biliary cholangitis was suspected at this juncture due to the persistence of cholestasis, but it was subsequently ruled out by liver biopsy. However, liver biopsy specimen demonstrated portal and periportal fibrosis, characterized by infrequent septa with portal spaces containing a lymphocytic and plasmocytic infiltrate. This infiltrate induces hepatocyte necrosis with the limiting plate forming an interface hepatitis. This histological presentation may correspond to autoimmune hepatitis or drug-induced liver injury. In collaboration with endocrinologists, the corticosteroid therapy was gradually discontinued. Hydrocortisone treatment was initiated at a dosage of 30 mg/day, and a regimen of radioactive iodine sessions commenced in February 2021. Biochemically, the progression was characterized by a transition to hypothyroidism (TSH = 3.01 mU/L, FT4 <0.42 pmol/L), requiring the initiation of hormonal substitutive treatment (Levothyroxine) at a daily dose of 75 µg. Cholestatic parameters remained stable over a 12-month period, followed by a gradual regression, ultimately leading to the liver tests complete normalization by January 2023.",
    "summary": "Here we present a case of a 27-year-old female, recently diagnosed with Graves' disease, who was prescribed methimazole and developed severe pruritus with cholestatic jaundice 13 days later. Concomitant causes of liver disease were ruled out. The treatment was discontinued, and a switch to corticosteroid therapy with a regimen of radioactive iodine sessions was initiated. The patient's condition showed a resolution of pruritus and jaundice, a disappearance of cytolysis with an aggravation of cholestasis followed by a gradual decrease, leading to the liver function normalization after 2 years."
  },
  {
    "id": "multiclinsum_gs_en_234.txt",
    "fulltext": "Patient and observation\nPatient information: A 54-year-old woman with a history of acute rheumatic arthritis (RAA) treated in childhood and type 2 diabetes mellitus with well-balanced Glimpepiride. Having no known exposure to SARS-CoV-2, she presented in our training two months after the administration of a first dose of ChAdOx1-S/nCoV-19 vaccine in a picture of dyspnoea, productive cough and haemoptoic expectoration, digestive disorders with liquid diarrhoea and bilious vomiting as well as arthro-myalgia and profound asthenia. A few days later, the aggravation was marked by the appearance of coldness of the extremities with dysesthesia with burning and tingling of the limbs. The patient reports that this symptomatology was initiated 24 hours after the vaccine.\n\nClinical findings: the neurological examination objectified decreased muscle strength in the lower limbs with hypoesthesia in the soles of the feet. The cutaneous-mucous examination revealed well-defined reticular lace erythematous plaques consistent with diffuse reticular livedo in the four limbs. The rest of the somatic examination was without particularities.\n\nDiagnostic approach: the biological assessment objectified a hypochromic microcytic iron-deficient anaemia (Hb: 9.8 g/dl, VGM: 79 fl, TCMH: 23 pg, ferritinemia: 15 mg/l), the other blood lines were without anomalies. The C-reactive protein (CRP) was at 30 mg/l and the lipid balance rechecked twice was disturbed (total cholesterol at 2.5 g/l, triglycerides at 1.4 g/l, HDL cholesterol at 0.45 g/l, LDL cholesterol at 1.7 g/l). Diabetes was balanced (glycated Hb at 7%). The D-dimers were negative (200 ng/ml). The rest of the balance, including the hepatic, renal, haemostasis balance, fibrinogen, serologies (hepatitis B/C, syphilis), complement as well as the immunological balance (AAN, anti-DNA antibodies, anti-cardiolipin antibodies, anti-B2 glycoprotein antibodies, anti-phospholipid antibodies, anti-MPO, anti-PR3) were negative. The nasopharyngeal polymerase chain reaction (PCR) coupled to the COVID-19 serology (IgM and IgG) were also performed, only showing elevated IgG.\n\nOn the radiological level, a thoracic angioscanner performed in search of a possible pulmonary embolism was normal. The transthoracic cardiac ultrasound did not reveal any anomalies. The arterial-venous ultrasound of the four limbs revealed a slight atheromatous infiltration of the lower limbs without upstream repercussions. In the neurological picture, the electroneuromyogram was normal and the cerebromedullary angio-MRI showed non-conflicting degenerative discopathies C5-C6 and L4-L5. In the context of research of a possible vascularitis, four millimetre skin biopsies of the wrist and thighs were performed, objectivising a non-specific chronic superficial dermatitis.\n\nTherapeutic intervention and follow-up: On the therapeutic level, the patient received symptomatic treatment with pregabalin (75 mg x 3/day), antiplatelet agent (acetylsalicylic acid at a dose of 100 mg/day) and statins (20 mg/day). The evolution was marked by the resolution of the initial symptoms with regression of neurological and articular pain as well as skin manifestations after 3 months of treatment. In view of the negativity of the whole assessment, a post-vaccinal livedo was retained.\n",
    "summary": "We present a rare case of post-vaccination reticulo-vascular livedo in a 54-year-old woman, which appeared 24 hours after vaccination, accompanied by respiratory, digestive and neurological disorders, and a change in general condition. Examinations revealed skin lesions consistent with reticulo-vascular livedo, a mild inflammatory syndrome, and hypercholesterolemia. Imaging was unremarkable. An immunological evaluation showed a positive lupus anticoagulant. The patient was treated symptomatically, with an improvement in neurological and articular symptoms, and a slight regression of the skin eruptions. After three months, the test of the lupus anticoagulant remained positive, confirming a post-vaccination antiphospholipid antibody syndrome (SAPL).\n"
  },
  {
    "id": "multiclinsum_gs_en_153.txt",
    "fulltext": "17-year-old female patient with a diagnosis of diffuse goiter of Graves' disease, who denied other significant history.\n\nHis case began six months earlier with progressive weight loss, episodes of anxiety and agitation, temperatures of 37.4 to 37.9 ºC, palpitations, abdominal pain and intermittent diarrhea. Two months later, the growth of the anterior face of the neck was added as a symptom; in the third month, he presented tachycardia of up to 130 beats per minute. When evaluated by Endocrinology, he was given 15 mg of thiamazole every 8 hours, which was suspended due to a case of agranulocytosis. Therefore, he began to be given lugol and propanol of 20 mg every 8 hours, without adequate response. Therefore, it was decided to apply a therapeutic dose of 131 iodine (I-131) 10 mcU.\n\n\nPhysical examination\nOn physical examination, the patient presented with a non-invasive blood pressure (NIBP) of 137/75 mmHg, heart rate (HR) of 105 bpm, respiratory rate (RR) of 16 bpm, SpO2 of 95%, and temperature of 37.4ºC. The patient was admitted walking, with mild agitation, cooperative attitude; she was hydrated and had no clinical data of difficult airway, but the mobility of the trachea was not assessed due to thyroid growth of approximately 7.5 x 7 x 10 cm). The surface of the neck was regular and its mobility had an adequate extension. There were no additional sounds on cardiopulmonary auscultation and the patient had heart sounds increased in frequency; likewise, the abdomen was soft, depressible, non-painful, with peristalsis present. The extremities were intact, with increased sensitivity to heat, palmar hyperhidrosis, strength 5/5, and fine tremor.\n\nBurch and Wartofsky scale was used and 40 points were obtained with high probability of thyroid storm, so multimodal anaesthesia was decided.\n\nIn the type 2 monitoring, the patient presented initial vital signs PANI 137/75 mmHg, heart rate 96 beats per minute, respiratory rate 16 breaths per minute, 95% Spo2, invasive blood pressure monitoring.\n\nThe patient was given 2 mg of midazolam by intravenous induction; 150 mcg of fentanyl; 5 mg of cisatracurium and 50 mg of propofol.\n\nAirway approach was performed with Glide Scope videolaryngoscope with 3 hyper-angled blade without complications. Invasive mechanical ventilation in volume mode presented low FIO2 flows (40%).\n\nBoth sides of superficial cervical block were performed with 4 ml of 0.2% ropivacaine on each side (16 mg total).\n\nSevoflurane CAM 0.8, dexmedetomidine infusion 0.7 to 0.4 mcg/kg/hour, lidocaine infusion 25 mcg/kg/hour, fentanyl plasma concentration 0.001 mcg/mL were used for maintenance.\n\nThe adjuvants used were paracetamol 750 mg + parecoxib 40 mg + intravenous ketorolac 30 mg + magnesium sulphate 1250 g in an infusion for one hour. The fluid balance was negative. The anaesthetic time was 215 minutes. During the operation, the patient was haemodynamically stable, with a mean arterial pressure of 67 to 75 mmHg, which is considered adequate for organ perfusion.\n\nThe patient presented analgesia for 12 hours in the postoperative period. Rescue with 1 g of metamizol was necessary, using a single rescue. Persistent postoperative dysphonia, without presence of odynophagia.\n",
    "summary": "17-year-old adolescent with Graves' disease with uncontrolled clinical manifestations, who did not respond to medical treatment and was scheduled for radical thyroidectomy. She had a 35 Burch and Wartofsky scale. She was managed with general anesthesia and decreasing airway and regional stimulation to decrease surgical stimulation. Adjuvant medications such as magnesium sulfate were used for intraoperative stability.\n"
  },
  {
    "id": "multiclinsum_gs_en_33.txt",
    "fulltext": "A 32 year old primigravida pregnant woman affected by Holt-Oram syndrome was referred to our institution for second trimester routine anatomy scan. She had a positive family history of Holt-Oram syndrome involving her mother and her sister. In all family members affected, the only clinical evidence of the syndrome regards the upper limb defects, with a carpal bone malformation and agenesis of the thumb. The ultrasound reported a bilateral aplasia radii, slightly curved ulna and bilateral twisted hand with four digital rays. A significant enlargement of the right atrium without tricuspid regurgitation was also detected. The patient refused the amniocentesis and decided to carry on with the pregnancy. At the time of follow-up ultrasound at 30 weeks, the right atrial enlargement was confirmed without tricuspid insufficiency or other cardiac malformations. The patient underwent emergent cesarean delivery at 40 weeks of gestation because of fetal bradycardia during labor. A male infant was delivered with a birth weight of 3,110 g and APGAR score of 9 and 9 at 1′ and 5′ min. Postnatal evaluation confirmed the severe radii hypoplasia, slightly curved ulna and agenesis of the first ray. Neonatal echocardiography ducted the right atrial enlargement noticing also an atrial and two little ventricular septal defects not detected prenatally. The genetic analysis was also performed, and TBX5 mutation was detected.",
    "summary": "We present a case of a 32 years old primigravida pregnant woman affected by Holt-Oram syndrome referred to our institution for second trimester routine anatomy scan. The ultrasound reported a bilateral aplasia radii, slightly curved ulna and bilateral twisted hand with four digital rays. A significant enlargement of the right atrium without tricuspid regurgitation was also detected. The patient refused the amniocentesis and the postnatal evaluation confirmed the diagnosis of Holt-Oram syndrome."
  },
  {
    "id": "multiclinsum_gs_en_344.txt",
    "fulltext": "A 52-year-old man was admitted to a hospital because of sudden-onset palpitation and general fatigue. Electrocardiography revealed ventricular tachycardia with a heart rate of 180 beats/min. His heart rhythm returned to a sinus rhythm after prompt cardioversion and he was then referred to our institution for further investigation. His past medical history included RV outflow tract reconstruction using a homograft and closure of a ventricular septal defect for TOF, which was performed 47 years previously. However, he was lost to follow-up thereafter. Upon referral to our institution, his blood pressure was 116/70 mmHg, heart rate 80 beats/min, and oxygen saturation of 99% (on room air). On inspection of the jugular venous pulsation, a prominent a wave and deep y descent were clearly observed, which were consistent with the increased RV filling pressure and compensated augmentation of RA contraction. Of note, auscultation revealed a harsh diastolic regurgitant murmur in the third left intercostal space, widely split first heart sound (S1), and a single second heart sound (S2), indicating a severely dilated RV due to free PR and the presence of a non-functioning pulmonary valve. Moreover, a third heart sound (S3) was auscultated at the fourth parasternal border, which was consistent with a right-sided S3. The electrocardiogram revealed complete right bundle branch block, with a QRS duration of 200 ms. Chest radiography showed cardiomegaly with dilation of the bilateral pulmonary arteries. Transthoracic echocardiography revealed complete regression of the pulmonary valve, which resulted in free PR and a prominent RV dilation. Volumetric assessment of the RV was performed using cardiac MRI, which revealed an RV end-diastolic volume of 428 ml (RV end-diastolic volume index of 240 ml/m2), RV ejection fraction of 36%, and regurgitant fraction of PR of 74%. Moreover, multi-detector row CT clearly showed complete regression of the pulmonary valve of the homograft.\n\nThe patient underwent catheter examination for further investigation of his hemodynamic state. His RA pressure waveform was particularly notable, consisting of a prominent a wave and deep y descent, which were coincident with the fourth heart sound (S4) and S3 on a phonocardiogram, respectively. Moreover, pulmonary arterial end-diastolic pressure and RV end-diastolic pressure were revealed to be almost identical due to the free PR. Thus the clinical assessment of the “heart sound quintet”, including a harsh diastolic regurgitant murmur, widely split S1, single S2, and the presence of right-sided S3 and S4, was confirmed using multimodal anatomical and hemodynamic evaluation as severe right-sided heart failure concomitant with a significantly dilated RV because of complete regression of the pulmonary valve and resultant free PR.\n\nAfter pulmonary valve replacement, the “heart sound quintet” had completely resolved.",
    "summary": "A 52-year-old man was referred to our institution for the evaluation of sudden-onset ventricular tachycardia. His medical history included RV outflow tract reconstruction at 5 years of age. Auscultation revealed a harsh diastolic regurgitant murmur, widely split first heart sound (S1), and a single second heart sound (S2), indicating a severely dilated RV due to severe pulmonary regurgitation (PR) and the presence of a non-functioning pulmonary valve. Moreover, the right-sided third heart sound (S3) and fourth heart sound (S4) were present, consistent with elevated RV filling pressure and the presence of a non-compliant RV. Eventually, the aforementioned “heart sound quintet” was confirmed using multimodal evaluation as right-sided heart failure with a concomitant severely dilated RV because of complete regression of the pulmonary valve and resultant free PR."
  },
  {
    "id": "multiclinsum_gs_en_482.txt",
    "fulltext": "38-year-old female with a history of left optic neuritis diagnosed at age 30 with clinically isolated syndrome, who had a complete recovery of visual impairment with steroid treatment. She has been taking B. serrata capsules (200 mg/day, manufacturer's recommended dose) regularly to strengthen her immune system since then. She developed hypersensitivity to light, ocular pain, nausea, dizziness, and weakness in the lower limbs 4 days after taking the first dose of BNT162b2 vaccine in July 2021 and increased the dose of B. serrata to 5 capsules (1,000 mg/day) 1 week after vaccination. After taking B. serrata capsules at a dose of 1,000 mg/day for 3 weeks, the patient had a generalized non-provoked tonic-clonic seizure and was admitted to the intensive care unit. The investigation revealed serum hyponatraemia (112 mmol/L [n, 135 - 150 mmol/L]), urinary sodium concentration of 58 mmol/L, serum osmolarity of 234 mosm/kg (n, 280 - 300 mosm/kg), urinary osmolarity of 739 mosm/kg (n, 450 - 600 mosm/kg), ACTH concentration of 85.9 pg/mL (n, 7.2 - 63.3 pg/mL), normal basal cortisol concentration, normal C-reactive protein concentration, leukocyte count of 11.4 (n, < 10/l), neutrophilia, lymphopenia, and rhabdomyolysis (maximum creatine kinase concentration of 76348 U/L (n, 1 - 145 U/L)). She had a cranial magnetic resonance imaging (MRI) that revealed three periventricular non-enhancing lesions that did not change in number or extent compared to the MRI 4 years earlier. The pituitary gland was normal. The investigation of malignancy was inconclusive. The patient was diagnosed with SIHAD and treated with levetiracetam, forced diuresis, and sodium chloride infusions. After 3 weeks of treatment and discontinuation of B. serrata capsules, the patient recovered completely.\n",
    "summary": "A 38-year-old woman diagnosed with clinically isolated syndrome was regularly taking capsules of B. serrata (200 mg/day) to strengthen her immune system. She developed hypersensitivity to light, eye pain, nausea, dizziness, and weakness in the lower limbs 4 days after taking the first dose of BNT162b2 vaccine and increased the dose of B. serrata to 1,000 mg/day 1 week after vaccination. After taking B. serrata at a dose of 1,000 mg/day for 3 weeks, she was admitted to the intensive care unit due to unprovoked generalized tonic-clonic convulsions. Diagnostic investigation revealed syndrome of inappropriate antidiuretic hormone secretion, which resolved completely after treatment and discontinuation of B. serrata.\n"
  },
  {
    "id": "multiclinsum_gs_en_468.txt",
    "fulltext": "A 26-year-old woman who was 14 weeks pregnant visited our hospital complaining of chest pain while in the left lateral decubitus position. Her medical history was unremarkable, and this was her first pregnancy. Her mother had been diagnosed with no pericardium, but she was both asymptomatic and untreated.\n\nThe patient’s physical examination was normal. However, chest X-ray revealed cardiomegaly with a cardiothoracic ratio of 65%, the cardiac silhouette was shifted to the left side, and the pulmonary artery was enlarged. An electrocardiogram showed a sinus rhythm and incomplete bundle branch block. Laboratory tests revealed no abnormal findings. Transthoracic echocardiography showed a ‘teardrop-shaped’ left ventricle and paradoxical motion of the interventricular septum on the parasternal view. The apical four-chamber view revealed compression of the middle of both ventricles. In cardiac magnetic resonance imaging, a bulging of the apex was apparent that was markedly accentuated when the patient was in the left lateral position. Although the imaging did not directly confirm the presence of the pericardium, the change in cardiac shadows during postural changes suggested a diagnosis of pericardial agenesis.\n\nur patient continued her pregnancy while avoiding the left lateral position. After 31 weeks of pregnancy, she was hospitalized to allow careful monitoring of her condition. Several meetings including members of the obstetrics, cardiology, cardiovascular surgery, and anaesthesiology departments were held to discuss her treatment plan. In addition to the pericardial defect, the pelvic position of the foetus made treatment decisions difficult. Two options were considered: caesarean section and external rotation followed by vaginal delivery. However, the pressure of external rotation risked inducing cardiac herniation. Thus, after further discussion, caesarean section was scheduled at 37 weeks of pregnancy, as foetal lung development would be completed around 34–35 weeks. However, at 34 weeks of pregnancy, the patient developed sudden, intermittent chest pain when in a supine position. An electrocardiogram taken at that time revealed negative T-waves in leads II and V3–V6. One hour after the test, her chest pain improved, and the negative T-waves disappeared. According to the European Society of Cardiology acute coronary syndrome (ACS) guidelines, the working diagnosis was non-ST elevation ACS (NSTE-ACS), based on the worsening chest symptoms, ST segment depression, and the absence of an elevated troponin level, which would have suggested unstable angina. Emergency cardiac magnetic resonance imaging was performed but it did not provide direct evidence of myocardial ischaemia, such as the myocardial oedema seen in black-blood T2-weighted images, or the wall motion abnormalities of the left ventricle seen in cine magnetic resonance images. Rather, the enlarged uterus had lifted the diaphragm and pushed the heart upward. It was assumed that the heart was strangulated in the pericardial defect. A continuation of the pregnancy would thus have been difficult, and an emergency caesarean section was successfully performed. Since the chest pain did not occur during pregnancy as long as the patient avoided the left lateral position and was caused by external mechanical compression, pharmacological treatment, including calcium antagonists and antithrombotic therapy, was not administered. Thereafter, she no longer had chest symptoms due to myocardial ischaemia, and a week later, she was able to leave the hospital. Her baby had no disabilities and developed normally. However, 6 months after delivery, she experienced brief chest pains when carrying her baby. Because she wanted a second child, she decided to undergo cardiac surgery before the next pregnancy. Additional imaging studies were performed for preoperative evaluation. Computed tomography showed lung tissue between the aorta and pulmonary artery. Coronary angiography showed no significant stenosis whereas left ventriculography revealed left ventricular enlargement and apex drooping. A year after delivery, cardiac surgery was performed to address the pericardial agenesis. The intraoperative findings showed that the left pericardium was absent. Additionally, an edge of the right pericardium was sclerotic and located on the inferior surface of the heart. The myocardial ischaemia was suspected to have been caused by compression of the right coronary artery by this sclerotic edge. Based on these findings, the final diagnosis was hemi-pericardial agenesis with a sclerotic edge of the right pericardium. During cardiac surgery, this edge was removed, the diaphragmatic and anterior surfaces of the heart were covered with Gore-Tex, and surgery was completed. There was no recurrence of the chest symptoms after surgery or in her daily life. One year after surgery, she became pregnant with her second child. She had no chest symptoms during her second pregnancy and safely gave birth to the child.\n\n",
    "summary": "A 26-year-old woman who was 14 weeks pregnant visited our hospital complaining of chest pain in the left lateral decubitus position. Although she carefully avoided lying on her left side, chest pain suddenly developed when she was in a supine position at 34 weeks pregnant. An electrocardiogram taken at that time revealed ischaemic changes, implying compression of the coronary vessels. As continuation of the pregnancy would thus be difficult, a caesarean section was successfully performed. A year after delivery, cardiac surgery was performed. The intraoperative findings revealed that the left pericardium was absent, and an edge of the right pericardium was located on the inferior surface of the heart. It was suspected that the myocardial ischaemia was attributable to compression of the coronary artery by this edge. During surgery, this edge was removed."
  },
  {
    "id": "multiclinsum_gs_en_470.txt",
    "fulltext": "31-year-old woman, native of and from Lima, Peru, with no known drug allergies, no relevant medical history, and no harmful habits. She presented to the emergency department with abdominal pain in the right flank of several days' evolution, accompanied by nausea and vomiting. Four days before admission, she developed fever and constipation. Her blood count, amylase and lipase were normal, and her serum beta-HCG was negative. An abdominal ultrasound revealed vesicular lithiasis and abundant intestinal meteorism. In the emergency department, given the persistent abdominal pain, biliary vomiting, marked abdominal distension and absence of peristalsis, an exploratory laparotomy was performed, with no findings to explain the condition. A small tumor was found in the ileum, which histopathologically corresponded to a benign wall cyst of the small intestine without atypia. Her postoperative evolution was favorable, and despite the persistence of abdominal pain, which was of lower intensity compared to admission, she was discharged six days later.\n\nThree days after discharge, the patient presented generalized tonic-clonic convulsions at home, so she was readmitted. The brain scan and lumbar puncture were normal. The summary of the auxiliary examinations requested is presented in Table I. On her third day of hospitalization, she presented visual hallucinations and again convulsions, despite the administration of antiepileptics. On the fifth day, she presented a decrease in muscle strength in both legs, with bilateral arreflexia. On the eighth day, she had sinus tachycardia, flaccid paraparesis and hypotonia, difficulty and severe respiratory acidosis, and was admitted to mechanical ventilation. The thyroid profile, antinuclear antibodies and complement C3 and C4 were found at normal levels.\n\nThe patient's clinical manifestations (abdominal pain, convulsions, visual hallucinations and decreased muscle strength) and the change in urine coloration led to the suspicion of an acute crisis of porphyria, and the diagnosis was confirmed with the determination of elevated levels of delta aminolevulinic acid. Administration of beta blockers and glucose solutions was initiated. On the other hand, the use of hemin was also considered, however, the drug was not available in the country.\n\nDue to the marked neuromuscular involvement, and despite initiating physical therapy, it was difficult to withdraw the mechanical ventilation, and he remained on mechanical ventilation for six weeks, with superimposed nosocomial infections.\n\nAfter five weeks in hospital, the patient was given arginate of hemin at a dose of 4 mg/kg/day. On the second day of administration, it was decided to discontinue the treatment due to hypertransaminemia. After 48 hours of normalization, the administration was restarted until the patient had received four days of treatment. A week later, there was evidence of improvement in muscle function, with recovery of mobility in the feet. The patient was then gradually weaned off mechanical ventilation, which took four weeks to be discontinued. The patient was then discharged with the recommendation of physical and occupational therapy.\n",
    "summary": "Patient with PAI, who presented with acute abdomen, convulsions, and subsequent neuro-psychiatric involvement and symmetrical motor neuropathy, who was admitted to mechanical ventilation. Due to the severity of the neurological involvement, he received arginate of hemine, with transient hypertransaminemia, an adverse event not previously reported. The evolution was favorable, and mechanical ventilation and hospital discharge were withdrawn.\n"
  },
  {
    "id": "multiclinsum_gs_en_546.txt",
    "fulltext": "78-year-old woman with a history of undifferentiated carcinoma of the cavum treated with chemo- and radio-therapy in 2013 and basal cell carcinoma in multiple locations treated surgically in 2017. A renal tumour lesion was detected during follow-up by computed tomography, and she underwent radical nephrectomy in 2020. The histopathological analysis revealed a renal cell carcinoma, clear cell variant, with a nuclear grade of Fuhrman 2 without vascular or ureteral invasion with free margins; and it was staged as pT2aN0M0 (stage II, AJCC-TNM 8). The patient did not receive adjuvant chemotherapy and was monitored periodically. Two years after the first diagnosis, during her oncological follow-up, a multi-slice computed tomography with intravenous contrast was performed that evidenced a nodular thickening in the background of the vesicle measuring 15 × 10 mm, with rounded contours with homogeneous enhancement after administration of arterial phase contrast. The patient was asymptomatic with no abnormal findings on physical examination. The blood test did not show any alteration, and the CA 19-9 tumour marker was normal. Despite the absence of biliary symptoms and based on the morphological aspect of the vesicle lesion (assuming vascularised vesicle polyp with probable carcinoma focus) we suggested the patient to undergo surgical extirpation. Laparoscopic cholecystectomy with hepatic pedicle lymphadenectomy was performed without complications. The intraoperative freezing of the cystic margin was negative for atypia. At the cut, the specimen presented in the mucosa four polipoid lesions, the largest measuring 11 mm and the smallest 7 mm in diameter. None of the 6 isolated lymphadenectomy nodes presented tumour involvement. At microscopic examination, the largest polipoid lesion corresponded to a epithelial neoplasm consisting of nuclei of small to medium size, hyperchromic, with wide and clear cytoplasm, arranged in solid nests and cords, with prominent microvascularisation compromising up to the muscularis mucosae, without involvement of the hepatic face. The rest of the polipoid lesions corresponded to accumulations of lipophages. No stones were found. The diagnosis of metastatic CRCC was confirmed by immunohistochemical staining that showed strong positivity for vimentin and PAX8, patchy positivity for CD10 and negativity for pancytokeratin. The surgical margins were free of tumour. Eight months after surgery, the periodic checks did not show recurrence and she is free of disease.\n",
    "summary": "We present the case of a 78-year-old woman with a history of undifferentiated carcinoma of the cavum, basal cell carcinoma and CRCC in the right kidney. She underwent radical nephrectomy. Histopathological analysis confirmed the diagnosis of CRCC without vascular or ureteral invasion. Two years later, during follow-up, a nodular lesion in the gallbladder was detected by computed tomography. Despite the absence of symptoms, surgical resection was decided. Laparoscopic cholecystectomy was performed without complications. Histopathological examination confirmed the presence of CRCC metastases in the gallbladder. The patient had a favorable outcome and was in follow-up without recurrence.\n"
  },
  {
    "id": "multiclinsum_gs_en_35.txt",
    "fulltext": "A 65-year-old woman was admitted with a one-month history of myalgia, generalised weakness, and intermittent non-specific chest pain.\n\nShe had suffered a stroke two years previously, which limited her mobility and for which she resided in a residential home. She had also experienced a non-ST elevation myocardial infarction (NSTEMI). with percutaneous coronary intervention to the left anterior descending artery five months prior to her current admission. Her other background included chronic kidney disease (CKD), dyslipidaemia, resistant hypertension, epilepsy, heart failure, type 2 diabetes mellitus, and asthma. She was a non-smoker and had no history of alcohol excess.\n\nHer pre-admission medication included multiple anti-hypertensive medications, aspirin, ticagrelor, and insulin. She was also prescribed atorvastatin 80 mg ON, which she had taken for almost two decades, though the dose had been increased from 20 mg ON two years prior.\n\nOn examination she had globally reduced power more prominent on the right, which was the side affected by her previous stoke, and generalised muscle tenderness. The rest of the clinical examination was grossly unremarkable with a normal cardiovascular examination and no other evidence of an underlying rheumatological process such as a rash or joint swelling.\n\nThe most notable finding from her initial laboratory investigations was a markedly elevated high sensitivity cardiac troponin T (hs-cTnT) level of 3794 ng/l (normal < 12 ng/l), with no significant dynamic change between serial tests, and which was noted to have been raised at a similar level several months prior following her NSTEMI. A creatine kinase (CK) was subsequently checked which was also found to be significantly raised at 9416 U/l (normal 25-200 IU/l).\n\nHer ECG showed no acute changes, and her transthoracic echocardiogram (TTE) showed left ventricular hypertrophy (LVH), but normal left ventricular ejection fraction without regional wall motion abnormalities, normal right ventricular function, and no significant valvular pathology.\n\nIt was initially unclear if her CK represented cardiac or skeletal muscle damage. The significance of the raised hs-cTnT was also uncertain. Acute coronary syndrome was thought to have been excluded as her initial presenting symptoms were inconsistent with this, there were no acute ECG or TTE changes, and the hs-cTnT levels were relatively static. The differential diagnosis was felt to be between chronic myocarditis, with the weakness being either due to co-existing myositis or deconditioning, and myositis without cardiac involvement and with a false hs-cTnT elevation.\n\nFurther tests were requested to differentiate between these two possibilities. A high sensitivity cardiac troponin I (hs-cTnI) was performed and was only mildly raised at 55 ng/l. A paired hs-cTnT taken at the same time remained significantly elevated at 4532 ng/l. A cardiac MRI showed no evidence of cardiac infiltration or inflammation. A focal area late gadolinium enhancement likely due to her previous NSTEMI was seen.\n\nBased on the above investigations significant acute cardiac injury was felt to have been excluded. Myositis with false hs-cTnT elevation was now considered the most likely diagnosis and a rheumatology opinion was sought. They advised a number of antibody tests. Of these HMG-CoA Reductase antibodies were positive and PM/SCL75 antibodies were weakly positive. Other additional recommended tests done at this time, including ANA, ANCA, and hepatitis B/C, were negative, and A CT thorax, abdomen, and pelvis showed no evidence of underlying malignancy. The initial finding of a raised TSH meant that hypothyroidism contributing to the myositis had to be considered. However the fT4 was found to be normal, indicating the patient had subclinical hypothyroidism and excluding this as a significant contributing factor.\n\nA bilateral MRI of the thighs was also advised, which revealed diffuse high signal change throughout the thigh muscles with surrounding oedema in keeping with widespread myositis.\n\nBased on the clinical, MRI, and antibody findings a diagnosis of statin-induced IMNM was made. For confirmation a muscle biopsy from the quadriceps was taken. The results were not available until after discharge but when examined showed changes consistent with IMNM.\n\nFollowing diagnosis her atorvastatin was stopped and the patient was started on prednisolone 40 mg OD. However she had a modest response, with a reduction of her CK levels but little change to her symptoms. Therefore after two weeks of steroid treatment she was commenced on an escalating dose of mycophenolate starting at 250 mg BD and intravenous immunoglobulin 2 g/kg over five days alongside a three-day course of IV methylprednisolone 500 mg OD followed by an increased dose of oral prednisolone at 60 mg OD. This resulted in a progressive improvement of symptoms and continued reduction in her CK levels. Her cTnT also decreased, but still remained significantly raised above her previous baseline, even after several months of treatment. She was discharged home on mycophenolate (1 g BD at time of discharge) and a weaning dose of prednisolone (30 mg OD at time of discharge). She was planned for follow up under the rheumatology team but unfortunately repeatedly did not attend her scheduled clinic appointments.",
    "summary": "Here we present a case of a 65-year-old woman on long term atorvastatin who presented with generalised weakness, non-specific chest pain, and a persistently elevated high sensitivity cardiac troponin T. Upon further investigation acute myocardial injury was excluded and a diagnosis of statin-induced immune mediated necrotising myopathy (IMNM) was made. The patient improved with cessation of atorvastatin and initiation of immunosuppressive therapy with mycophenolate, intravenous immunoglobulin, and steroids."
  },
  {
    "id": "multiclinsum_gs_en_199.txt",
    "fulltext": "An 80-year-old Japanese man presented to our hospital with complaints of fever and left leg pain, as well as bilateral lower extremity swelling. Although mild edema was always observed in his bilateral lower extremities, it gradually worsened 1 week prior to admission. On the day of admission, he had high fever accompanied by chills. He denied any recent leg trauma. His past medical history was significant for pulmonary tuberculosis at 30 years of age, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). A pacemaker was inserted because of atrial fibrillation (AF) with symptomatic bradycardia. He was an ex-tobacco smoker (100 pack year history) and did not drink alcohol. His maintenance medications were dabigatran (220 mg), furosemide (20 mg), and an inhaled corticosteroid/long-acting β2-agonist.\n\nAt initial presentation, he was alert and oriented but appeared distressed. His vital signs were as follows: body temperature, 38.8 °C; blood pressure, 135/90 mmHg; heart rate, 96 beats per minute with irregular rhythm; blood oxygen saturation, 93% with room air; and respiratory rate, 22 breaths per minute. He had a barrel-shaped chest, coarse crackles were heard over the lung base, and wheezes were heard over both lung fields. Pitting edema was observed in his lower extremities. His left foot had more erythema and edema than his right foot. His left lower extremity was warm and tender to touch. There were no skin breaks or other potential infection entry sites. Tinea pedis was ascertained by a potassium hydroxide test.\n\nArterial blood gas analysis showed the following results: pH, 7.408; partial pressure of carbon dioxide, 44 mmHg; partial pressure of oxygen, 72 mmHg; bicarbonate, 22.5 mmol/L; and lactate, 1.8 mmol/L. A complete blood count revealed the following results: white blood cells, 9,000/μL; red blood cells, 384 × 104/μL; hemoglobin, 12.4 g/dL; and platelets, 9.6 × 104/μL. Chemistry results were as follows: serum creatinine, 0.81 mg/dL; blood urea nitrogen, 19.0 mg/dL; albumin, 3.7 g/dL; total bilirubin, 2.1 mg/dL; aspartate aminotransferase, 43 U/L; alanine aminotransferase, 22 U/L; C-reactive protein, 0.36 mg/dl; and brain natriuretic peptide (BNP), 471 pg/mL (our patient’s basal BNP level was approximately 100 pg/mL). A coagulation test showed prolonged prothrombin time-international normalized ratio (1.29) and activated partial thromboplastin time (52.3 seconds). A chest X-ray showed a nodular lesion on the right pulmonary apex compatible with previous tuberculous infection without any infiltrations. An electrocardiogram showed AF with pacemaker rhythm without any sensing and pacing failures. Based on these results, we diagnosed our patient as having cellulitis and immediately admitted him to hospital because his respiratory status continued to worsen, necessitating supplemental oxygen therapy for dyspnea relief. We also considered a risk of sepsis and mortality because his sequential organ failure assessment score was 5 points (2 points greater than baseline) at initial presentation.\n\nCefazolin (1 g every 8 hours) was initially administered intravenously to treat his cellulitis, but after 25 hours of incubation, two sets of aerobic blood culture bottles (BD BACTEC™ Plus Aerobic/F Medium; BD Diagnostics, Sparks, MD, USA) were found to be positive (detected by BD BACTEC™ FX, Blood Culture System; BD Diagnostics, Sparks, MD, USA) for GNRs. The positive culture broth was inoculated onto a blood agar plate (BD BBL™ Trypticase™ Soy Agar with 5% Sheep Blood; Nippon Becton Dickinson Company, Fukushima, Japan) and light yellow colonies were observed after incubation of 24 hours at 37 °C. The causative organism was confirmed as GNF-GNR on day 4. Accordingly, we switched antibiotics to intravenously administered meropenem (1 g every 8 hours) on the same day, considering antibiotic resistance. On day 6, the causative organism was identified as S. spiritivorum. It was identified by BD PHOENIX™ System (BD Diagnostics, Sparks, MD, USA) and matrix-assisted laser desorption/ionization time of flight mass spectrometry, using Microflex LT with MALDI Biotyper version 3.1 database (Bruker Daltonik, Bremen, Germany). Our patient’s condition gradually improved with the antibiotic use. We decided to switch antibiotics to orally administered levofloxacin (500 mg/day) on day 12, considering the antibiotic sensitivity of S. spiritivorum isolated from the blood culture. Trimethoprim/sulfamethoxazole was an alternative but was not used out of concern for adverse drug reactions considering our patient’s age. He was discharged on day 16 without any complications, and the antibiotic was discontinued on the same day. We followed up with him 2 weeks after discharge, during which he did not have any residual symptoms related to cellulitis.",
    "summary": "An 80-year-old Japanese man with chronic obstructive pulmonary disease and congestive heart failure visited the Kariya Toyota General Hospital, Aichi, Japan with the chief complaint of fever accompanied by chills and left leg pain. At initial presentation, he was distressed and dyspneic. He was febrile (38.8 °C), and his left foot was swollen with reddening and tenderness. We diagnosed him as having cellulitis, and he was hospitalized for antibiotic therapy. Initially, he was treated with intravenously administered cefazolin, but after the isolation of a glucose non-fermenting Gram-negative rod from blood cultures, we decided to switch cefazolin to intravenously administered meropenem on day 4, considering the antibiotic resistance of the causative organism. The causative organism was identified as S. spiritivorum on day 6. His condition gradually stabilized after admission. Meropenem was switched to orally administered levofloxacin on day 12. He was discharged on day 16 and treated successfully without any complications."
  },
  {
    "id": "multiclinsum_gs_en_263.txt",
    "fulltext": "48-year-old male patient who was admitted to our hospital unit after sustaining an injury to his left hand following an axial load, as well as compression after being struck by a motor vehicle; on admission, a joint incongruity in the Gilula lines was identified. In addition to sustaining a fracture in the proximal metaphysis with extension to the distal metaphysis of the third finger, a traumatic amputation with disarticulation of the F1-F2 plus denudation of the fourth finger, a bleeding wound of the fifth finger plus injury to the extensor of the fifth finger in zone V. On admission, he underwent damage control surgery plus closed reduction of peri-escafo-transtrapecio-transtrapezoidal dislocation.\n\nDuring his stay, he was treated with antibiotic impregnation plus analgesia; after the antibiotic impregnation, he underwent a definitive procedure where he had a carpectomy of the left wrist with arthrodesis of the interphalangeal joint of the third finger and the fourth finger and a tenotomy of the extensor of the fifth finger and a blood-soaked wound flap in the fifth finger. Surgical technique. It was performed with a posterior longitudinal approach (given that it provides better exposure and reduces the risk of nerve injuries), using the Lister tubercle as a reference, the skin edges of the extensor retinaculum are released, freeing the space between the third and fourth posterior extensor compartments, observing the joint capsule, we identify the posterior interosseous nerve on the inner side of the Lister tubercle, we perform a T-shaped capsulotomy with a transverse incision 2 mm from the radial edge of the capsular insertion and, parallel to it, a vertical incision in the axis of the third metacarpal; we examine the integrity of the lunate and scaphoid fossae to be able to carry out the resection of the first row (performing traction and flexion of the palm), in this way we can carry out the removal of the bones of the first row of the carpus (taking care not to injure the cartilage of the large bone); we begin with the removal of the lunate, posterior of the pyramidal and finish with the scaphoid; after that, adequate flexo-extension of the wrist is verified; we continue with the closure of the T-shaped capsulotomy, as well as the annular ligament, subcutaneous cellular tissue and skin.\n",
    "summary": "48-year-old male patient who entered our hospital unit after suffering an injury to his left hand after being struck by a motor vehicle, with axial loading mechanism, presenting a deformity of the left thoracic extremity, a fracture of the proximal metaphysis of the second phalange of the third finger as well as a dislocation of the proximal interphalangeal joint, with traumatic amputation of the second phalange of the fourth finger plus extensive injury in zone V of the fifth finger with loss of skin coverage of the fourth and fifth fingers. He came to our hospital unit 24 hours after the injury.\n"
  },
  {
    "id": "multiclinsum_gs_en_445.txt",
    "fulltext": "A previously healthy female toddler presented with several episodes of emesis and decreased urine output. There was no history of diarrhea or bloody stool, intake of contaminated food or water, or international travel. She was born prematurely at 30 weeks and was fully immunized. Past medical history was unremarkable for solid organ or bone marrow transplantation, malignancy, autoimmune disorders, intake of nephrotoxic drugs, infections, or hypertension. There was no family history of renal disease. Prior renal function showed a serum creatinine of 0.3 mg/dL at one month of life.\n\nVital signs showed an afebrile child with a pulse of 140 beats/minute and blood pressure of 88/56 mm Hg (<50th percentile). Physical examination was unremarkable except for signs of mild dehydration.\n\nInitial investigations upon presentation are shown in Table 1. Due to progressive decline in renal function, a kidney biopsy was performed on day two of admission which showed 39 normocellular glomeruli with no segmental sclerosis, necrosis, crescent, mesangiolysis, or capillary thrombosis. There were patchy areas of acute tubular injury (ATI) characterized by tubular dilation, epithelial attenuation, mitotic figures, and sloughing of cells. There were no tubular necrosis and significant cellular infiltrates. Immunohistochemical stains for myoglobin and hemoglobin were non-contributory. Immunofluorescence was negative for immunoglobulins and complements. Electron microscopy showed intact podocyte foot processes, the absence of electron-dense deposits, and segmental glomerular basement membrane (GBM) splitting without multi-lamination. There were no platelet or fibrin thrombi of the microvasculature, vascular mucoid intimal edema, onion skinning, detachment of glomerular endothelial cells, and “double contours”. The peripheral blood flow cytometry showed normocytic anemia with no clonal B cells, abnormal T cells, or blasts. Bone marrow biopsy showed normocellular bone marrow (90–95%) with no increase in blasts.\n\nOn day three of the presentation, bloody stools appeared which led to a high index of suspicion for HUS. Stool examination was negative for ST but positive for EAEC (BioFire FilmArray GI PCR panel). We could not specify the serotyping as it was not available commercially. Serum complements C3 and C4 were normal. A genetic test for atypical HUS was sent for gene variants of various complement proteins. ADAMTS13 activity was normal. The platelet counts remained normal, and the peripheral blood smear continued to show the absence of schistocytes.\n\nThe differential diagnoses included partial HUS, and AKI secondary to severe volume depletion induced by vomiting, non-microangiopathic hemolytic anemias, and malignancies. Although AKI and histological features of tubular injury could be due to severe volume depletion from vomiting, the presence of concurrent hemolytic anemia warranted a high index of suspicion for conditions such as partial HUS.\n\nIsotonic intravenous (IV) saline with bicarbonate was initiated upon admission. However, the renal function continued to worsen with peak serum creatinine 4.4 mg/dL and BUN 141 mg/dL. Given oligoanuria and electrolyte abnormalities, she received three sessions of daily hemodialysis (HD) with unfractionated heparin for anticoagulation. Loop diuretic was not administered given concern for dehydration-induced oliguria. On day three of admission, a single dose of IV eculizumab 300 mg was given after administration of meningococcal vaccine and penicillin therapy, with rapid recovery of renal function and hemolytic markers. No further dosages of eculizumab were required. Blood pressure remained normal. A follow-up of laboratory testing showed the absence of autoantibodies to factor H and I, normal serum factor H and I levels, and elevated soluble complement 5B-9 (SC5B-9) levels. Atypical HUS genetic susceptibility panel showed no deletion or duplication of C3, C4BPA, CD46, CD59, CFB, CFH, CFI, CFHR5, DGKE, THBD, PLG, and MMACHC genes (Cincinnati Children’s Clinical Laboratories, Cincinnati, OH, USA). Platelet counts did not decrease throughout the hospital course. Urinalysis continued to show dipstick positive for blood but absence of microscopic hematuria along with 1+ to 2+ proteinuria. Urine beta-2 microglobulin was elevated (3200 mcg/L, normal: <300 mcg/L, Mayo Clinic Laboratories, Rochester, MN, USA). Serum albumin remained in 3.5–4 g/dL range. Serum uric acid returned to normal following hemodialysis and stayed normal with no need for anti-hyperuricemic therapies such as rasburicase.\n\nIn a short-term follow-up of six months, the patient was normotensive with normal renal function and blood counts with resolution of tubular proteinuria. There were no medication-related adverse events. Follow-up genetic testing showed no complement or factor deficiencies and the absence of complement gene mutations.",
    "summary": "A female toddler presented with hemolytic anemia, oliguric acute kidney injury (AKI) without thrombocytopenia, and peripheral schistocytes. The stool examination for ST was negative but positive for EAEC. She required several hemodialysis sessions and received one dosage of eculizumab with rapid reversal of AKI and hemolytic markers. A kidney biopsy revealed acute tubular injury and segmental glomerular basement membrane splitting. Genetic testing was negative for complement mutations or deficiencies. A follow-up six months later showed persistently normal renal function and hematological markers."
  },
  {
    "id": "multiclinsum_gs_en_223.txt",
    "fulltext": "This is a 50-year-old male patient who presented with a complaint of severe tongue pain and swelling of three days duration. Associated with this, he had pain while swallowing, difficulty opening his mouth, shortness of breath, and drooling saliva. Likewise, he had a high-grade fever and a global type of headache. Otherwise, he had no trauma to his tongue, no recent dental or oral procedures, no history of cigarette smoking, and no history of chronic medical illness like diabetes mellitus, cardiac disease, and hypertension. Historically, he had severe standing dental pain for the past six months prior to his current complaint. He has been chewing khat since his childhood and had poor oral hygiene.\n\nOn physical examination, he was acutely sick looking and his vital signs were, blood pressure 115 by 70 mmHg, pulse rate 120 beats per minute, respiratory rate 20, temperature 39 degrees centigrade, and oxygen saturation 92% off oxygen. On HEENT examination there was significant tongue swelling on the left anterolateral area, fluctuant on palpation, and had a erythematous border. There is multiple teeth decay in both maxillary and mandibular areas. There were no pertinent findings on the remaining systems.\n\nAfter informed consent was taken the patient was transferred to the operation room with the diagnosis of tongue abscess. Subsequently, incision and drainage were done under general anesthesia, and about 30mL of thick pus was drained. The pocket was washed with normal saline and 2% hydrogen peroxide. The patient was transferred to the surgical ward with stable vital signs and had been on ceftriaxone 1 gm iv twice daily (BID) and metronidazole 500 mg iv three times per day (TID) for two days. He was discharged after two days of hospital stay with improvement and Augmentin 625 mg PO TID for five days.",
    "summary": "This is a 50-year-old male patient who presented with a complaint of severe tongue pain and swelling of three days duration. Associated with this, he had pain while swallowing, difficulty opening his mouth, shortness of breath, and drooling saliva. Likewise, he had a high-grade fever and a global type of headache. On physical examination, there was significant tongue swelling on the left anterolateral area, fluctuant on palpation, and had erythematous border. After informed consent was taken the patient was transferred to the operation room with the diagnosis of tongue abscess. Subsequently, incision and drainage were done under general anesthesia, and about 30mL of thick pus was drained. The pocket was washed with normal saline and 2% hydrogen peroxide. The patient was transferred to the surgical ward with stable vital signs and had been on antibiotics. He was discharged after two days of hospital stay."
  },
  {
    "id": "multiclinsum_gs_en_361.txt",
    "fulltext": "76-year-old female patient, sedentary, obese, with depression and systemic arterial hypertension, who presented typical angina at rest, an electrocardiogram with dynamic changes in the T wave and high sensitivity troponin serum elevation (2180 ng/ml). Coronary angiography showed epicardial coronary arteries without significant lesions and anomalous origin of the left coronary trunk.\n\nThe transthoracic echocardiogram showed apical akinesia and hyperkinesia of the basal segments and left ventricular systolic dysfunction.\n\nCoronary artery angiography showed a truncus arteriosus anomaly in the proximal segment of the right coronary artery.\n\nThe patient recovered well and a transthoracic echocardiogram three months after the initial event showed that the mobility disorders were transient.\n",
    "summary": "76-year-old female patient presented with typical angina at rest, with an electrocardiogram showing dynamic changes in the T wave and elevation of biomarkers. Coronary angiography showed epicardial coronary arteries without significant lesions and anomalous origin of the left coronary trunk from the proximal segment of the right coronary artery. The patient recovered well and the transthoracic echocardiogram showed no mobility disorders three months after the event.\n"
  },
  {
    "id": "multiclinsum_gs_en_410.txt",
    "fulltext": "72-year-old man admitted to the Internal Medicine Service from the No. 43 Family Medicine Unit for the finding of pancytopenia in a control laboratory study. He had a history of systemic arterial hypertension and chronic renal failure with no history of haematological diseases. On examination, the patient reported asymptomatic, denied fever or weight loss, as well as haemorrage data. On the laboratory studies, the following was found: erythrocytes 3.41 x106/µL, haemoglobin 11.2 g/dL, corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean corpuscular haemoglobin 32.8 pg, mean\n\n\nEvolution\nAfter ruling out secondary causes of pancytopenia such as liver disease, splenomegaly, viral infections and nutritional deficiencies, a haematologist was consulted who, in view of the diagnostic suspicion of myelodepression syndrome, performed a bone marrow aspirate with immunophenotype.\n\nAspirate reported hypocellular bone marrow with dysplasia > 10% in all 3 cell lines as well as 45% of type II and type III myeloblasts, which is consistent with morphologically hypocellular bone marrow compatible with AML with myelodysplasia-related changes according to the 2017 WHO classification for myeloid neoplasms.\n\nThe bone marrow immunophenotype sample was sent to an external laboratory. Reference was made to the Haematology Service of the Siglo XXI National Medical Centre. The patient was accepted to continue the study and treatment protocol. Four days after discharge, the immunophenotype result was received, corroborating the diagnosis of AML, with an undetermined cytogenetic risk. The patient initiated treatment with a venetoclax 400 mg/day + azacitidine 75 mg/m2/day (days 1 to 7) scheme with a bone marrow aspirate after induction without the presence of blasts.\n",
    "summary": "72-year-old man, hospitalized for pancytopenia, without a history of hematological diseases, asymptomatic, without adenomegaly or hemorrhage. The hematological cytometry documented pancytopenia without blasts in peripheral blood. Secondary causes such as infection, splenomegaly and nutritional deficiencies were discarded. In the bone marrow aspirate 45% of myeloblasts and myelodysplasia were observed. The immunophenotype was compatible with AML. The patient was referred to Hematology of the Siglo XXI National Medical Center to initiate chemotherapy.\n"
  },
  {
    "id": "multiclinsum_gs_en_51.txt",
    "fulltext": "A 25-year-old male presented to our emergency department (ED) one hour after a road traffic accident (RTA). Upon initial assessment, the patient was awake and alert. The patient exhibited overlying occipital abrasion. Although no palpable skull fracture was identified, the patient experienced confusion and disorientation. His Glasgow Coma Scale (GCS) score was 14 (E4, V4, and M6). Physical examination revealed symmetric and reactive pupils, with no evidence of focal neurological deficits. The power motor was 5/5 bilaterally and the sensation and cranial nerves were intact. Further evaluation in the ED revealed normal vital signs. A body temperature was 36.2°C, respiratory rate was 20 beats/min, pulse rate was 79 bpm, blood pressure was 140/100 mmHg, and oxygen saturation was 97% on room air. Examination of the neck, chest, heart, and abdomen yielded unremarkable results. Blood results showed creatinine at 0.94 mg/dl, urea at 18 mg/dl, PT at 12 seconds, and platelet count at 3000/microliter. Given the acute nature of the trauma and the young age of the patient, it was determined that renal and liver function tests were not immediately essential for the management of this case. Computed tomography (CT) showed an acute epidural hematoma with air pockets along the right parieto-occipital convexity, indicating a right transverse sinus rupture and an associated frontal hemorrhagic contusion. Within one hour of admission, the patient’s neurological status deteriorated. With a GCS decrease to 13 (E3, V4, M6). Urgent consultation with neurosurgery was sought, and the patient underwent emergent craniotomy for evacuation of the extradural hematoma and placement of a suction tube in the intensive care unit (ICU). The patient was placed in a prone position. Unilateral paramedian suboccipital craniectomy was performed using a high-speed drill, and the hematoma was completely evacuated.\n\nThirty hours after the operation, the patient’s GCS score decreased to 12 (E3, V4, and M5). Due to this deterioration, a control CT scan was performed, revealing a hematoma. After neurosurgical consultation, urgent evacuation was performed. Subsequent CT imaging revealed a sizable acute epidural hematoma with a mass effect and minimal right acute subdural hematoma, prompting consideration for reoperation. Hematoma evacuation, bleeding control, and suction tube insertion were performed. The volume of the hematoma was calculated using the ellipsoid volume equation: A×B×C/2, where A, B, and C are the maximum diameter of the hemorrhage in three 3 dimensions. This gives the hematoma volume in cubic centimeters. As per the ellipsoid formula, the initial volume was 2.19×6.73×6/2 = 44.41 cm3, and the subsequent volume was 2.18×6.09×5/2 = 33.19 cm3. Following the second surgical intervention, the patient’s GCS score improved to 13 (E3, V4, and M6). Imaging indicated a minimal residual subdural hematoma and stable right parietal bone craniotomy. After 15 days, repeat CT imaging demonstrated resolution of the hematoma with intact craniotomy sites, and the patient’s GCS score improved to 15 (E4, V5, and M6).",
    "summary": "We report the case of a 25-year-old male who presented to the emergency department following a fall, exhibiting confusion and a Glasgow Coma Scale (GCS) score of 14. Imaging revealed a significant acute epidural hematoma with associated mass effect, frontal hemorrhagic contusion, and right transverse sinus rupture. The initial hematoma volume was calculated to be 44.41 cm3 using the ellipsoid formula. Prompt neurosurgical intervention was performed, including craniotomy for hematoma evacuation and suction tube placement. Despite a decline in GCS score postoperatively, subsequent surgical management led to hematoma resolution and neurological improvement. The hematoma volume had decreased to 33.19 cm3 after the second intervention. After 15 days, the patient achieved a GCS score of 15."
  },
  {
    "id": "multiclinsum_gs_en_440.txt",
    "fulltext": "We present the case of a 31-year-old woman with a history of a mitral valve defect. She was diagnosed at the age of 3 years with a ventricular septal defect. She was treated with a pericardium patch and a Bjork-Shiley 27 mm prosthetic mitral valve. She had acute thrombosis and obstruction of the prosthetic mitral valve at the age of 11 years. She had a Saint Jude 27 mm prosthetic mitral valve and a Saint Jude 19 mm aortic prosthesis. She had a progressive heart failure secondary to periprotective mitral regurgitation at the age of 23 years. In 2013, a surgical solution was chosen: Saint Jude 29 mm prosthetic mitral valve (mechanical) and Magna Ease 29 mm bioprosthetic tricuspid valve. She had a prolonged postoperative stay in the intensive care unit. She presented with a picture of dyspnoea with small effort, progressive weight loss, abdominal volume and lower limbs. On physical examination, she had a systolic-diastolic murmur in the precordium without irradiation, jugular engorgement without pulmonary congestion elements, ascites and oedema of the lower limbs. An echocardiogram was performed: preserved systolic function of the left ventricle and right ventricle, non-functional aortic prosthesis, mild to moderate insufficiency of the mitral prosthesis without significant gradient, moderate to severe tricuspid regurgitation and pulmonary congestion. Right cardiac auscultation: pulmonary artery pressure and cardiac output within normal range, trans-tricuspid gradient of 20 mmHg. Cardio-resonance: preserved systolic function of the left ventricle and elements of systolic dysfunction of the right ventricle. Computed tomography: multiple calcifications in the leaflets of the tricuspid prosthesis with an inner diameter of 27 mm, calcifications in the leaflets of the pulmonary valve with dilation of the pulmonary artery up to 36 mm, dilated right ventricle with a cavity of 45 mm at the level of the tricuspid annulus, coronary arteries without lesions. Severe tricuspid regurgitation was found in a biological prosthesis and surgical treatment was indicated.\n\nCardio-surgical group discussion: high risk patient for multiple cardiac surgeries, STS risk score 13 points, high risk of right ventricular failure post-operative. It was decided to opt for percutaneous tricuspid replacement with Edwards Sapiens 3 (S3) prosthesis of 29 mm considering the original diameter of the Magna Ease biological prosthesis. It was performed in the angiography room, under general anaesthesia and trans-esophageal echocardiography (TE). Access to the implant of the right femoral vein prosthesis. F5 radial arterial access, JL3.5F5 guide catheter was inserted in the left coronary artery through which the BMW 0.014 guide was advanced to the septal branch of the descending anterior artery, the outer end of the guide was connected to the pacemaker stimulator. The catheter was advanced through the femoral artery to the right pulmonary artery, the right Judkins 4 (JR4) catheter of 29 mm was exchanged for the 260 cm standard 0.035 guide catheter, the guide was used to position the catheter in the distal branch of the left pulmonary artery. The Amplatz Super Stiff 260 cm (Cook Medical) catheter was advanced to the same branch, the JR4 catheter was removed. To avoid difficulty in passing the prosthesis, the tricuspid valve was pre-dilated with Nucleus 18 mm balloon (NuMED). The S3 prosthesis was loaded in the Commander release system in reverse to the usual way. The S3 prosthesis was advanced through the right femoral artery and positioned under fluoroscopy taking as reference the Magna prosthesis in tricuspid position. The release of the prosthesis was performed under 140/min pacemaker stimulation. The release system was removed, the F5 pigtail catheter was used to perform right ventricular ventriculography: no evidence of tricuspid valve regurgitation and 2 mmHg trans-tricuspid gradient. 3 mmHg echographic gradient (TE). The patient was referred to the intensive care unit and admitted without the need for vasoactive agents. In the first 24 h there was evidence of tachypnea and hypoxaemia, a total of 3 litres of ascites fluid was drained with clinical improvement and persistence of oxygen therapy requirement. Three days post implant an echocardiogram was performed: S3 prosthesis 29 mm in tricuspid position and average gradient 5 mmHg, right and left ventricular function preserved and no change from the previous examination. The patient was discharged on the sixth day post implant. She evolved with remission of symptoms and after 12 months of the intervention she was in good condition.\n",
    "summary": "A 31-year-old woman who had previously undergone aortic, mitral and tricuspid valve replacement in three surgical procedures was admitted to our cardiology department with symptoms consistent with right heart failure. She was evaluated by echocardiography, right/left cardiac probe, cardiac angio-CT and cardiac resonance. A severe tricuspid stenosis secondary to a dysfunction of a biological prosthesis was diagnosed. Due to the high surgical risk and the risk of postoperative right ventricular failure, the patient was rejected for surgical valve replacement. It was decided to carry out a tricuspid valve replacement procedure \"valve in valve\". It was successfully performed by femoral venous approach, expandable balloon prosthesis. The tricuspid stenosis was corrected and the patient recovered with remission of the symptoms of heart failure.\n"
  },
  {
    "id": "multiclinsum_gs_en_150.txt",
    "fulltext": "A previously well, 55-year-old male was referred to emergency department by his family doctor complaining of a 3-week history of fevers, productive cough, dyspnea and wheeze. He had an 80-pack year smoking history and a positive family history of lung cancer. He had been treated by his family doctor with a course of oral amoxicillin and oral prednisone, but his symptoms deteriorated. On presentation to emergency department his white cell count was 16.4 × 109/L (normal range: 4.0–10.0 × 109/L) neutrophil count of 13.8 × 109/L (normal range: 2.0–7.0 × 109/L), C-reactive protein was 118 mg/L (normal 0–5 mg/L) and serum sodium was 112 mmol/L (normal range: 136–145 mmol/L). Other biochemical markers were within normal limits. A chest X-ray showed right middle and lower lobe consolidation with associated moderate pleural effusion. He was admitted and treated as community acquired pneumonia and work-up confirmed SIADH.\n\nThe patient deteriorated despite intravenous Piperacillin–Tazobactam and oral Clarithromycin with worsening of consolidation on repeat chest X-ray. The patient was transferred to the intensive care unit and subsequently intubated and ventilated. A computerized tomography (CT) scan of his thorax revealed a right hilar mass with mediastinal involvement and right-sided hilar adenopathy with superimposed extensive air space consolidation. A biopsy performed during bronchoscopy revealed histologically monotonous, small cells with dark ovoid nuclei. No nucleoli were seen, and several mitotic figures were present. The cells have narrow ill-defined cytoplasm. Immunohistochemistry performed on the tumor cells showed CD45 negativity, AE1/AE3, TTF1 positivity. Focal minimal synaptophysin and chromogranin A positivity were also seen. This immunohistochemical profile was consistent with a diagnosis of small cell lung cancer.\n\nFull staging consisting of a CT-scan of the brain and Thorax–Abdomen–Pelvis confirmed extensive stage disease with adrenal metastases. The patient’s ECOG performance status was poor due to a combination of the SCLC and respiratory distress warranting artificial ventilation. As response rates with chemotherapy in SCLC are generally high, chemotherapy doublet in the form of carboplatin and etoposide were commenced while the patient was intubated in the ICU.\n\nThe patient responded well to treatment and was extubated and transferred to the ward on noninvasive ventilation. A re-staging CT-Thorax after 1 cycle showed good partial response to treatment.\n\nOn cycle 2 day 3 of chemotherapy, the patient developed lower back pain and bilateral lower limb weakness. Examination identified bilateral lower limb motor (Medical Research Council [MRC] Grade 3) and sensory paresis. Sensory examination revealed absent light touch, pinprick, coordination and proprioception in the lower limbs. Day 3 of Etoposide was held as a result of the new neurological findings.\n\nA CT-Brain, Magnetic Resonance Imaging (MRI)-Brain and MRI-spine were performed to investigate the new neurological findings. All radiology was reported as normal with no evidence of intracerebral metastases, stroke, myelitis or leptomeningeal disease. In addition, there was no obvious radiographic evidence of spinal cord compression either by extrinsic compression by osseous metastatic deposit or intramedullary or leptomeningneal deposits.\n\nTwo days later, a repeat neurological examination revealed tetraplegia, MRC Grade 0 in both upper and lower limbs. All deep tendon reflexes were absent. Head and neck muscles, cognition and speech were unaffected, and cranial nerve examination was normal.\n\nRoutine blood investigations including C-reactive protein and erythrocyte sedimentation rate were normal. Specific blood investigations including serum vitamin B12, folate, HIV serology, Lyme disease serology, Epstein-Barr virus serology, Brucella serology, thyroid antibodies, thyroid function tests, ANCA, ENA, ANA and serum protein electrophoresis were all negative or normal. Antibodies for Hu, Ri and Yo blood tests were sent, and all were negative. At this point a diagnosis of acute ascending motor and sensory symmetrical polyneuropathy was suspected and a lumbar puncture was performed. The results of cerebrospinal fluid (CSF) revealed an elevated total protein of 3.32 g/L (normal 0.15–0.45), and other parameters were normal, with a repeat 3 days later showing similar results. CSF cytology was negative for malignancy and CSF culture was also negative.\n\nElectromyography was consistent with diffuse predominantly motor polyneuropathy; sensory potentials were preserved but they were of small amplitude. The motor conductions show mixed axonal/demyelinating features, which was not typical of Guillain–Barre Syndrome.\n\nElectromyography and nerve conduction studies were conducted to investigate the patient’s acute motor and sensory polyneuropathy. The nerve conduction studies revealed the following:\n\n•Motor nerves:\n◦Compound muscle action potential (CMAP) amplitudes were markedly reduced in the tibial and ulnar nerves bilaterally (tibial: 1.2 mV; normal > 4 mV; ulnar: 0.8 mV; normal > 3 mV).\n◦Motor conduction velocities (MCV) were slowed in the tibial and ulnar nerves (tibial: 30 m/s; normal > 40 m/s; ulnar: 34 m/s; normal > 50 m/s), consistent with demyelination.\n◦Distal motor latencies were prolonged, with a mixed axonal and demyelinating pattern.\n•Sensory nerves:\n◦Sensory nerve action potential (SNAP) amplitudes were preserved but of small amplitude in the sural and median nerves (sural: 4 μV; normal > 10 μV; median: 6 μV; normal > 15 μV).\n◦Sensory conduction velocities (SCV) were within normal limits.\nThe electrophysiological findings revealed a predominantly motor polyneuropathy with mixed axonal and demyelinating features, atypical for classical paraneoplastic syndromes, which are generally sensory predominant and characterized by absent SNAPs.\n\nIn the interim, while these investigations were ongoing, the patient was started on intravenous dexamethasone and 0.4 g/kg/day of intravenous immunoglobulin without any symptomatic improvement.\n\n3. Outcomes and follow up\nDespite a significant initial oncological response to chemotherapy, the patient’s neurological condition deteriorated rapidly. Following 1 cycle of carboplatin and etoposide, imaging confirmed a partial response with a reduction in tumor size. However, the onset of severe, ascending motor and sensory polyneuropathy led to respiratory compromise. This dissociation between the oncological and neurological responses highlights the aggressive and refractory nature of PNS, even when cancer treatment is effective. Although intravenous dexamethasone and intravenous immunoglobulin were administered promptly, they failed to improve neurological outcomes.\n\nLengthy repeated multidisciplinary discussions were held with the patient and his family regarding further Intensive Care Unit admission for ventilatory support. The patient was well informed and aware that reversibility of his neurological symptoms was unlikely and therefore he opted for best supportive care. The patient subsequently died 3 weeks after initial symptoms. The patient’s decision to decline further invasive ventilatory support in favor of palliative care highlights the ethical considerations surrounding quality of life in rapidly progressive paraneoplastic syndromes.",
    "summary": "Patient concerns: A 55-year-old male with an 80 pack-year history of smoking presents to the hospital with a 3-week history of fevers, productive cough, dyspnoea, and wheeze. He had no significant comorbidities.\n\nDiagnoses: Extensive radiological investigations revealed a large mass at the right hilum compressing on the right lower bronchus with metastatic adrenal deposits. Biochemical investigations confirmed syndrome of inappropriate antidiuretic hormone secretion, and histology identified SCLC.\n\nInterventions: Despite initiating a combination chemotherapy with carboplatin and etoposide, the patient developed progressive motor paralysis and sensory loss over 4 days, leading to a diagnosis of paraneoplastic acute motor and sensory polyneuropathy.\n\nOutcomes: He deteriorated rapidly and died 14 days after symptom onset due to respiratory failure, underscoring the aggressive nature of paraneoplastic syndromes."
  },
  {
    "id": "multiclinsum_gs_en_213.txt",
    "fulltext": "A 35-year-old female with a history of recurrent miscarriages was brought to the emergency after she was trapped for 11 hours during an earthquake. Upon arrival, medical staff found the following vitals: Blood pressure: 100/40 mmHg, Heart rate: 137 beats/min, Temperature: 37.2°C, Respiratory rate: 26 breaths/min and Oxygen saturation: 96%. The Glasgow Coma Scale was assessed, yielding a score of 14/15 (patient confused).\n\nPhysical examination revealed significant swelling with ecchymosis and muscle tension in the left arm and thigh. Total functional impairment was noted, and peripheral pulses were challenging to discern in the traumatized limbs. Cervicofacial examination showed facial swelling in the left parotid region.\n\nLaboratory findings were remarkable for hemoglobin of 17.6 g/dl, hematocrit of 53.3%, white blood cell count of 41 630 cells/ml, and platelets of 396 000/mm3. Electrolyte abnormalities included blood urea nitrogen at 0.43 g/l, creatinine at 18.87 g/l, potassium at 5.89 mmol/l sodium at 138.4 mmol/l, chloride at 112.8 mmol/l, calcium at 84.44 mmol/l, phosphorus at 67.24 mmol/l., Additional laboratory results included alanine aminotransferase at 185 IU/l, and aspartate aminotransferase at 538 IU/l. Arterial blood gas analysis showed metabolic acidosis with a pH of 7.19, bicarbonate of 9.11 mmol/l, and PaCO2 of 21.3 mm Hg. The initial creatinine kinase was 42 670 IU/l, and lactate dehydrogenase was 3325 IU/l.\n\nHead computed tomography and abdominal ultrasound showed no signs of acute injury or pathology.\n\nThe trauma team immediately began resuscitation efforts, establishing two intravenous lines. Upon admission, the patient received an agressive vascular filling by isotonic saline and was promptly transported to the operating room for fasciotomy incisions on the left upper and lower limbs. Massive fluid resuscitation continued for the first 24 hours, with a total of 12 liters of 0.9% normal saline administered.\n\nEmergent fasciotomies were performed on the left lower extremity and left upper limb in the operating room. After the procedure, the patient remained intubated and was transferred to the chirurgical intensive care unit (ICU). After fasciotomies, pulses returned to the left upper and lower extremities, with close monitoring by the surgical team.\n\nDiuretic treatment (furosemide) was initiated after massive fluid resuscitation and in the face of persistent oliguria. Hemodialysis was subsequently performed on the same day of admission, with a total of 9 hemodialysis sessions conducted during the stay in ICU.\n\nThe patient stayed in ICU for 25 days, and her overall evolution was favorable. There was normalization of biological parameters; renal function and creatine kinase. She was referred to plastic surgery for further.",
    "summary": "A 35-year-old woman trapped under rubble during11 hours during a seismic event, presenting with compartment syndrome in her left arm and thigh and crush syndrome. Emergent fasciotomy and aggressive fluid resuscitation were performed, preventing renal failure and metabolic derangement. Post-fasciotomy, pulses returned to her affected limbs. She was extubated and moved to the ICU under close surgical supervision."
  },
  {
    "id": "multiclinsum_gs_en_497.txt",
    "fulltext": "A 60-year-old man with a history of bilateral laser-assisted in situ keratomileusis (LASIK) presented to the emergency department via ambulance immediately upon sustaining severe penetrating trauma to his right orbit. The patient was riding his bicycle when he rode over a rock, lost balance, and impaled his right orbit on the bicycle’s metal handlebar; he then pulled his head back and found that his right globe was dislodged anteriorly from the orbit. He did not lose consciousness but experienced significant nausea and vomiting. On examination in the emergency department, the patient had no light perception (NLP) in the right eye. The right pupil was nonreactive, and there was an afferent pupillary defect by reverse. The patient had a full-thickness horizontal right upper eyelid and canalicular laceration extending along the lid crease from the medial canthus to a few millimeters shy of the lateral canthus. The right globe was totally avulsed through this laceration and rotated nasally with apparent transection of the optic nerve and extraocular muscles. Orbital soft tissue was also prolapsed through this laceration. There was additionally a short full-thickness horizontal right upper eyelid laceration just superior to the lid margin as well as a superficial vertical laceration of the nasal bridge at the level of the eyebrows. Examination of the left eye was normal.\nThe patient was taken to the operating room by the ophthalmology service for urgent surgical exploration and repair by the attending oculofacial plastic surgeon. The optic nerve and all extraocular muscles were confirmed to have been completely transected. The avulsed globe was attached to the intraorbital contents by a thin band of connective tissue. Given the patient’s NLP vision in the right eye on presentation, the fact that the initial penetrating trauma had induced a near-total enucleation, and the concern for phthisis bulbi and necrosis if the nonviable globe was repositioned within the orbit, enucleation was completed intraoperatively. The right upper eyelid canalicular laceration was repaired, and a bicanalicular Crawford stent was inserted and sutured to the nasal mucosa. The transected levator palpebrae superioris muscle was then repaired. A plastic conformer was placed to prevent forniceal shrinkage. Skin was reapproximated using a combination of simple interrupted and running sutures. The patient healed well and had a smooth postoperative course.",
    "summary": "A 60-year-old man presented with total avulsion of the right globe following a penetrating injury to the right orbit from a metal bicycle handlebar. There was no light perception in the right eye on presentation. External examination revealed a full-thickness, canalicular-involving, horizontal right upper eyelid laceration through which the luxated globe and other orbital contents extruded. The globe was intact. The patient underwent urgent surgical exploration. In the operating room the optic nerve and all extraocular muscles were found to be completely transected from the globe. The globe was enucleated, and the eyelid laceration was repaired with bicanalicular stent placement."
  },
  {
    "id": "multiclinsum_gs_en_158.txt",
    "fulltext": "Patient details\nA 65-year-old Japanese man who had been undergoing regular hemodialysis for end-stage renal disease of unknown etiology since his 30s developed pancytopenia in 2017. His anemia made him dependent on regular red cell transfusion in 2018. In February 2019, we performed a bone marrow examination and found dysplasia in granulocytes and erythroid lineages with 1.8% of myeloblasts. G-banding method revealed normal karyotype. We thus diagnosed myelodysplastic syndrome with excess blasts in the recent International Consensus Classification [10] and myelodysplastic neoplasm increased blasts 1 in the 5th edition of WHO classification [11]. We administered three courses of azacitidine but ceased it due to severe cytopenia. The blast cells increased in his peripheral blood with disseminated intravascular coagulation in November 2019, indicating transformation to AML. To reduce the blast cells, the fourth course of azacitidine was administered, but it was ineffective. Since the genetic analysis identified a mutation in the tyrosine kinase domain of FLT3 in the AML cells, we started to administer 120 mg of gilteritinib every day. Although gilteritinib showed a temporary effect of decreasing white blood cells and lactate dehydrogenase on day 2 after initiation without obvious adverse events, they began to rise on day 4, and the treatment was deemed ineffective. We decided to terminate treatment for AML as well as hemodialysis and to use the best supportive care. The patient subsequently died of arrhythmia on day 7.\n\nWritten consent for genome sequencing and publication had been obtained from the patient. This research was approved by the local institutional review board (approval no. JHTF-2019-003) and conducted ethically following the World Medical Association Declaration of Helsinki.\n\nSample collection and processing\nBlood samples were collected immediately before the first dose of gilteritinib (referred to as “before” in this study) and 4 days after the initiation of the treatment (referred to as “after” in this study). The CD34+ cells were isolated from the blood samples using CD34 MicroBead Kit-UltraPure (Miltenyi Biotec, Gladbach, Germany) following the manufacturer’s instructions. CD34+ cells were quantified using a flow cytometer at Kotobiken Medical Laboratory (Ibaraki, Japan).\n\nAssay for transposase-accessible chromatin (ATAC) with high-throughput sequencing\nLibrary preparation, sequencing, mapping, and Gene Ontology (GO) analysis for ATAC-seq were performed at DNAFORM (Yokohama, Japan). Cells were lysed, and the rearrangement reaction was performed using Tn5 transposase (#FC121-1030, Illumina CA, USA) for 30 minutes at 37 ℃. The reaction solution was purified using the MinElute PCR Purification Kit (#28004, Qiagen, Hilden, Germany). Next, five cycles of polymerase chain reaction (PCR) using custom Nextera PCR primers were conducted using NEBNext Q5 Hot Start HiFi PCR Master Mix (#M0543, New England Biolabs, MA, USA). The number of additional PCR cycles was determined using qPCR of the partially amplified product. PCR products were prepared using Agencourt AMPure XP beads (#A63881, Beckman Coulter, CA, USA) following the manufacturer’s instructions. Paired-end sequencing was performed on the NextSeq 500 instrument (Illumina). The obtained reads (GEO accession number GSE210617) were mapped on the basis of the human GRCh38.p13 genome using the Burrows–Wheeler aligner (BWA-MEM: ver. 0.7.17-r1188).\n\nBioinformatic analysis of ATAC-seq\nBioinformatic analysis was performed as described previously. Peak calling was performed using MACS2 (ver. 2.2.6) and epic2 (ver. 0.0.41) with default parameters. Peak annotation was performed using HOMER (ver. 4.9.1). For GO analysis, we first extracted peaks that exhibited at least a twofold increase in ATAC signal before and after gilteritinib treatment. We then compiled a list of the protein-coding genes nearest to each peak and performed the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses using DAVID2021 (https://david.ncifcrf.gov/tools.jsp). The differential peaks were identified by calculating the log2FC value (< −0.75 or > 0.75). Next, the functions and transcription factor regulations among the peaks were analyzed by comparison with the transcription active site (Histone H3K27 acetylation site) or transcriptional repression site (Histone H3K9 di-methylation site) using ChIP-Atlas (http://chip-atlas.org/). Histone acetylation or methylation site data in the leukemia cells of the patient with AML were obtained using Chromatin Immunoprecipitation (ChIP) of H3K27ac (SRX4496694) and H3K9me2 (SRX1136016), respectively. The motif enrichment analyses were performed using the MEME-ChIP algorithm.\n\nResults\nThe laboratory data of the patient at before and after timepoints are presented in Table 1. Immature granulocytes along with blast cells seen in the peripheral blood before the treatment, remained until day 4 (after). From the before and after specimens, 4.66 × 103 and 2.14 × 103 of CD34+ cells were isolated, respectively. They were subsequently analyzed using ATAC-seq. As expected, the signal peaks were concentrated around transcription start sites (TSS). After the treatment, greater than fivefold changed peaks were detected in 137 (upregulated) and 105 (downregulated) regions. Along with the affected regions, half of the regions (66 out of 137 upregulated and 37 out of 105 downregulated) were located in the intergenic regions that were assumed to serve as regulators for the adjacent genes. A GO analysis of affected genes listed the mitogen‑activated protein kinase pathway, consistent with the previous findings of intracellular signalling pathways potentiated by the FLT3 genetic mutations in leukemia cells. We then took a closer look at the loci of the listed genes associated with cancers. No alteration on the FLT3 gene locus was seen due to the treatment. On the gene locus of PPP2R2B (a subunit of tumor suppressor protein phosphatase 2A), the peaks were decreased, suggesting reduced chromatin accessibility. In contrast, upregulation peaks were observed on the gene locus and adjacent noncoding region of platelet-derived growth factor D (PDGFD) that is associated with the progression of various types of cancer, including AML. As the profiles of chromatin openness were affected, we tested whether de novo binding of DNA-binding transcription factors was generated by gilteritinib. By a motif enrichment analysis of DNA binding sites of transcription regulators in the open chromatin areas, no significant alteration of enrichment was seen between before and after treatment scenarios.",
    "summary": "A 65-year-old Japanese male patient who was receiving regular hemodialysis developed pancytopenia in 2017. He required recurrent red blood cell transfusions due to anemia in 2018. In 2019, he was diagnosed with myelodysplastic syndrome with excess blasts. We administered three courses of azacitidine but ceased it due to severe cytopenia. His disease had transformed to acute myeloid leukemia. The fourth course of azacitidine was administered, but it was ineffective. Since a tyrosine kinase domain mutation in FMS-like tyrosine kinase 3 was detected in the acute myeloid leukemia cells, we administered gilteritinib at a dose of 120 mg. Although the treatment initially showed efficacy, the disease progressed, and he died 7 days after the initiation of gilteritinib. To assess the epigenetic changes in acute myeloid leukemia during the treatment with gilteritinb, we performed the assay for transposase-accessible chromatin with sequencing using the leukemia cells obtained from the patient before and after gilteritinib treatment. After the treatment, greater than fivefold changed assay for transposase-accessible chromatin peaks were detected in 137 (upregulated) and 105 (downregulated) regions. Among them, half of the regions were located in the intergenic regions. A Gene Ontology analysis of affected genes listed the mitogen‑activated protein kinase pathway, which is potentiated by the FMS-like tyrosine kinase 3 genetic mutations in leukemia cells. No significant changes were noted at the FMS-like tyrosine kinase 3 locus. On the gene locus of PPP2R2B, a known cancer-associated gene, the peaks were decreased, suggesting reduced chromatin accessibility. Conversely, upregulation peaks were observed on the gene locus and adjacent noncoding region of PDGFD that is associated with the progression of various types of cancer including acute myeloid leukemia."
  },
  {
    "id": "multiclinsum_gs_en_502.txt",
    "fulltext": "Female, Caucasian, 73 years old patient who sought a breast disorder service with a complaint of a pink change in the skin of the right breast about 30 days ago. A bilateral mammography 5 months before the consultation showed benign changes (Breast Imaging Reporting and Data System – BI-RADS™ 2). The patient had a history of invasive ductal carcinoma in the right breast G3 without special type, which was treated with segmental resection and axillary lymph node dissection levels I and II in December 2011. At the time of surgery, a tumor measuring 3.0 cm and three axillary lymph nodes showing metastasis (3/10) were observed. Immunohistochemistry revealed that the tumor was positive for estrogen receptor (90%), positive for progesterone receptor (2%), HER-2 negative, Ki-67 positive (60%) and of the luminal B subtype. The patient's adjuvant therapy included six cycles of doxorubicin, cyclophosphamide and paclitaxel therapy, followed by radiotherapy (25 sessions with a dose of 50Gy in the right breast and supraclavicular fossa, plus a boost of 10Gy). The patient is currently undergoing endocrinological treatment with letrozole (6 years of treatment). On physical examination, she presented two pink lesions in the right breast, one erythematous and almost imperceptible at the junction of the upper quadrant (JQS), and the other a more intense violet lesion at the junction of the lower quadrant (JQI) measuring 0.5 cm.\n\nAn incisional biopsy of the lesion was performed at the JQI, which demonstrated atypical vascular lesion in hematoxylin-eosin staining. A complementary immunohistochemical study of the angiosarcoma was suggested for completion of the diagnosis. Following the outcome of this study, the patient underwent resection of both skin lesions. The anatomic pathological report of the resected specimen showed well-differentiated angiosarcoma (G1), a neoplasm characterized by aligned vascular anastomoses of atypical endothelial cells, characterized by the presence of hyperchromatism and anisocytosis and, in some cases, containing erythrocytes, organized in a pattern of infiltrated growth, permeating the mammary parenchyma and the dermis in the JQI, measuring 1.9x1.4cm, and in the JQI, constituting neoplasm restricted to the dermis, measuring 1.1x0.5cm. The immunohistochemical examination revealed positivity for expression of the group of differentiation 31 (CD31) and oncogene C-MYC, confirming the malignancy secondary to radiation therapy. The computed tomography of the thorax and abdomen and the bone scintigraphy did not show signs of distant metastasis. The patient underwent a simple mastectomy of the right side, without reconstruction as a complementary treatment. The final histopathological report showed well-differentiated angiosarcoma (G1) and three more microscopic foci were found in the mammary parenchyma, the largest of which measured 2mm. Two years after surgery, the patient did not develop a recurrence.\n",
    "summary": "We report the case of a 73-year-old woman with a history of right breast cancer treated conservatively, who presented with a discrete pink change in the skin of the ipsilateral breast. A mammogram showed a result consistent with benign changes (BI-RADS 2). In the incisional biopsy material, hematoxylin-eosin demonstrated atypical vascular lesion and suggested immunohistochemistry for diagnostic clarification. The patient underwent resection of the lesions, and the histology demonstrated radiogenic angiosarcoma. Subsequently, a simple mastectomy was performed. Immunohistochemistry demonstrated positivity for the antigens related to CD31 and CD34, and the amplification of the oncogene C-MYC confirmed the diagnosis of radiogenic angiosarcoma induced by breast radiation. Delayed diagnosis is an important issue. Considering that the initial skin changes of radiogenic angiosarcoma are subtle and can be confused with other benign skin conditions, such as telangiectasias, in this report we highlight the clinical aspects, in order to alert about the possibility of breast angiosarcoma in patients with a history of adjuvant radiotherapy for the treatment of breast cancer. The patient remained asymptomatic 16 months after surgery.\n"
  },
  {
    "id": "multiclinsum_gs_en_154.txt",
    "fulltext": "38-year-old male patient with no relevant medical history, presented to the emergency department with a one-year history of a condition characterized by a history of multiple teeth falling out (1st, 2nd, 3rd upper left molar, 3rd upper right and lower molar); no association with trauma, smoking or poor dental hygiene. In the last month he presented gingival recession and difficulty chewing. On physical examination, he presented increased mobility in posterior teeth of the maxilla and mandible, associated with severe gingivitis and halitosis. Panoramic radiography showed multiple lesions in the bilateral mandibular body of the punch-drilled type. Complementary study with a CT scan of the skull showed multiple bilateral bone lytic lesions in the mandible, maxilla, left temporal bone and ipsilateral sphenoid zygomatic region. In the histopathological study, the mandibular biopsy presented foci of chronic inflammatory lymphoplasmocytic infiltrate, micro granulomas in fibrous connective tissue and hemorrhagic foci composed of histiocytic cells. Immunohistochemistry presented positive markers for CD1a, CD68 and S100. In the extension study in bone scintigraphy, increased osteoblastic activity was observed in the axial and appendicular skeleton, and in the myelogram, myeloid hyperplasia with 5% plasma cells and rouleaux, all findings consistent with HCL.\n\nIn the course of the evaluation, the patient had polyuria, polydipsia and nocturia; so a suspicion of a pituitary gland condition was raised, and general and hormonal laboratory studies were requested, highlighting panhypopituitarism with diabetes insipidus, hypogonadism, hypothyroidism and secondary adrenal insufficiency. In addition, a brain MRI was requested, which showed a hypothalamic nodule of 12 × 8 × 7.2 mm that compromised the infundibular region, associated with the absence of the normal signal of hyperintensity of the neurohypophysis in T1, a lesion highly suggestive of granulomatous infiltration.\n\nGiven the clinical background, laboratory, imaging and pathological findings, a therapeutic management was decided as a HCL of multisystem involvement, with involvement of the central nervous system. A bucomaxillofacial defocalisation of the primary mandibular lesion was performed, hormonal supplementation of the affected axes and a chemotherapy scheme was initiated, initially an induction scheme of vinblastine/prednisone/6-mercaptopurine, however, when a hypophyseal involvement was demonstrated, and taking into account the guidelines of the Ministry of Health of Chile and the Chilean Society of Haematology, it was changed to a scheme with cladribine (2-CdA) plus cytarabine for 5 cycles, achieving a first complete remission (RC1) with a decrease of the pituitary gland nodule by 50%, radiotherapy was indicated at low doses to the first lumbar vertebra (L1) with improvement of the pain. Biphosphonates were not indicated due to being considered of high risk due to maxillary involvement. He is currently in RC1 in follow-up, fully integrated into his work activities and maintaining hormonal supplementation without problems. The patient was asked for informed consent for disclosure of his clinical background.\n",
    "summary": "We present the case of a 38-year-old man with a history of long-standing loss of multiple teeth, with no association to trauma, smoking or poor dental hygiene. Computed tomography (CT) of the skull showed multiple mandibular lytic lesions. The result of mandibular biopsy and immunohistochemistry were consistent with the finding of HCL. During its evolution, it presents with polyuria, polydipsia and nocturia, confirming by hormonal study diabetes insipidus and panhypopituitarism. Brain magnetic resonance (MR) shows hypothalamic neoplasia with infundibular involvement and image suggestive of pituitary granuloma. Maxillobucal defocalisation, hormonal supplementation, along with chemotherapy and radiotherapy were decided. The patient evolved favorably.\n"
  },
  {
    "id": "multiclinsum_gs_en_391.txt",
    "fulltext": "53-year-old woman with a history of RA of 15 years of diagnosis in treatment with methotrexate, rest of the history without important data, who presented clinical picture 8 months ago (before coming to our service) with progressive asthenia and adynamia, pallor of teguments, unquantified thermal elevations of nocturnal predominance, unintentional weight loss of 15 kg in approximately 6 months, without medical evaluation or follow-up, to which was added 3 months later dyspnea of large to medium efforts, and whose symptomatology became acute 5 days ago (before coming to our service), together with bleeding from the upper digestive tract (STDA), characterized by abundant melena evacuations, 3 evacuations in 24 hours, hematemesis on 2 occasions, scarce, without apparent cause. The patient denied consumption of non-steroidal analgesics (AINE) and had an increase in volume in the left leg, which hurt her and had the presence of oedema and erythema, with limitation to mobility, which is why she came to (our) Emergency Service.\n\nDuring her hospitalization with severe anaemia without haemodynamic repercussion, 3 erythrocyte concentrates were transfused without apparent complications. After her stabilisation, a diagnostic approach was initiated for consumptive syndrome. Due to the clinical picture of the left lower limb, a US Doppler was performed that evidenced deep venous thrombosis. An ultrasound of the abdomen was performed for probable hepatopathy due to methotrexate, which reported splenic and hepatic infarctions, as well as the presence of chronic hepatic changes. Endoscopy was performed with evidence of small varices, without active bleeding. Due to the suspicion of neoplasia due to the patient's background and clinical picture, a simple and contrasted axial tomography of the thorax and abdomen was performed and hepatosplenomegaly and multiple axillary, mediastinal and paraaortic lymph node clusters were found, suggesting infiltrative activity. This was assessed by the General Surgery Service for the performance of a biopsy of the right axillary lymph node, where a neoplastic proliferation of lymphoid cells was reported. Subsequently, the Haematology Service of the unit was assessed, laboratory studies (Table I) were requested and a bone marrow aspirate was performed in which dysplastic plasma cells and reticular cells were evident, for which it was concluded that there was the presence of infiltrative lymphoplasmocitary activity. With the background, clinical picture and complementary studies, a diagnosis of stage IV NHL was made and the patient was sent to a third-level hospital for the performance of immunohistochemistry, staging and initiation of treatment. In the third level, a diffuse B-cell lymphoma with B CD20 immunophenotype with an overgrowth of dendritic cells was identified, and the patient was assessed for the initiation of treatment with chemotherapy.\n",
    "summary": "55-year-old woman with a history of RA who was admitted to an internal medicine department for gastrointestinal bleeding; she presented clinical data of deep venous thrombosis in the left pelvic limb and a consumptive syndrome under study. During her admission she was identified with splenic and hepatic infarctions, as well as multiple ganglion conglomerates, so an axillary lymph node biopsy was performed that reported neoplastic proliferation of lymphoid cells and aspirate of bone marrow with the presence of lymphoplasmocytic infiltration, with which a diagnosis of non-Hodgkin lymphoma stage IV was determined. The patient was sent to a third-level hospital for the start of treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_56.txt",
    "fulltext": "Clinical presentation\nA 63-year-old male presented with acute-onset intermittent dizziness and hemi-ring visual disturbances under flashlight illumination. He developed a persistent left temporal headache lasting approximately 40 min over several days, aggravated by exercise but relieved with acetaminophen. There were no changes in colour saturation, light intensity, or postural correlation. The patient denied photophobia, phonophobia, neurological deficits, or a family history of headaches. Additional symptoms included pulsatile low-pitch tinnitus, bilateral muscle cramps, and nasal stiffness over the past 2 weeks.\n\nInvestigation/image findings\nPhysical examination revealed left post-auricular bruits. Doppler ultrasound showed low-resistance flow in the left external carotid artery (ECA). Electroencephalography (EEG) detected rhythmic spiky discharges over the left hemisphere, peaking at T3T5, suggesting a non-convulsive seizure. Anti-epileptic therapy was thereby initiated.\n\nMRI unveiled tortuous vessels at the left parieto-occipital region and left occipital scalp, along with abnormal signals in the left sigmoid sinus and suspected arteriovenous shunting. Diagnostic cerebral angiography confirmed a dural arteriovenous fistula (dAVF) at the left sigmoid sinus, with arterial feeders originating from branches of both ECAs and the left meningohypophyseal trunk. Multiple shunting points were noted at the medial left transverse sinus, left transverse-sigmoid sinus junction, and the mid-sigmoid sinus, with venous drainage into multiple cortical veins and internal jugular vein, classifying the condition as Cognard type IIb.\n\nTreatment\nTo prevent haemorrhage, transvenous embolization was performed successfully using coils and 3 vials of Onyx 34. Post-procedural angiography disclosed complete resolution of the arteriovenous fistula. On-table CT showed no haemorrhage. The patient remained stable, without headaches, nausea, vomiting, or signs of increased intracranial pressure.\n\nComplications and long-term outcome\nThree days later, the patient developed headaches, mild dizziness, visual discomfort, and alexia, with impaired reading and writing but preserved comprehension and speech. MRI demonstrated T2-FLAIR hyperintensity without diffusion weighted imaging (DWI) hyperintensity over the left temporo-occipital area, suggesting vasogenic oedema due to venous outflow obstruction. Despite enoxaparin and hydration, symptoms progressed to naming difficulties, memory decline, reduced speech fluency, and non-convulsive seizures.\n\nCT revealed post-embolization white matter changes in the left parieto-occipital lobes and focal hypodensity in the left capsular region. Dexamethasone improved symptoms, enable discharge. Follow-up CT at 2 weeks showed mild resolution.\n\nAt 1 month, reading and speech fluency returned to baseline, with gradual improvement in writing over 3 months. Muscle cramps resolved with reinstated anti-epileptic medication. MRI after 3 months of treatment showed resolution of oedema and minimal gliosis, remaining stable after 1 year.",
    "summary": "A 63-year-old male presented with acute onset of intermittent dizziness, visual disturbances, and left temporal headache. Investigations revealed a dural arteriovenous fistula (dAVF) at the left sigmoid sinus, classified as Cognard type IIb. Successful therapeutic transvenous embolization was performed using coils and Onyx, resulting in complete resolution of the dAVF without immediate complications. However, 3 days post-embolization, the patient developed headache, dizziness, visual discomfort, and alexia. MRI findings suggested vasogenic oedema in the left temporo-occipital area due to venous outflow obstruction. Despite treatment with enoxaparin and dexamethasone, the patient experienced progressive symptoms including difficulty in object naming, memory decline, and nonconvulsive seizures. Follow-up imaging indicated improvement of oedema and stable minimal focal gliosis."
  },
  {
    "id": "multiclinsum_gs_en_267.txt",
    "fulltext": "76-year-old woman of Paraguayan nationality, resident in the Autonomous City of Buenos Aires, with no history of recent travel, with a history of aortic stenosis and arterial hypertension, regular medication: bisoprolol. She began 5 days prior to admission with fever, cough with mucopurulent expectoration and respiratory dyspnoea that progressed to class functional III-IV, abdominal pain and headache. She was treated on an outpatient basis 48 hours prior to admission with amoxicillin-clavulanic acid; SARS-CoV-2, influenza A and B virus and respiratory syncytial virus were tested by polymerase chain reaction, which was negative. She consulted the hospital for respiratory dyspnoea class IV, nausea and abdominal pain, a computed tomography (CT) scan was performed that showed bilateral interstitial infiltration. She was admitted to the Intensive Care Unit on 30 March 2023, with secondary septic shock to respiratory focus, fever 38 °C, 120 beats per minute and acidosis, the severity scores of the Sepsis Related Organ Failures Assesment (SOFA) totaled 7 points and Acute Physiology and Chronic Health Classification System II (APACHE II) 21 points. Reanimation with fluids was initiated, clinical analyses were performed, which showed increased haematocrit, haemoconcentration, leukocytosis and acute renal failure, samples were taken for haemocultures, urine culture and respiratory culture. Samples were sent to the blood virology laboratory for dengue virus and CHIKV. A point of care ultrasound (POCUS) was performed, which showed moderate aortic stenosis, with a peak speed of 3.4 m/sec, preserved left ventricular systolic function, without segmental mobility alterations, without signs of acute cardiac failure, and no vegetations were observed in the valves by this approach. She was initiated with broad spectrum antibiotics: ceftriaxone and vancomycin. She progressed with respiratory, haemodynamic and renal failure. She required mechanical ventilation, high dose vasopressors, furosemide infusion for oliguria, refractory shock, and died on 31 March 2023. After death, bacteriological cultures of blood, urine and tracheal secretions concluded without bacterial development, real-time polymerase chain reaction and NS1 antigen not detectable for dengue virus, and real-time polymerase chain reaction for CHIKV detectable in serum.\n",
    "summary": "A 76-year-old woman with a history of hypertension and aortic stenosis was admitted to the intensive care unit for septic shock with respiratory focus, with a pattern of interstitial pneumonia, a torpid evolution and death within 24 hours of admission. The postmortem result of a detectable Chikungunya virus by real-time polymerase chain reaction was received.\n"
  },
  {
    "id": "multiclinsum_gs_en_45.txt",
    "fulltext": "A 37-year-old Caucasian woman, 35 weeks pregnant with a history of two previous miscarriages, began to have profuse epistaxis from the left nostril. She was brought to the emergency room of the local hospital, and the patient was hemodynamically unstable, and the monitoring was consistent with severe fetal distress, which led to an emergency cesarean section. During the induction of anesthesia, a focal convulsion (attributed to the induction of anesthesia in the context of severe hypovolemic shock with cerebral hypoperfusion) occurred. The patient continued to epistaxis, receiving five units of packed red blood cells and one unit of fresh frozen plasma over 2 days. Due to failure to control the epistaxis with a local hemostatic balloon, she was transferred to a tertiary hospital for angiography and possible embolization. During this period, she did not show any change in mental status and maintained hemodynamic stability, with the hemostatic balloon in place.\n\nThe first angiography was performed using 50mL of low-osmolarity, organic non-ionic contrast medium, administered into the internal and external carotid arteries. Abnormal vascular flushing was observed in the left nasal cavity, dependent on branches of the sphenopalatine artery, and embolisation was performed. However, epistaxis returned shortly afterwards, and 2 hours later, a new angiography was performed, in which the existence of residual vascular flushing was excluded, confirming the success of the first embolisation. The total non-ionic contrast used in both angiographies was 90mL. Local tamponade in the left nasal cavity was maintained.\n\nShortly after the second angiography, in the post-anaesthetic recovery room, the patient began to show signs of disorientation, with sleepy speech, but without formal visual complaints or motor deficits. Within 2 hours of the second procedure, the patient was awake, but crying continuously, developed hyperventilation, could not obey orders, could not fix her gaze and had repetitive, unintelligible speech, without the ability to formulate sentences. She was hemodynamically stable, afebrile and without meningeal signs. She was transferred to the intensive care unit (ICU) due to clinical evolution and the possible need for airway protection, in a context of acute confusional state without known cause.\n\nThe patient's agitation and lack of cooperation made it impossible to adequately assess language, thought content, or mood, so that a possible aphasia could not be ruled out at that time. A formal psychiatric evaluation within a few hours of the onset ruled out these possibilities, as well as the more common postpartum psychosis (PPP). There were no motor deficits, changes in cranial nerves, or other focal signs suggestive of extensive focal neurologic injury. Given the acute presentation, an MRI was performed to assess possible complications of the angiography, and a lumbar puncture was performed to exclude infectious or inflammatory disease of the central nervous system. An electroencephalogram was also performed.\n\nThe MRI examination showed a small hyperintense focus on the diffusion-weighted image at the level of the white matter of the left corona radiata, with hypointensity on the apparent diffusion coefficient map and discrete hypointensity on the fluid attenuated inversion recovery. There was also edema in the posterior temporal-occipital-parietal cortex bilaterally with discrete hyperintensity on the fluid attenuated recovery but without diffusion restriction suggesting vasogenic edema. The cerebrospinal fluid was clear with normal opening pressure and had four cells per field, glucose of 72 mg/dL, protein of 53 mg/dL and lactate dehydrogenase (LDH) of < 30 IU/L. The polymerase chain reaction was negative for an extensive panel of neurotropic viruses; all bacterial cultures were negative. There were no electrolyte disturbances, and the systemic tests for autoimmunity were negative.\n\nThe EEG had predominantly theta activity in the posterior projection, beta in the anterior and infrequent theta-delta in the frontotemporal region, with left-sided dominance, sometimes with rhythmic morphology followed by baseline suppression. The EEG revealed diffuse slowing of basal electrogenesis to a moderate degree. There was slow activity in the left frontotemporal hemisphere with a few associated paroxysmal components, but mild and non-continuous.\n\nSedative analgesia and mechanical ventilation were maintained for 2 days, with withdrawal after clinical stabilisation as well as MRI and EEG results to exclude additional brain damage, which might require a different treatment.\n\nThe patient was extubated and had a very poor vocabulary (maximum 40 words), without focal deficits. In less than 24 hours, a progressive improvement in speech and rational content was observed, without other changes in the examinations. Renal function always remained normal.\n\nA new MRI was performed 48 hours after the first one, showing few millimetric and diffuse bilateral cortical/subcortical lesions, probably related to the previous angiography. There was a complete resolution of the posterior cortical oedema. The rest of the brain parenchyma was without other relevant changes in the evolution of the signs.\n\nThe patient did very well clinically with a rapid recovery of speech and all neurological deficits. The tamponade was removed on day 3 and the patient was discharged 5 days after the cesarean.\n",
    "summary": "A 37-year-old pregnant woman in her 35th week was admitted to a local hospital for severe epistaxis, which resulted in shock and the need for emergency cesarean delivery. After tamponade failed to control the hemorrhage, angiographic treatment was decided. After the procedure, she was admitted to the neurocritical care unit, where she was confused and agitated, requiring sedation and orotracheal intubation. In the intensive care unit, investigations included magnetic resonance imaging, lumbar puncture with viral panel, electroencephalogram, tests for autoimmunity, and hydro-electro- and metabolic assessments. The magnetic resonance imaging showed a restricted point-like area in the left corona radiata in the heavy diffusion imaging sequences, as well as mild posterior cortical edema (without restriction to diffusion), and the electroencephalogram showed moderate diffuse slow activity, slow frontoparietal activity, and scant associated paroxysmal components in the left hemisphere. Other examinations showed no relevant changes. Because of the temporal relationship and clinical history, as well as magnetic resonance imaging, the diagnosis of contrast-induced encephalopathy was made. Sedation was withdrawn after 2 days in the intensive care unit, and the patient was extubated, with complete neurological recovery within the next 24 hours.\n"
  },
  {
    "id": "multiclinsum_gs_en_64.txt",
    "fulltext": "37-year-old female patient with multiple medical consultations since early age: episodes of headaches plus compromised consciousness, non-specific chest pain, intestinal transit disorders, tremors and dysfunction of perineal musculature and pelvic floor. Evaluated by specialists, depression and interstitial cystitis are diagnosed, and the functional character of disorders is concluded, from the neuropsychiatric point of view. Therapeutic management by Psychiatry and treatment with lamotrigine, escitalopram, clonazepam, pregabalin, quetiapine and aripiprazole.\n\nConsulted in the emergency department for atypical chest pain, without other manifestations or findings. SARS-CoV-2 infection was diagnosed by PCR COVID-19 in nasopharyngeal secretion. Electrocardiogram, cardiac enzymes and angioTC of the chest were normal. Discharged with symptomatic treatment. Three days later, he consulted for the same pain, without other symptoms, physical and complementary examinations, again normal.\n\nHe consulted for the third time in the emergency department a week later, this time for fatigue, shortness of breath and left precordial pain, exacerbated by the compression of sterno-costal joints, without irradiation. No other symptoms. On physical examination: well perfused, tachycardia 118 bpm, normotension, respiratory rate 25 bpm, pulse oximetry 99% (FiO2 0.21). Chest X-ray normal. Electrocardiogram: sinus tachycardia, no signs of ischaemia. Elevated troponins. He presented with loss of consciousness, with mid-sopor, interrupted by awakenings in relation to thoracic pain. SARS-CoV-2 associated myopericarditis was considered and he was hospitalised in a monitored unit. In the Intermediate Treatment Unit, the compromise of consciousness was deepened until coma. Tachycardia 180 bpm, blood pressure 140/90 mmHg, respiratory rate 50-60 bpm, pulse oximetry 80% with erratic curve, T° 36°C, poor perfusion, mottling score of 4, distal coldness and slow capillary filling, bilateral maintained palpebral tremor, cervical and upper and lower limb muscle contracture. Diagnoses of conversion disorder and possible severe respiratory alkalosis were considered. A mask with reservoir was placed (with FiO2 0.21) and intravenous boluses of lorazepam and saline solution 0.9% were administered. A new electrocardiogram objectified tachycardia of 167 bpm and diffuse infradesnivel ST in the anterior wall. Control examinations confirmed severe respiratory alkalosis with pH 7.68 and PaCO2 of 10 mmHg.\n\nAfter several boluses of lorazepam, she slowly regained consciousness. The muscle contractures and chest pain disappeared. The vital signs and peripheral perfusion were normalized. After the recovery of the crisis, and in the following days, multiple examinations and multidisciplinary evaluation were performed. Electrocardiograms, cardiac enzymes and echocardiogram were normal. Gases and other normal biochemical parameters. The patient remained stable and had no memory of the episode.\n\nAfter 5 days of hospitalization, she was discharged after a multidisciplinary evaluation (cardiology, neurology and psychiatry) that ruled out an organic origin.\n",
    "summary": "We present the case of a 37-year-old woman with a history of conversion disorder. While infected with SARS-CoV-2 (without pulmonary involvement), she presented to the emergency department with a panic attack. On admission, she developed a new conversion disorder with progressive clinical deterioration, hyperventilation and severe respiratory alkalosis (pH 7.68, bicarbonate 11.8 mEq/L and PaCO2 10 mmHg). She was clinically comatose with respiratory and heart rates of 55 and 180 per min, blood pressure of 140/90 mmHg, perfusion impairment (widespread lividity, distal coldness and severe mottling of the skin) and tetany. She also had electrocardiographic changes and elevated troponin levels suggestive of ischemia, and hyperlactatemia. She was treated in hospital with intravenous benzodiazepines. The clinical and laboratory manifestations resolved rapidly, without the need for invasive measures and without systemic repercussions.\n"
  },
  {
    "id": "multiclinsum_gs_en_524.txt",
    "fulltext": "A 9-year-old male patient presented to the Urology Department of Mulago National Referral Hospital with a history of a painless scrotal mass, which was initially small in size and had gradually increased in size over 3 years. As a baby, he was fairly well until the scrotal swelling ensued. His early childhood was unremarkable.\n\nPhysical examination revealed a non-tender fixed-left scrotal mass of 5 cm in diameter. The overlying skin was intact. No palpable regional lymph nodes seen.\n\nA complete blood count showed hemoglobin of 12.3 g/dL and a white blood cell count of 7600 cells/mm3. The liver and renal function tests were within normal limits.\n\nAn enhanced computed tomography (CT) scan of the abdomen and pelvis for local staging and assessment of distant metastasis demonstrated a heterogeneously enhancing mass (30–55 HU), occupying the region of the scrotum extending into both inguinal regions and the pelvis, making it difficult to delineate the testicles. No bone erosion was detected. The abdomen was negative for metastasis. The chest X-ray was also unremarkable.\n\nAn ultrasound-guided Tru-Cut biopsy was carried out and the sample was sent for histopathological and immunohistochemical examination.\n\nIn the histopathological review, the hematoxylin and eosin-stained section revealed a tumor composed of sheets of bland cells with spindle-shaped nuclei and pale eosinophilic cytoplasm forming a storiform pattern and diffusely infiltrating the underlying adipose tissue. Myxoid stroma with prominent thin-walled vessels was seen. The tumor cells were diffusely and vigorously positive for CD34.\n\nSurgical removal was performed, with negative resection edges, and the patient was placed on adjuvant radiotherapy. He received a total dose of 60 Gy using conventional external beam radiotherapy with a cobalt-60 machine, in fractions of 2 Gy per day, using direct anterior fields to the primary tumor site. He completed the treatment with no immediate or late complications and good tolerance. The patient was doing well on follow-up.",
    "summary": "We present a 9-year-old male with a history of a left scrotal mass for 3 years. An enhanced computed tomography (CT) scan of the pelvis showed a heterogeneously enhancing mass in the scrotum with extension into both inguinal regions. Histology showed spindle-shaped cells forming a storiform pattern in the hypercellular area and myxoid stroma with prominent thin-walled vessels. Immunohistochemically, the cluster of differentiation 34 (CD34) was positive. The mass was removed by surgical excision with negative resection edges, and then adjuvant radiotherapy of 60 Gy was given. The patient had a good outcome with treatment and was doing well on follow-up."
  },
  {
    "id": "multiclinsum_gs_en_262.txt",
    "fulltext": "Female, 34 years old. History of benign tumour in the right submaxillary salivary gland and multiple fibroadenomas of the breast. Smoker. Consulted for sudden diplopia, altered coordination of the right upper limb, bradilalia and isolated anomalies. On admission, neurological condition improved with normal examination. Blood pressure and blood glucose normal. MRI of the brain was performed, which showed a restrictive image in the diffusion sequence at the level of the left thalamus. Admission to the cerebrovascular unit was decided for monitoring, screening studies and treatment. General laboratory, erythro-sedimentation, C reactive protein, beta subunit of hCG, HIV, VDRL, collagenogram and toxicological analysis in urine were normal. Acquired and genetic thrombophilias were negative. Angiotomography of intra- and extracranial vessels, with embryonic-fetal origin of the left posterior cerebral artery, without other relevant findings. 72-hour telemetry with no evidence of cardiac arrhythmias. Considering possible paradoxical embolism, a Doppler of the four limbs was performed without thrombosis, transcranial Doppler with contrast with spontaneous bubble passage in the form of a curtain in both the left and right carotid arteries and a transthoracic echocardiogram with contrast (ETT-c) that reported a right-left short circuit with moderate spontaneous passage before the second heartbeat. It was interpreted as a stroke associated with probable FOP and treatment was initiated with double antiplatelet therapy and statins. During the procedure prior to the closure of FOP, an intracardiac echocardiogram was performed with no evidence of atrial septal defect or intracardiac right-left short circuit. Selective arterial inflow catheterisation was performed and it was completely occluded with an endovascular device, preserving the normal arteries. During follow-up, clinical, gynaecological, oncological and rheumatological evaluation was performed with no relevant findings. The patient did not meet any of the Curaçao diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome), i.e. recurrent epistaxis, cutaneous/ mucosal telangiectasias and multiple visceral involvement, nor did she have a first-degree family member with the disease. It was also decided to carry out a genetic study with a panel of hereditary hemorrhagic telangiectasia (genes: ACVRL1, ENG, EPHB4, GDF2, RASA1 and SMAD4), with a negative result. The finding was interpreted as a sporadic HHT. The patient is currently stable clinically and neurologically. The patient signed informed consent authorising the publication, reproduction and dissemination of the clinical case.\n",
    "summary": "We present the case of a 34-year-old woman with left thalamic ischemic stroke. A “curtain” bubble was detected in cerebral arteries by transcranial Doppler. Intracardiac ultrasound did not find a patent foramen ovale, which is why pulmonary angiography was performed, which confirmed the presence of PVA. The patient received successful endovascular treatment.\n"
  },
  {
    "id": "multiclinsum_gs_en_355.txt",
    "fulltext": "A 24-year-old male patient was admitted to the Otorhinolaryngology Department at Welcare Specialty Hospital. He had a painless swelling in the anterior region of the hard palate that had gradually increased in size over the past five years. The patient reported no history of trauma and infection. During the examination, it was observed that the swelling was well-defined, firm, and non-tender. It was located on the left side of the anterior maxillary wall and had extended to the floor of the left nasal cavity, pushing the nasal septum to the right side. Intra-orally, the mass bulged on the anterior hard palate and there were no pulsation or signs of infection were visible. During a nasal endoscopy, it was observed that there was swelling in the floor of the left nasal cavity, and the septum was deviated towards the right nasal cavity. A computed tomography (CT) scan showed an oval-shaped radiolucent lesion in the midline of the maxilla and bony remodeling, 51mm in size. A vitality test revealed positive for all anterior teeth and FNAC was done to exclude malignancy. Based on clinical and radiological findings, the patient was diagnosed with a nasopalatine duct cyst. All necessary preoperative tests were conducted and the results were found to be within the normal range. The patient underwent a transnasal endoscopic marsupialization procedure under general anesthesia to treat the cystic swelling in the left nasal cavity. Initially, a greenish fluid was drained, followed by an incision made on the roof of NDC (floor of the left Nasal cavity). The incision was then enlarged and the roof of NDC was removed and sent for histopathology. Following a postsurgical nasal endoscopic evaluation, no signs of recurrence were observed.\n\n\nHistopathological Examination\nMicroscopic examinations revealed the presence of fragments of cystic tissue. These fragments are partly lined by stratified squamous epithelium and partly by pseudostratified columnar epithelium which contain variable goblet cells and cilia. The cyst wall is composed of fibrous tissue that has mucinous glands, cartilaginous rests, arteries and veins, and mixed inflammatory cells.",
    "summary": "A 24-year-old male patient with a large nasopalatine duct cyst with a diameter of 51 mm was managed by transnasal endoscopic marsupialization under general anesthesia. The presentation involves painless swelling around the left side of the anterior maxilla and bulging of the hard palate. No postoperative complications were observed after a 3-month follow-up. Transnasal endoscopic marsupialization is a minimally invasive surgery for large NDC."
  },
  {
    "id": "multiclinsum_gs_en_488.txt",
    "fulltext": "A 61-year-old Syrian male with a history of alcoholism and heavy smoking presented to the dermatology department with complaints of itchy pigmented lesions without telangiectasias, scaling, or atrophy on the right side of his trunk and his right thigh. The patient denied prior history of exposure to chemicals or solvents, and there was no family history of skin cancers, skin diseases, or relevant systemic conditions. These lesions were persistent for 3 years, and the patient was previously prescribed a topical 0.1% hydrocortisone cream by a local dermatologist to relieve the itching; the patient used the cream intermittently and only when the itching was severe. Upon clinical examination, hyperpigmented patches on the right side of his trunk and the lateral surface of his right thigh were evident, with no other clinical features. Blood tests of the patient were all within normal ranges except a slight increase in the white blood cell count. Given the nonspecific features, a skin biopsy was performed for further evaluation, and histopathological examination of the biopsy revealed parakeratosic hyperkeratosic epidermis with slight spongiosis. Papillary dermis was infiltrated moderately by atypical lymphocytes with mild deposition of melanophages. Lymphocytic infiltrate was situated in clusters and in linear basilar distribution along the dermoepidermal junction. Immunochemistry of the atypical lymphocytes were CD3+, CD8+, CD4−, CD20−. A chest and abdomen computed tomography (CT) scan was conducted, but yielded only normal findings with no lymphadenopathy or organomegaly. The patient was diagnosed with early stage HPMF and was subsequently referred to a specialized hospital to receive the treatment. Our patient underwent psoralen and ultraviolet A light (PUVA) therapy, with oral 8-methoxypsoralen two times a week, and was prescribed a topical 0.1% betamethasone dipropionate. After 12 weeks of treatment, the itching was relieved, and the hyperpigmentation regressed, but did not disappear. The patient’s long-term prognosis is excellent, and he was instructed to apply moisturizer and avoid sun exposure and is being evaluated every 6 months to detect any further relapse or new lesions on other areas of the body.\n\n",
    "summary": "A 61-year-old Syrian male presented to the dermatology clinic complaining of a persistent pigmented itchy lesion on the right side of the trunk and right thigh. Histological examination of the skin biopsy showed parakeratosic hyperkeratosic epidermis with spongiosis and deposition of melanophages, immunohistochemistry showed CD3+, CD4-, CD8+, and CD20-, and our patient was diagnosed with hyperpigmented mycosis fungoides, and subsequently treated with psoralen and ultraviolet A therapy, a very good improvement was noted, and the prognosis was excellent."
  },
  {
    "id": "multiclinsum_gs_en_540.txt",
    "fulltext": "A 47-year-old female with a history of congenital CHB presented with complaints of left-sided neck pain and left ear pain. Approximately 30 months prior to presentation, the patient had noticed a small mass on the left side of her neck, which had gradually increased in size. The pain was initially localized to the neck region but had intensified over time and extended to the left ear area.\nInitially, due to left ear pain, the patient consulted several otolaryngologists and was treated for a preliminary diagnosis of otitis media. However, despite treatments, the pain persisted. Eventually, an otolaryngologist referred the patient for an ultrasound, which revealed a mass in the left side of the neck, leading to a surgical referral. After initial evaluations, a CT angiography was requested, which revealed an oval-shaped mass measuring 30 by 50 mm at the left carotid artery bifurcation, suggestive of a Shamblin type II CBT.\n\nPreoperative cardiovascular evaluations\nGiven the patient's history of congenital CHB, a comprehensive preoperative cardiovascular assessment was conducted. This included a 12‑lead electrocardiogram (ECG), which confirmed the presence of CHB with a stable ventricular escape rhythm. Transthoracic echocardiography was performed to evaluate cardiac structure and function, revealing normal ventricular systolic function with no evidence of structural abnormalities. Additionally, a cardiology consultation was obtained to assess the patient's fitness for surgery and to optimize perioperative management.\n\nAnesthetic considerations\nDue to the patient's congenital CHB and the potential for hemodynamic instability during surgery, a detailed anesthetic plan was formulated. The patient was classified as American Society of Anesthesiologists (ASA) physical status III. Preoperatively, an external temporary pacemaker was placed to ensure adequate heart rate control, and an arterial catheter was inserted for continuous blood pressure monitoring. Induction of anesthesia was performed using a combination of etomidate (0.3 mg/kg) and fentanyl (2 μg/kg) to minimize hemodynamic fluctuations. Maintenance was achieved with sevoflurane (1–2 %) and rocuronium (0.6 mg/kg) for muscle relaxation. Hemodynamic parameters, including heart rate, blood pressure, and oxygen saturation, were continuously monitored. Additionally, a central venous catheter was placed to monitor central venous pressure and administer vasoactive medications if needed. The anesthesia team maintained close communication with the surgical team to promptly address any intraoperative hemodynamic changes.\n\nSurgical approach\nThe patient underwent surgery on May 19, 2024, after precise localization of the CBT via CT angiography. The surgical approach was chosen based on the Shamblin type II classification, indicating partial encasement of the carotid arteries. Given the tumor's proximity to critical neurovascular structures, including the vagus and hypoglossal nerves, an open surgical approach was deemed the most appropriate to ensure complete resection while minimizing complications.\nFollowing general anesthesia induction, the patient was positioned supine with the neck extended and rotated to the right. An oblique incision was made parallel to the left sternocleidomastoid muscle, extending from the mastoid process to the sternal notch. After skin incision and platysma dissection, the carotid sheath was carefully exposed. The common carotid artery and its bifurcation into the internal and external carotid arteries were identified. The tumor, measuring 30 × 50 mm, was observed at the carotid bifurcation and meticulously dissected from surrounding tissues.\n\nSpecific maneuvers and precautions\n1.\nTemporary vascular clips were applied to the internal and external carotid arteries to control blood flow during tumor dissection. This minimized bleeding and provided a clear surgical field.\n2.\nIntraoperative neuromonitoring was used to assess the integrity of the vagus and hypoglossal nerves. Continuous feedback ensured that neural structures were preserved during dissection.\n3.\nThe tumor was carefully separated from the carotid arteries and surrounding neural structures using a combination of sharp and blunt dissection. Hemostasis was achieved using bipolar cautery and surgical clips to minimize bleeding.\n4.\nThe external pacemaker was actively monitored throughout the procedure to ensure stable heart rate and rhythm. The anesthesia team was prepared to administer atropine or epinephrine if significant bradycardia or hypotension occurred.\n2.5. Postoperative management\nAfter ensuring no active bleeding and reestablishing blood flow, tissues were returned to their original position, and the wound was closed in multiple layers. Appropriate dressing was applied. The surgery was completed without complications and with minimal bleeding in 2 h and 10 min. The patient was then transferred to the vascular ICU for close monitoring.\nPostoperatively, the patient was monitored in the ICU for 24 h and later transferred to the general ward after clinical improvement. The external pacemaker was removed on postoperative day 1, as the patient maintained a stable ventricular escape rhythm. The patient was discharged in good general condition on postoperative day 3 without specific complaints.\n2.6. Follow-up and long-term outcomes\nHistopathological examination confirmed the definitive diagnosis of CBT in the patient. Follow-up evaluations were conducted at 2 weeks, 1 month, 6 months, and 1 year post-surgery to assess both surgical and cardiac outcomes. At each visit, the patient underwent a 12‑lead ECG to monitor the congenital CHB, which remained unchanged throughout the follow-up period. Transthoracic echocardiography was repeated at 6 months and one year, showing no deterioration in cardiac function and stable ventricular systolic function.\n\nTo evaluate the impact of tumor removal on cardiac function, heart rate variability (HRV) analysis was performed preoperatively and at 6 months post-surgery. Preoperative HRV analysis demonstrated reduced parasympathetic activity, likely due to vagal nerve compression by the tumor. Postoperative HRV analysis showed a significant improvement in parasympathetic tone, suggesting that tumor removal alleviated vagal nerve compression and restored normal autonomic function.\nAdditionally, the patient reported complete resolution of neck and ear pain following surgery, with no recurrence of symptoms during the follow-up period. Imaging studies, including Doppler ultrasound and CT angiography, were performed at 6 months and 1 year, confirming no evidence of tumor recurrence or vascular complications.",
    "summary": "We report the case of a 47-year-old female with a history of left neck and ear pain, accompanied by a gradually enlarging neck mass over 2.5 years. Following initial evaluations and multiple differential diagnoses, CT angiography revealed an oval-shaped mass measuring 30 × 50 mm at the left carotid bifurcation, confirming a Shamblin type II CBT. Preoperative assessments demonstrated congenital CHB on electrocardiogram and echocardiography. The patient underwent complete tumor resection with all necessary precautions, including temporary pacemaker placement and careful monitoring."
  },
  {
    "id": "multiclinsum_gs_en_166.txt",
    "fulltext": "An 87-year-old Persian male patient, previously farmer, who was bedridden because of a hip fracture since 2 years ago, was admitted to Shahid Mohammadi hospital, a tertiary care center in the south of Iran, due to loss of consciousness (LOC), respiratory distress, tachypnea, and oliguria.\n\nHe had a history of 10 days of hospitalization in another hospital due to fever and cough. In that center, a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) test was performed for the patient which was negative, however, based on ground glass opacity on his chest computed tomography (CT) scan and being on the outbreak of COVID-19, he fulfilled case definition of COVID-19; therefore, he received protocol’s treatment; remdesivir 200 mg stat and 100 mg daily for 5 days plus dexamethasone 6 mg daily intravenously. After relative recovery, he was discharged. The patient had no history of any chronic disease and did not receive any medications.\n\nHe had a history of weakness, fatigue, and loss of appetite which he received serum therapy in an outpatient clinic.\n\nIn our center, he was ill and toxic. His Glasgow Coma Scale (GCS) was seven.\n\nPhysical examination revealed heart rate = 107 beats per minute, blood pressure = 100/60 mmHg, temperature = 36.7 °C, saturation = 85% in room air, coarse crackle in lung auscultation, and bilateral pitting edema in his feet. There were no other findings in his physical examination. The patient was in stupor state without eye or verbal contact. He was only responsive to painful stimulus. Pupils were reactive to light and gag reflex was absent. Plantar reflex was normal. The patient had a suprapubic catheter because of benign prostatic hyperplasia for therapeutic purposes since 2 months before admission.\n\nWe asked for blood tests and CT scans for the patient. Blood tests showed WBC of 4.1 × 109 (neutrophils 86%, lymphocytes 9.6%), anemia (RBC = 4.34 cells/mcL, hemoglobin level = 8.8 g/dL, hematocrit = 28.8%, hypochromia ++, schistocyte +), thrombocytopenia (platelet = 110,000/mcL), abnormal electrolytes level (sodium = 158 mmol/L, potassium = 3 mmol/L, phosphorus = 5.4 mg/dL, calcium = 7.2 mg/dL), urea of 140 mmol/L, lactate dehydrogenase of 602 U/L, erythrocyte sedimentation rate (ESR) of 20 mm/h, C-reactive protein of 87.41 mg/L, creatinine of 2 mg/dL and serum albumin of 1.6 g/dL and blood sugar of 121 mg/dL.\n\nBrain CT scan was performed, as the patient had LOC, which revealed senile brain atrophy without any abnormal findings.\n\nHis chest CT scan showed air trapping in the anterior aspect of both lung fields, right upper lobe (RUL) involvement and diffuse peribronchial cuffing, diffuse patchy ground glass opacity (GGO), and consolidation that some of them were subpleural and some of them showed crazy paving appearance because of adding interlobular septal thickening that they could be due to viral infection. Moreover, diffuse bilateral peribronchial thickening was seen.\n\nBlood cultures were taken from two different sites which revealed no growth after 48 hours.\n\nDuring his hospitalization, nasal respiratory viral panel multiplex RT-PCR was taken and revealed co-infection of influenza virus and RSV; therefore sepsis and pneumonia treatment was initiated for the patient including meropenem 1gr infused over 3 hours once a day, vancomycin 1 gr every 72 hours intravenously and oseltamivir 75 mg every 12 hours orally. He also received Albumin twice a day because of decreased level of albumin. Intravenous infusion of 5% dextrose water and half saline was administered according to standard protocols to maintain hydration and balance hypernatremia in the patient.\n\nOn the 7th day of his hospitalization the patient had become anuric. Creatinine and blood urea nitrogen (BUN) level increased (creatinine: 4 mg/dL, BUN: 122 mg/dL), venous blood gas test revealed a metabolic acidosis (PH: 7.11, pCO2: 18.2, HCO3: 8.6) which was resistant to treatment. An urgent surgery consultation was requested for central venous catheter placement for performing dialysis but in the meantime, his blood pressure (BP) dropped and norepinephrine drip was infused. Because of low BP, the patient could not tolerate dialysis. Due to septic shock, he had cardiopulmonary arrest at night, and regardless of intubation and 45 minutes of cardiopulmonary resuscitation, he died.",
    "summary": "An 87-year-old Persian man was admitted to the hospital due to loss of consciousness, respiratory distress, tachypnea, and oliguria. He had previously hospitalized because of cough, fever, loss of appetite, and fatigue. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) test was performed which was negative; however, based on ground glass opacity on his chest computed tomography (CT) scan and being on the outbreak of COVID-19, he fulfilled case definition of COVID-19; therefore, he received protocol’s treatment (remdesivir) for COVID-19 and relatively recovered and discharged. In our center, we requested brain and chest CT scans, blood tests, and multiplex PCR. Multiplex PCR revealed co-infection of influenza virus and RSV. Although we had started pneumonia and sepsis treatment, old age, weak immune system and the delay in initiation of right antibiotic and antivirus therapy altogether led him to die."
  },
  {
    "id": "multiclinsum_gs_en_449.txt",
    "fulltext": "A 5-month-old male infant was admitted to the pediatric emergency department with a history of cough and nasal obstruction for three days. He had a worsening of his general condition in the previous 24 hours, with fever, respiratory effort, reduced appetite and vomiting after feedings.\n\nHe was a previously healthy infant, with a gestational history of a low-risk pregnancy, with late-onset prenatal care (3rd trimester), normal obstetric ultrasonography (at 26 weeks of gestational age); however, morphological ultrasonography was not performed. He was born by vaginal delivery, at full-term, with adequate weight for gestational age, without complications.\n\nOn physical examination at admission, he was afebrile (36.8°C), tachycardic (158 bpm); tachypneic (50 bpm); with hypoxemia (SpO2 92%). Pulmonary auscultation showed reduced breath sounds on the left hemithorax and the presence of fine rales, rhonchi and diffuse wheezing bilaterally. Hyaline coryza and respiratory distress were observed, with moderate to severe intercostal, subcostal and sternal retraction. Cardiac auscultation showed muffled heart sounds. There was an improvement in oxygen saturation (98%) and respiratory effort with the administration of oxygen by a nasal catheter.\n\nThe patient was diagnosed with AVB and admitted to the pediatric ward due to the need of supplemental oxygen and moderate to severe respiratory effort. Laboratory and imaging tests were requested.\n\nRespiratory syncytial virus was detected on nasopharyngeal swab. Complete blood count revealed normal leukocyte count (8,000/μL), with a predominance of lymphocytes (72%=5,760/μL) and the presence of reactive lymphocytes (2%=160/μL), in addition to mild thrombocytosis (487,000/μL). C-reactive protein (CRP) was normal (5.8 mg/L; reference value: less than 10 mg/dL). Chest radiography showed an enlargement of the cardiac silhouette.\n\nDue to the radiographic finding, cardiac investigation was performed, identifying troponin levels of 86.5 pg/mL (reference value: up to 19.8 pg/mL) and creatine phosphokinase-MB mass (CKMB mass) levels of 18 U/L (reference value: up to 16U/L). Electrocardiogram showed alteration of left ventricular (LV) repolarization. Echocardiogram showed a heterogeneous mass, measuring 52×38 mm, on the lateral wall of the LV, with areas of calcification, preserving the LV inflow and outflow tract.\n\nChest CT angiography showed a large intramural cardiac mass in the LV with significant ventricular volume restriction and extracardiac extension, small foci of central calcification and small pericardial effusion.\n\nCardiac MRI showed a mass in the LV, measuring 5.5×5.3 cm, mobile with the cardiac cycle, extending closely to the pulmonary artery and into the mediastinum. A large mass effect was noted in the LV, with reduction of the ventricular cavity, moderately impairing its global function (LV Ejection Fraction [EF]=46%). T2-weighted images showed a mild myocardial hypersignal and markedly delayed contrast uptake (>10 minutes).\n\nThe extracardiac extension of the lesion and pericardial effusion suggested aggressive behavior. However, the site and tissue characterization, i.e. foci of calcification and markedly slowed enhancement, suggested fibrotic components. Therefore, the hypotheses suggested by the imaging tests were rhabdomyosarcoma and cardiac fibroma.\n\nA Holter was performed and showed a pattern of complete right bundle branch block and isolated supraventricular extrasystoles. A total abdominal MRI and transfontanellar ultrasound were performed, due to the possibility of cardiac rhabdomyosarcoma, both being normal.\n\nThe patient underwent cardiac catheterization for biopsy, and fragments were sent for histopathological and immunohistochemical analysis. Since the biopsy was inconclusive, it was decided to start an off-label use of sirolimus.\n\nDuring the use of sirolimus, periodic echocardiograms were performed, in addition to weekly laboratory tests, including blood count, CRP, serum sirolimus dosage, renal function, liver function, and lipid profile. During this period, serum sirolimus was maintained within the therapeutic range, between 5 and 10 ng/mL, with no changes in other laboratory tests.\n\nThe echocardiogram in the second week of sirolimus use identified significant pericardial effusion, causing right ventricle (RV) dysfunction, and a pericardiocentesis was performed, draining 48 mL of serosanguineous fluid.\n\nAfter three weeks of sirolimus use, a control MRI was performed and there were no significant changes in the size or characteristics of the tumor mass, therefore the off-label use of sirolimus was discontinued.\n\nA new cardiac catheterization with biopsy was performed. Two tissue fragments were sent for anatomopathological analysis, the largest measuring 1.5 cm in length and 0.1 cm in diameter. Histopathological analysis this time was conclusive for cardiac fibroma.\n\nThe mass was a histologically benign tumor, but with aggressive behavior due to its size, location and infiltration in the myocardium. The patient required prolonged hospitalization, with the use of vasoactive drugs due to hemodynamic compromise. The tumor was not responsive to the off-label use of sirolimus, requiring cardiological polypharmacy, multiple hospitalizations due to cardiac decompensation, and the patient evolved with functional class 3 congestive heart failure (CHF), reaching an EF of 35%.\n\nDue to the progressive worsening of the EF and, consequently, of the functional class of CHF, it was decided to include the patient in the heart transplantation list, since the tumor resection was impossible due to its infiltration in the left ventricular myocardial wall.\n\nSix months after diagnosis, the patient underwent heart transplantation at the same hospital where the diagnosis was made, with a good postoperative course. Anatomy and histopathological findings of the surgical specimen confirmed the diagnosis of cardiac fibroma.",
    "summary": "A 5-month-old male infant was admitted to the pediatric emergency department with acute viral bronchiolitis requiring hospitalization. He presented a detectable respiratory syncytial virus in oropharyngeal swab, blood test with lymphocytosis and a chest radiography revealed cardiomegaly. Further cardiologic testing was performed detecting elevation of cardiac biomarkers, an electrocardiogram with alteration of left ventricular repolarization and echocardiogram with a heterogeneous mass in the left ventricular, with areas of calcification. A chest angiotomography suggested rhabdomyosarcoma or cardiac fibroma and a magnetic resonance showed a mass, with characteristics suggesting fibroma. The final diagnosis was made after two cardiac catheterizations for biopsy of the lesion, confirming cardiac fibroma by anatomopathological examination. Because the patient had moderate to severe systolic dysfunction, he was submitted to heart transplant."
  },
  {
    "id": "multiclinsum_gs_en_19.txt",
    "fulltext": "A 15-year-old boy was presented to our clinic with the main complaint of focal hypertrichosis of white hair for 4 months. He had a history of vitiligo since age 10. The vitiligo lesion was located on his right neck and treated with topical tacrolimus 0.1% ointment approximately twice daily and 308 nm excimer (500 mJ/cm2) and fractional CO2 laser (25 W, pulse width 2 ms, pitch 1.3 mm) therapy every 2 weeks during the past years, and he noticed the abnormal white hair 4 months ago. The abnormal white hair on the vitiligo lesion grows faster than normal hairs on other parts of the neck. He denied ever using other ointment to the area. After he stopped using tacrolimus for half a month, white hairs on his right neck ceased to grow. At the 2-month follow-up, no further growth of white hairs was observed. During this period, the patient continued to receive the 308-nm excimer and fractional CO2 laser therapy every 2 weeks. We propose that the focal hypertrichosis was induced by tacrolimus.",
    "summary": "We present a 15-year-old boy with focal hypertrichosis of white hair for 4 months, after treatment with topical tacrolimus 0.1% ointment. He denied ever using other ointment to the area. After he stopped using tacrolimus for half a month, the focal hypertrichosis improved."
  }
]