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This case report describes a patient with large-cell neuroendocrine pancreatic carcinoma (LCNEPAC), exhibiting metastatic dissemination to lymphatic and hepatic sites. The identification of a CCDC6::RET fusion prompted inclusion into the LIBRETTO-001 trial. The patient showed a remarkable response to selpercatinib, as evidenced by CT staging and serum tumor markers. Beyond established clinical staging measures, smartwatch-derived data revealed immediate improvements in physical activity (increase in the number of daily steps) and physiological metrics (decrease in baseline heart rate). This case exemplifies the integration of innovative wearable technology into routine cancer care, thus enhancing the granularity of patient-centric monitoring and care. | 4.097656 | 0.962402 | sec[0]/p[1] | en | 0.999996 | 39085487 | https://doi.org/10.1038/s41698-024-00659-x |
In April 2022, a 56-year-old male received the diagnosis of pancreatic adenocarcinoma with lymph node and liver metastases. The patient first received the FOLFIRINOX chemotherapy regimen (folinic acid, fluorouracil, irinotecan, and oxaliplatin). Subsequent treatment with nab-paclitaxel and gemcitabine led to a mixed response: while liver metastases decreased in size, abdominal and cervical lymph nodes significantly increased in size, most notably the Virchow’s lymph node (located above the left clavicle). Additionally, the patient presented with several cutaneous soft tissue metastases, including a particularly noteworthy lesion adjacent to the right parasternal area. Radiological evaluation revealed extensive retroperitoneal lymph node metastases and an additional lesion in the left adrenal gland. The mixed response indicated the need for a reevaluation of the treatment strategy. Consequently, the patient’s oncologist pursued a re-biopsy of Virchow’s lymph node and changed therapy towards fluorouracil and nanoliposomal irinotecan (5-FU/nal-IRI) . Collaborating with the molecular tumor board of the Comprehensive Cancer Center Mainfranken (CCC MF), which has a special focus on community outreach and clinical trial inclusion 7 , the oncologist initiated an extensive histopathological and molecular examination. Of note, the histopathological analysis of the lymph node biopsy revealed a transition from pancreatic adenocarcinoma to large-cell neuroendocrine pancreatic carcinoma (LCNEPAC). This change was supported by the immunohistochemical expression of synaptophysin and Insulinoma-associated protein 1 (INSM1), along with pancytokeratin and cytokeratin 7, and a high Ki67 index. Notably, TTF1 was negative . The diagnostic shift from pancreatic adenocarcinoma to LCNEPAC may suggest the initial presence of a mixed neuroendocrine non-neuroendocrine neoplasm (MiNEN) subset initially not represented in the pathological specimen. Subsequent genomic profiling, utilizing DNA-based cancer panel sequencing (Oncomine Comprehensive Assay Plus), revealed a homozygous deletion of the CDKN2A and MTAP gene locus but did not identify further actionable mutations. However, a targeted RNA-based fusion analysis employing the Archer Lung Panel revealed the presence of a CCDC6::RET fusion, shown in Fig. 1c . This pivotal finding prompted the molecular tumor board to recommend the patient’s inclusion in the LIBRETTO-001 trial 5 , 6 . Within two weeks after confirming the RET alteration and following the ineffectiveness of 5-FU/nal-IRI, the patient was enrolled in the study. Fig. 1 Clinical course, pathology, and genetic fusion in LCNEPAC. a Timeline of clinical courses, including treatment duration. b Pathologic examination revealed a partially necrotic, poorly differentiated carcinoma that grew in solid sheets or trabeculae without obvious gland formation, morphologically compatible with large-cell neuroendocrine carcinoma. Immunohistochemistry (IHC) showed strong and uniform expression of synaptophysin, along with a high Ki-67 proliferative index of 70–80%. Scale bar (overview): 1 mm; Scale bar (inserts): 100 µm. c A schematic representation of the in-frame CCDC6 :: RET fusion gene, with the breakpoint indicated on chromosome 10, and the resulting retained protein domains from both CCDC6 and RET. The CCDC6::RET fusion was visualized using Arriba, version v2.4.0 18 (image modified). | 4.242188 | 0.870117 | sec[1]/sec[0]/p[0] | en | 0.999996 | 39085487 | https://doi.org/10.1038/s41698-024-00659-x |
The initiation of selpercatinib therapy (160 mg twice daily) marked a turning point in the patient’s clinical course. Within a few days, the patient reported pronounced shrinkage of the palpable supraclavicular lymph node and other palpable soft tissue metastases, along with a marked reduction in pain and decreased requirement for hydromorphone. Most remarkably, within 5 days of commencing selpercatinib therapy, the patient’s mobility improved to the extent that a walker was no longer necessary. | 3.376953 | 0.979492 | sec[1]/sec[1]/p[0] | en | 0.999998 | 39085487 | https://doi.org/10.1038/s41698-024-00659-x |
This case demonstrates the synergistic value of combining smartwatch-derived data with conventional clinical measures, illustrating the progress in precision oncology. Selpercatinib’s role in treating RET fusion-positive pancreatic neuroendocrine carcinoma exemplifies the merging of targeted therapy with digital health tools, signifying a shift toward more adaptive, patient-focused oncological care, and emphasizing the importance of digital biomarkers in monitoring and improving treatment outcomes. | 4.003906 | 0.860352 | sec[2]/p[2] | en | 0.999995 | 39085487 | https://doi.org/10.1038/s41698-024-00659-x |
However, our study is not without its limitations. Notably, the occurrence of RET fusions as actionable targets is uncommon, and there is an increasing evidence base pointing to both primary and secondary resistance to RET inhibitors in fusion-positive cancers 15 , 16 . Additionally, while our study greatly benefitted from the patient’s diligent monitoring of his health data via a smartwatch across his entire treatment journey, it is essential to recognize that our patient´s high levels of commitment and compliance may not be universally representative. Nevertheless, this case report highlights the potential benefit of integrating wearable technology and digital solutions into our cancer care algorithms 17 . | 3.730469 | 0.53418 | sec[2]/p[3] | en | 0.999997 | 39085487 | https://doi.org/10.1038/s41698-024-00659-x |
In this case report, the Apple Watch Series 3, acquired by the patient, was implemented as a tool to measure physical activity levels and heart rate during the treatment period. This device is equipped with a motion sensor capable of tracking physical activity. The software automatically analyzed the total steps taken each day. To provide a clearer picture of the patient’s mobility trends amidst the natural daily variations in activity, the median value of these daily averages was computed on a weekly basis. This method ensured a stable and accurate analysis of the patient’s mobility changes throughout the treatment, giving insights into the physical condition and any potential treatment impacts on mobility. Additionally, the heart rate monitoring feature of the smartwatch collected data on the patient’s average resting heart rate. By focusing on periods of inactivity, this measurement provided valuable information on the patient’s cardiovascular health and the indirect impact of treatment on overall fitness. | 4.09375 | 0.900879 | sec[3]/sec[1]/p[0] | en | 0.999998 | 39085487 | https://doi.org/10.1038/s41698-024-00659-x |
A 24-year-old female patient arrived at the hospital exhibiting significant edema of the lower extremities, frequent nocturia, and excessive thirst. Her vital signs showed a temperature of 98.6°F, a heart rate of 88 beats per minute, a respiration rate of 16 breaths per minute, and a blood pressure of 180/110 mmHg. On physical examination, no angiokeratomas or corneal abnormalities were noted. The cardiovascular examination revealed elevated blood pressure, and an echocardiogram showed left ventricular hypertrophy. | 3.501953 | 0.987793 | sec[1]/p[0] | en | 0.999998 | 39092329 | https://doi.org/10.7759/cureus.63661 |
Routine lab tests revealed hypoalbuminemia and hypercholesterolemia, with serum albumin at 2.8 g/dL, total cholesterol at 302 mg/dL, and elevated blood creatinine levels at 1.5 mg/dL. All other tests, including serum electrolytes, liver function tests (LFTs), and a complete blood count (CBC), were normal. Complement levels (C3, C4) were within normal ranges, and autoimmune tests, including cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) and perinuclear antineutrophil cytoplasmic antibody (p-ANCA), were negative (Table 1 ). | 3.837891 | 0.480713 | sec[1]/p[1] | en | 0.999995 | 39092329 | https://doi.org/10.7759/cureus.63661 |
An ultrasound (USG) of the kidneys indicated normal-sized kidneys with increased cortical echogenicity. Due to the unexplained renal dysfunction, along with significant proteinuria, a kidney biopsy was performed. Histopathological findings from light microscopy revealed global and segmental glomerulosclerosis with prominent vacuolization of the podocytes. Electron microscopy demonstrated osmiophilic lamellated structures known as zebra bodies within the visceral epithelial cell cytoplasm, suggesting the diagnosis of Fabry disease. To confirm this, specific biochemical tests were conducted. Plasma lyso-Gb3 levels were found to be elevated at 45 ng/mL (normal range: <1.8 ng/mL), and GLA activity in leukocytes was markedly reduced, measured at 3 nmol/hr/mg protein (normal range: 40-200 nmol/hr/mg protein). Given the results of the biopsy and biochemical tests, a diagnosis of Fabry disease was established. | 4.117188 | 0.560547 | sec[1]/p[2] | en | 0.999994 | 39092329 | https://doi.org/10.7759/cureus.63661 |
Given the diagnosis of Fabry disease, a comprehensive treatment plan was initiated. The patient was started on telmisartan 40 mg once daily to manage proteinuria and control blood pressure. Dietary modifications such as salt restriction and controlled protein intake were advised to reduce the burden on the kidneys and manage edema . The initial follow-up after two months showed a significant decrease in proteinuria and a reduction in pedal edema, with better-controlled blood pressure. Regular follow-ups every three to six months were planned to monitor kidney function, proteinuria levels, and blood pressure. Long-term management included exploring financial assistance for ERT since the patient could not afford it and providing patient education about Fabry disease, adherence to the treatment plan, and genetic counseling. Referrals to a nephrologist, cardiologist, and genetic counselor were made to ensure a multidisciplinary approach to managing the patient's condition and improving her quality of life. | 3.748047 | 0.967773 | sec[1]/p[4] | en | 0.999995 | 39092329 | https://doi.org/10.7759/cureus.63661 |
This case highlights the phenotypic heterogeneity of Fabry disease. The patient's presentation with nephrotic syndrome, significant proteinuria, and the absence of classic symptoms initially diverted attention from Fabry disease. The identification of a GLA gene mutation through whole exome sequencing (WES) was crucial in diagnosing this atypical presentation. WES involves sequencing all the protein-coding regions of genes in a genome, capturing and sequencing these regions, and then using bioinformatic tools to analyze the data and identify genetic variants. This comprehensive approach allows for the detection of mutations that may not be evident through traditional diagnostic methods. Early diagnosis and treatment are vital to prevent irreversible organ damage and improve patient outcomes . | 4.140625 | 0.902344 | sec[2]/p[0] | en | 0.999997 | 39092329 | https://doi.org/10.7759/cureus.63661 |
The clinical symptoms, in this case, included pallor, hypertension, and palpitations, which led to the suspicion of Fabry disease or nephrotic syndrome. Confirming the diagnosis of Fabry disease, WES revealed a pathogenic mutation responsible for the phenotype. This aligns with other reported cases where genetic testing played a crucial role in diagnosing Fabry disease in patients with atypical presentations . For example, in another study, a patient presented with proteinuria and ventricular septal thickening, and subsequent genetic testing confirmed Fabry disease. The patient responded well to ERT, further supporting the benefits of early genetic diagnosis and treatment . | 4.019531 | 0.703613 | sec[2]/p[2] | en | 0.999997 | 39092329 | https://doi.org/10.7759/cureus.63661 |
Upon intra-oral examination, no abnormalities were discovered in relation to the alveolar ridge, tongue size and form, labial and buccal vestibule height, and gingival state. The permanent teeth are present, with an 8 mm overjet and a 4 mm overbite, as determined by the hard tissue examination. The molar relation on the right side is Class I, and the canine is in the end-of relation, while on the left side, it is Class II. A significant issue has been identified in the maxillary region involving the crossbite of a deciduous molar, with a narrowing of the maxillary arch. This issue requires our immediate attention, and we need to take appropriate measures to address it . | 3.029297 | 0.913086 | sec[1]/p[2] | en | 0.999998 | 39092401 | https://doi.org/10.7759/cureus.63660 |
A pre-treatment orthopantomography (OPG) showed that teeth 15 and 25 (FDI - Federation Dentaire Internationale numbers) were congenitally missing, while teeth 55 and 65 were retained and not submerged in relation to their adjacent teeth . On the contrary, the mandibular arch exhibited the presence of all teeth. Moreover, the permanent second molars' tooth development in both the maxillary and mandibular arches was found to be closely matched. The patient's parents did not report any instances of missing teeth or related conditions in their family history. Based on the cephalometric evaluations, it was found that the patient had a normodivergent facial profile and a skeletal Class II relationship. The patient's facial profile was slightly convex, and no asymmetries were observed . The aforementioned diagnosis has been duly noted and will be taken into account when determining the most appropriate treatment protocol for the patient. | 3.794922 | 0.970215 | sec[1]/p[3] | en | 0.999996 | 39092401 | https://doi.org/10.7759/cureus.63660 |
After a month of initial treatment, strapping of the lower arch was done. Alignment was started with 0.016" nickel-titanium wire in both the maxillary and mandibular arch. Subsequently, a thorough alignment and leveling process was carried out for a duration of three months, resulting in the successful correction of the crossbite . Initial leveling and alignment of the arches were started with round wires, followed by rectangular wire until 0.019 × 0.025 stainless steel wire. In order to correct the Class II canine and molar relation, Class II elastics were used: initially, pink elastics (size of 3/8" and 3.5 oz. force) for two months, followed by blue elastics (size of 1/4" and 4 oz. force) for four months. The arches were completely leveled and aligned without the need for extractions. After an 18-month course of treatment, the appliances were removed, and removable types of retainers were delivered. | 3.839844 | 0.84082 | sec[1]/p[10] | en | 0.999997 | 39092401 | https://doi.org/10.7759/cureus.63660 |
After an 18-month therapeutic intervention, the treatment culminated in a Class I molar connection, while the mandibular premolars and the deciduous maxillary second molars exhibited good functional occlusion . The post-treatment extra-oral and intra-oral photographs revealed a marked improvement in profile, overjet of 2 mm, overbite of 2 mm, and crossbite correction. The therapy significantly enhanced the appearance of the smile, corrected the proclination of the upper and lower teeth, and fostered functional occlusion . | 3.818359 | 0.854492 | sec[1]/p[12] | en | 0.999995 | 39092401 | https://doi.org/10.7759/cureus.63660 |
It was concluded that maintaining the primary teeth for as long as possible was the most prudent approach due to the patient's reluctance to undergo additional extractions. This strategy can help prevent atrophic changes in the alveolar bone and periodontal ligament, as long as the primary teeth maintain proper occlusal function. Furthermore, the even distribution of occlusal forces can minimize excessive stress on the retained primary teeth, promoting long-term stability. The patient has notably responded well to this treatment strategy, focused on preserving the primary teeth. | 3.384766 | 0.869629 | sec[2]/p[3] | en | 0.999997 | 39092401 | https://doi.org/10.7759/cureus.63660 |
Patients with retained deciduous teeth may face challenges such as tooth agenesis, impactions, transpositions, and deformities, complicating the development of a final treatment plan, particularly in growing children. However, early diagnosis, prompt intervention, and a multidisciplinary approach that combines restorative and orthodontic care can significantly improve the quality of care and expand treatment options. This case demonstrates that it is possible to integrate retained deciduous teeth with a favorable prognosis into the final occlusion, resulting in positive long-term clinical outcomes. | 3.779297 | 0.872559 | sec[3]/p[0] | en | 0.999996 | 39092401 | https://doi.org/10.7759/cureus.63660 |
As an opportunistic pathogen such as Enterococcus gallinarum , it causes nosocomial infection among immunosuppressed hosts. Recently, owing to the rise in broad-spectrum antibiotics and invasive procedures, Enterococcus gallinarum infection and multi-drug resistance have garnered increasing attention . Previous case series reported extra-intestinal infections such as endocarditis , meningitis , peritonitis , and cholangitis attributed to Enterococcus gallinarum . Currently, there is no report of respiratory system infection caused by Enterococcus gallinarum . Here, we presented a case of empyema due to Enterococcus gallinarum infection. | 3.697266 | 0.924316 | sec[0]/p[0] | en | 0.999996 | PMC11293086 | https://doi.org/10.1186/s12879-024-09531-6 |
An 81-year-old male was transferred to our hospital because of fever and dyspnea. In the past three years, this patient presented to the medical facility several times with recurrent choledocholithiasis complicated by cholangitis. One week prior to admission, he was readmitted for an acute attack and underwent percutaneous cholecystostomy with balloon dilation. Following surgery, the patient presented with fever. Despite receiving empirical anti-infectious therapy, the fever persisted and dyspnea ensued. The blood culture was found to be positive for a Gram-positive coccus. For further diagnosis and treatment, she was referred to our hospital. He had a history of arterial hypertension, coronary artery disease accompanied by atrial fibrillation, chronic obstructive pulmonary disease, and iron deficiency anemia. He had undergone cholecystectomy and Billroth II subtotal gastrectomy. Additionally, he had a 50-pack-year smoking history and had quit 18 years before the presentation. | 3.595703 | 0.987793 | sec[1]/p[0] | en | 0.999996 | PMC11293086 | https://doi.org/10.1186/s12879-024-09531-6 |
On arrival, he presented with a temperature of 38.6℃, a blood pressure of 135/90 mmHg, a pulse rate of 90 beats per minute, a respiratory rate of 20 breaths per minute, and an oxygen saturation of 93% while breathing room air. Auscultation of the chest revealed absent breath sounds and dullness to percussion over the right lower lung field. During abdominal examination, tenderness was noted in the right upper quadrant without rebound pain. Additionally, bilateral pitting edema was present in the lower extremities. | 3.410156 | 0.984863 | sec[1]/p[1] | en | 0.999998 | PMC11293086 | https://doi.org/10.1186/s12879-024-09531-6 |
Laboratory investigations showed white blood cell count 12.08 × 10 9 /L (normal value 4.0–10.0 × 10 9 /L) with neutrophils 11.6 × 10 9 /L. C-reactive protein significantly increased to 123.79 mg/L, accompanied by a mild elevation of procalcitonin to 0.26 ng/ml. Magnetic resonance cholangiopancreatography indicated mild dilation of the intrahepatic and extrahepatic bile ducts and multiple gallstones in the common bile duct. Chest CT scan showed a right subpulmonic effusion . Thoracic ultrasonography confirmed an anechoic area with an anterior-posterior diameter of approximately 8.2 cm, exhibiting striped light bands and grid-like lesions within. Thoracoscopy showed extensive adhesion and purulent fluid, accompanied by necrotic materials within the thoracic cavity . Analysis of pleural fluid revealed exudative pleural effusion, with a nucleated cell count of 6.2 × 10 9 /L, glucose level at 0.74 mmol/L, total protein concentration at 36.4 g/L, albumin concentration at 20.2 g/L, lactate dehydrogenase at 4032 U/L, and adenosine deaminase at 16.1 U/L. Cytology revealed the presence of inflammatory cells, including lymphocytes, neutrophils, and macrophages. Enterococcus gallinarum was identified in the pleural effusion culture, showing natural resistance to vancomycin but sensitivity to ampicillin, teicoplanin, penicillin G, ciprofloxacin, linezolid, and levofloxacin. Pleural biopsy showed granulation with fibrinous exudation . | 4.152344 | 0.803711 | sec[1]/p[2] | en | 0.999997 | PMC11293086 | https://doi.org/10.1186/s12879-024-09531-6 |
The patient underwent thoracic drainage and intrathoracic urokinase injection. Given the history of allergy to penicillin and sulfa, linezolid, as the most sensitive of the remaining antibiotics, was administered (600 mg twice daily) after the thoracic drainage. One week later, his temperature returned to normal and dyspnoea was significantly relieved. Oral linezolid was continued for one month after discharge. A follow-up after six months showed complete resolution of pleural effusion according to the chest CT scan. | 3.179688 | 0.988281 | sec[1]/p[6] | en | 0.999996 | PMC11293086 | https://doi.org/10.1186/s12879-024-09531-6 |
Enterococcus gallinarum is a catalase-negative, facultative anaerobic, chain-arranged Gram-positive coccus isolated from the intestines of chickens . As an opportunistic pathogen, Enterococcus gallinarum could colonize mesenteric veins, lymph nodes, liver, and spleen through an impaired intestinal barrier, leading to autoimmune diseases in susceptible individuals . Additionally, Enterococcus gallinarum could also migrate to distant organs and cause systemic infections. It is the first case of empyema due to Enterococcus gallinarum infection which responded well to linezolid and had a favorable prognosis. | 3.722656 | 0.63916 | sec[2]/p[0] | en | 0.999998 | PMC11293086 | https://doi.org/10.1186/s12879-024-09531-6 |
The Enterococcus genome is characterized by a robust antimicrobial resistance pattern, with vancomycin resistance being an inherent feature. Enterococcus gallinarum specifically harbors the vanC resistance gene, demonstrating a high level of vancomycin resistance. Recent isolations of strains carrying vanA and vanB genes, in addition to vanC, have shown elevated resistance to both vancomycin and teicoplanin . Moreover, Enterococcus gallinarum strains have occasionally exhibited resistance to linezolid, with recent identifications of linezolid-resistant strains possessing the cfr, optrA, and poxtA genes . Sometimes, it may still be ineffective, even if it is sensitive in vitro. This patient has received an appropriate dose of linezolid and achieved satisfactory improvement after four weeks of treatment. Suboptimal treatment may result in pleural scarring due to visceral pleural fibrosis and lung function deficits or even death. Failure of treatment often requires surgery, which further increase the cost and the burden of the disease. This case highlights the need for healthcare professionals worldwide to raise awareness of empyema caused by rare pathogens such as Enterococcus gallinarum . | 4.28125 | 0.541016 | sec[2]/p[3] | en | 0.999997 | PMC11293086 | https://doi.org/10.1186/s12879-024-09531-6 |
A 56-year-old male presented with a six-week history of progressive lower extremity weakness, subsequent gait instability, paresthesias, and one episode of urinary incontinence. Magnetic resonance imaging (MRI) imaging of the spinal axis demonstrated prominent flow voids in the thoracolumbar spine with associated T2 hyperintense signal changes within the thoracolumbar spinal cord. Subsequent spinal digital subtraction angiography (DSA) confirmed the presence of a spinal dAVF originating from the left L2 segmental artery. Based on these MRI and DSA findings , the patient was diagnosed with a type I spinal dAVF at the L2 level. Given the progression and severity of his symptoms, surgical intervention was recommended. | 3.964844 | 0.980469 | sec[1]/p[1] | en | 0.999997 | 39092384 | https://doi.org/10.7759/cureus.63657 |
The patient was taken to the operating room with a surgical plan of L2 hemilaminotomy for visualization and surgical ligation of the intradural dorsal spinal AVF. Preoperative imaging data were integrated into the AR platform, providing a 3D holographic representation of the patient’s spinal anatomy and the AVF location (Video 1 ). The patient was intubated and placed under general anesthesia. Intraoperative neuromonitoring was used during the case, specifically somatosensory-evoked potentials, motor-evoked potentials, and lumbar-level electromyograms. The patient was then positioned prone on a Jackson table with a Wilson frame attachment in standard fashion. X-ray fluoroscopy was used to mark the location of surgery. A 5 cm incision was created, and a unilateral subperiosteal dissection was carried down to the L2 lamina under intraoperative microscope visualization. X-ray fluoroscopy confirmed the correct surgical location. Dura was exposed via an L2 hemilaminectomy and was opened to demonstrate the patient’s lumbar nerve roots as well as an obvious intradural vascular lesion of an arterialized vein. This lesion was carefully dissected and then ligated. The wound was closed in standard fashion. | 3.894531 | 0.960449 | sec[1]/p[7] | en | 0.999997 | 39092384 | https://doi.org/10.7759/cureus.63657 |
There is a growing body of literature demonstrating the utility of augmented reality for presurgical and intraoperative planning . An interactive and 3D understanding of patient anatomy can provide the surgical team with heightened spatial awareness of the case and offer a visual understanding that may not be appreciated with traditional 2D imaging. This case demonstrates the utility of AR technology in the surgical management of spinal dural AVFs. By providing real-time, 3D visualization of complex anatomical relationships, AR can significantly improve the surgeon’s ability to perform precise and safe dissections, allowing for minimally invasive approaches such as the case described. This report describes an early use of the latest mixed-reality headset, the Apple Vision Pro. The system utilizes advanced computation to render high-quality and seamless 3D models for the user to interact with. The computational power of the system will be critical as the field of neurosurgery demands high-detail and high-precision renderings of medical scans . For this case, the high level of imaging detail afforded by the headset enabled the surgeon to visualize the 3D relationship between the bony vertebrae and vascular lesion. | 4.074219 | 0.80957 | sec[2]/p[0] | en | 0.999998 | 39092384 | https://doi.org/10.7759/cureus.63657 |
Spinal dAVFs are a rare disease process; however, they represent the most common form of spinal AVMs . Surgical management of these lesions is considered superior to endovascular treatments, with higher rates of definitive occlusion on the first treatment and lower recurrence and subsequent treatment rates . The surgical technique for the treatment of these lesions typically consists of either a full laminectomy or a hemilaminectomy centered around the levels surrounding the nidus. Some reports describe up to three levels of laminectomy, while others describe more minimally invasive techniques. Depending on the patient’s anatomy and location of the nidus, minimally invasive approaches may be challenging for the surgeon. This case demonstrates the utility of applying AR technology to the surgical management of spinal dural AVFs. This technology was able to incorporate DYNA CT imaging from the patient’s pre-operative angiogram, providing the precise and targeted anatomic location of the nidus in relation to the patient’s bony anatomy. The technology allowed the surgeon to visualize the positioning and proximity of the dAVF to the vertebrae and thus assisted the surgical team in performing a minimally invasive approach to the lesion via a single-level hemilaminotomy window. Presurgical planning in 3D space for this case was useful for understanding these spatial relationships and demonstrated the potential application for further AR applications within microsurgical spinal techniques. Questions remain about the potential for intraoperative use of the Apple Vision Pro and augmented reality more generally. As with any new technology, further studies are warranted to assess the broader applicability of AR in spinal surgery and its long-term surgical benefits. | 4.214844 | 0.591309 | sec[2]/p[1] | en | 0.999997 | 39092384 | https://doi.org/10.7759/cureus.63657 |
The applications and value of augmented reality in the field of neurosurgery continue to expand. This case report demonstrates the integration of the Apple Vision Pro for presurgical planning and visualization of patient-specific anatomy in a case of spinal dural AVF. The report illustrates the ability of the Apple Vision Pro heads to provide 3D visualization of the spinal vasculature and vertebrae. By providing a more comprehensive understanding of the anatomy, AR can enhance surgical precision, reduce intraoperative risks, and improve patient outcomes, suggesting a promising future for AR in complex neurosurgical procedures. In particular, the use of the Apple Vision Pro is novel, given the recent release of this breakthrough AR device. Further studies are warranted to assess the broader applicability of AR and Vision Pro in spinal surgery and their long-term surgical benefits. | 4.058594 | 0.904785 | sec[3]/p[0] | en | 0.999996 | 39092384 | https://doi.org/10.7759/cureus.63657 |
Interestingly, Bouhamdani et al. describe a unique case presentation of Nocardia farcinica cerebral abscess in a male patient with sudden immunodeficiency several months after mild COVID-19. This case strengthens the notion of immunomodulation after COVID-19 and well after the viral infection has cleared, and draws attention to the need for timely consideration of opportunistic infections for patients with a history of COVID-19. | 3.621094 | 0.921875 | sec[1]/p[1] | en | 0.999997 | PMC11295108 | https://doi.org/10.3389/fneur.2024.1452895 |
A 40-year-old female reported to the Outpatient Department of Oral Medicine and Radiology, Sharad Pawar Dental College and Hospital, Wardha, with a chief complaint of pain in the lower left region of the jaw for the past six months. The pain was dull, aching, and intermittent, which gets aggravated when chewing as well as stimulated by hot and cold stimuli. The pain relieves itself on its own. The patient also experienced swelling in the left region of the jaw two months ago, which was initially smaller in size and gradually progressed to its current size. The patient did not give a history of hot and cold compression on the swelling. The patient visited a private dental clinic for pain and swelling, where the dentist took a small yellow color abnormal discharge sample from the left posterior region two months ago. After a few days, the swelling subsided, as told by the patient. The patient had a history of peptic ulcers 20 years ago and was on medication for them. The patient did not provide details about medications. The patient reported a prior extraction in the left-back region of the jaw one year ago at a private dental clinic, which was uneventful. The patient is not allergic to any drug known to him until now. | 3.164063 | 0.990723 | sec[1]/p[0] | en | 0.999996 | PMC11296215 | https://doi.org/10.7759/cureus.63722 |
On extraoral examination, no gross asymmetry of the face was seen, as shown in Figure 1 . Temporomandibular joint movements were bilaterally smooth and synchronous. No tenderness was present on palpating the temporomandibular joint and its associated muscles. A single, firm, mobile, and tender lymph node in the left submandibular area, measuring roughly 0.5×0.5 cm, was palpable. | 3.400391 | 0.968262 | sec[1]/p[1] | en | 0.999996 | PMC11296215 | https://doi.org/10.7759/cureus.63722 |
On intraoral examination, diffuse swelling was seen with 36-38, which was obliterated on the lower gingival sulcus in the 36, 37, and 38 regions of the jaw, extending anterior-posteriorly on the distal side of 35 to the retromolar region of the mandible and superior-inferiorly to the crest of the residual alveolar ridge to the depth of the vestibule. The size of the swelling was approximately 5×4 cm, with a roughly oval shape and diffused margins. The overlying mucous membrane was normal, as shown in Figure 2 . On palpation, tenderness was present. There was no pus discharge on manipulation of the swelling. On clinical examination, a provisional diagnosis of "ameloblastoma involving the left side of the mandible" was given. | 3.677734 | 0.977051 | sec[1]/p[2] | en | 0.999995 | PMC11296215 | https://doi.org/10.7759/cureus.63722 |
The orthopantomogram of the patient in Figure 3 shows well-defined multilocular radiolucency on the left side of the mandible, extending anterior-posteriorly from the 36 to the left ramus of the mandible and superior-inferiorly from the superior aspect of the left ramus of the mandible to 5 mm above the lower border of the mandible of approximately 6×5 cm, roughly oval in shape, and well-defined and corticated margins. Internal structures were radiolucent. The radiographic diagnosis of the patient was OKC. The patient was advised to undergo a biopsy. | 3.630859 | 0.972168 | sec[1]/p[3] | en | 0.999997 | PMC11296215 | https://doi.org/10.7759/cureus.63722 |
Prior to the procedure, informed consent was obtained from the patient after a detailed discussion regarding the surgery. The patient received comprehensive information about the potential recurrence of the lesion and the possibility of a pathological fracture. Under all aseptic conditions, the patient was prepared for the surgery. The inferior alveolar nerve block was given, and a full-thickness mucoperiosteal flap was reflected with no. 15 carbon steel surgical blade on the most prominent part of the left retromolar region, and the underlying bone was exposed. Cystic lining was curetted, and a small part of the bone was removed by C166 Edenta Lindemann Oral Surgery carbide bur under normal saline irrigation. Enucleation was done, and Carnoy's solution was used to chemically cauterize the bone cavity of the lesion. The aspirate from the cavity was sent for histopathological examination, as shown in Figure 4 . | 3.708984 | 0.976563 | sec[1]/p[4] | en | 0.999994 | PMC11296215 | https://doi.org/10.7759/cureus.63722 |
Repositioning of the flap was done, and the incision was closed with a 3.0 absorbable surgical vicryl suture (braided coated polyglactin). The patient was on antibiotics for five days. The antibiotics advised to the patient were amoxicillin 500 mg three times a day (TDS) and metronidazole 400 mg TDS for five days. The analgesic advised to the patient was diclofenac 100 mg twice daily for five days. The patient was also advised to take warm saline gargles and 0.2% chlorhexidine mouthwash three times daily for five days. The patient was instructed to consume a bland diet and periodic hydration, maintain good oral hygiene, and limit sugar and acidic foods. The patient was recalled after five days to monitor the healing of the bone and early recurrence. Microscopic examination of the lesion shows a cystic cavity lined by thin para-keratinized stratified squamous epithelium supported by a connective tissue wall. Surface corrugation of the keratinized layer was observed. Basal cells of the lining epithelium are columnar with polarized hyperchromatic nuclei resembling "tombstone." Histopathological features are characteristic of OKC, as shown in Figure 5 . | 3.820313 | 0.978027 | sec[1]/p[5] | en | 0.999999 | PMC11296215 | https://doi.org/10.7759/cureus.63722 |
A post-operative radiograph, as shown in Figure 6 , shows a surgical defect involving the left side of the mandible, extending from 36 to the ramus region. Other radiographic findings were interdental wiring seen with 15-16, 24-25, 33-34, and 44-45 regions for the mobility of the teeth. Splinting of teeth is done to stabilize loosened teeth, promote healing of the supporting structures, restore proper function and occlusion while reducing pain, and prevent pathological fracture. Considering the close proximity of the lesion with caries involving periapical infection, tooth 35 was extracted. | 3.486328 | 0.955566 | sec[1]/p[6] | en | 0.999997 | PMC11296215 | https://doi.org/10.7759/cureus.63722 |
On admission, his general condition was fair (GCS- E4V2M5). Bilateral pupils were 2 mm in diameter, and reactive to light. He was alert, conscious and well oriented to time, place, person. His vital signs were stable and within normal limits. There was no pallor, icterus, lymphadenopathy, edema, dehydration, cyanosis or clubbing. There was weakness in his left upper and lower limbs (muscle power was 4/5 and 4/5 respectively). There was no weakness in his right upper and lower limb with muscle power 5/5. Bulk and tone of his upper and lower limbs were normal. There was decreased sensation in his left hand and below left knee. However, sensations of right upper and lower limbs were intact. Bilateral plantar reflex was down going. His higher mental function and cranial nerves were normal. There was no facial deviation. Cerebellar sign, meningeal irritation, clonus was absent. His heart sounds S1 and S2 were normal with no murmur. His breathing sounds were normal with no added sounds. The rest of the systemic examination findings were regular. | 3.40625 | 0.986816 | sec[1]/p[1] | en | 0.999996 | 38996792 | https://doi.org/10.1016/j.ijscr.2024.109982 |
The patient underwent right temporoparietal craniotomy. Meningioma and high-grade glioma were excised and sent for biopsy. Histopathological report confirmed it was high grade glial tumor (WHO grade 4) and fibrous meningioma (WHO grade 1) as shown in Fig. 4 , Fig. 5 , Fig. 6 . The diagnosis of meningioma along with high-grade glioma was made. The patient was recommended to have radiation therapy, but because of the low resource setting, not all hospitals have access to radiotherapy setups, and when they do, the cost is high. As a result, the patient did not receive radiotherapy. | 3.257813 | 0.987305 | sec[1]/p[3] | en | 0.999998 | 38996792 | https://doi.org/10.1016/j.ijscr.2024.109982 |
The simultaneous occurrence of meningioma and glioma in the same patient with no history of radiotherapy, phacomatosis or any genetic abnormalities is very rare. The literature has reported about 67 cases of concurrent meningioma and glioma since the first case was described in 1938. The exact underlying mechanism behind this is still in controversies . A patient with multiple primary brain tumors with different histology at the same time is a very rare condition. This condition can be related to radiotherapy or phacomatosis, but it can also occur without any reason . In this case report, we present a case of a patient with concurrent meningioma and glioma, who had no history of radiotherapy, phacomatosis or any genetic disorders. | 3.726563 | 0.967285 | sec[2]/p[0] | en | 0.999997 | 38996792 | https://doi.org/10.1016/j.ijscr.2024.109982 |
A five-month-old preterm infant, born at 35 weeks gestation due to maternal gestation hypertension, presented to the outpatient clinic with symptoms of bronchiolitis. Incidentally, the physical examination revealed a wide anterior fontanelle and persistence of the posterior fontanelle, with head circumference at the upper limit of normal. The patient, however, presented with neurodevelopment consistent with age and a normal neurological physical examination. There was no other positive past medical history. Family history was negative for the father, mother, and sibling; however, the mother was illiterate and living in a low socioeconomic situation. | 3.320313 | 0.990234 | sec[1]/p[0] | en | 0.999996 | PMC11296396 | https://doi.org/10.7759/cureus.63750 |
Based on the physical examination findings, the following studies were requested. Brain ultrasound showed a circular structure with homogenous nature measuring ~1.2 cm x 1 cm size with no flow noted on color doppler examination localized to the roof of the right lateral ventricle. No ventricular dilations or midline deviations were detected . Further studies were conducted with the purpose to rule out malignancy versus infectious cause. Computed tomography (CT) of the central nervous system (CNS) without contrast demonstrated a oval, hypodense image, with well-defined borders, measuring approximately 1.2 to 1 cm in diameter, located at the level of the right frontal white matter, adjacent to the roof of the lateral ventricle ipsilateral to which it imprints, which presents adjacent to the upper pole a spontaneously hyperdense area with calcification measuring approximately 6 x 5 mm. A small left frontal cortical calcification, 35 mm in diameter, was also visualized . | 3.978516 | 0.878418 | sec[1]/p[1] | en | 0.999997 | PMC11296396 | https://doi.org/10.7759/cureus.63750 |
This case illustrates a rare presentation of pediatric CCM, which presented with multiple lesions and was diagnosed at a routine physical examination. CCMs or cavernous angiomas are congenital cerebral vascular malformations, consisting of multilobed cavities of different sizes, well delineated, which contain blood in different evolutionary stages. Its walls are made up of an endothelium of connective tissue without elastic or muscular fibers and without intervening nervous tissue . These cavernomas are the only of its kinds that exclusively affect the venous system . | 3.916016 | 0.88623 | sec[2]/p[0] | en | 0.999997 | PMC11296396 | https://doi.org/10.7759/cureus.63750 |
We have presented a case of a pediatric patient with multiple cavernous malformation syndrome, a rare and infrequent pathology encountered in clinical practice. It is important to know its epidemiological, clinical, and prognostic factors for appropriate monitoring, treatment, and advice of these patients. Seizures are the most frequent and common clinical presentation, when symptomatic. There is no association in the literature that suggests a normal physical examination in a previously healthy patient with no focal neurological deficits with multiple cavernous malformation syndrome, indicating that clinicians should not rule in cavernous malformation syndrome in healthy patient. There is no strong evidence to support the use of anticonvulsants for seizure prophylaxis. However, the current recommendations are for screening for other cutaneous and retinal vascular lesions, genetic testing, and regular follow-up for patients with serial MRI in those with a positive family history. It is important to acknowledge that if bleeding is present at diagnosis, there is an increased subsequent risk of hemorrhagic events. This temporal clustering underscores the importance of close monitoring and early intervention strategies to mitigate the risk of re-bleeding and associated neurological complications. Caution is recommended for the use of NSAIDs, heparin, or warfarin due to the concern for increased risk of bleeding. | 4.121094 | 0.95459 | sec[3]/p[0] | en | 0.999996 | PMC11296396 | https://doi.org/10.7759/cureus.63750 |
We report the case of a patient presented with an emergent severe epigastric pain and hemorrhagic shock, who was found to have a ruptured GSAA. He was successfully treated using surgical approach. This case report is, to our knowledge, the first case of a GSAA complicated with a fistula to the stomach and transverse colon simultaneously. It is important to highlight that the patient initially presented with rare symptoms and complications. We highlight the challenges encountered in managing this unique case as a per the SCARE 2023 Guidelines. | 3.65625 | 0.985352 | sec[0]/p[1] | en | 0.999997 | 39093788 | https://doi.org/10.1097/MD.0000000000039159 |
A 50-year-old male presented to the ER with acute epigastric abdominal pain, dizziness, and altered consciousness accompanied with a hemorrhagic shock (blood pressure of 70/40 mm Hg, hemoglobin of 3.3 g/dL). The patient is a heavy smoker without medical, surgical, or familial past history. In addition to that the patient complained of early satiety after meals and had a history of 20 kg weight loss during the last 7 months prior to the current admission despite having good appetite. | 3.130859 | 0.989746 | sec[1]/p[0] | en | 0.999998 | 39093788 | https://doi.org/10.1097/MD.0000000000039159 |
His clinical history began 7 months ago when he suffered suddenly from acute epigastric pain followed after an hour by loss of consciousness. The patient was referred to the hospital and on that admission; he was pale with hemodynamic collapse state. The initial lab test included a hemoglobin of 5.1 g/dL, an international normalized ratio of 1.4, and the fecal occult blood test was negative. The patient was resuscitated by blood transfusion. Several investigations were done as follows: abdominal ultrasound revealed an arterial aneurysm in the epigastric region measuring (9 × 11 cm) with a large hematoma surrounding it. Then upper GI endoscopy was done revealing a small sliding diaphragmatic hernia without presence of peptic ulcers. After that contrast-enhanced multi-slice CT (MSCT) demonstrated the presence of splenic artery aneurysm in the distal third measuring (10 × 12 cm) in diameter with a true lumen measuring (7 × 3.5 cm) and a large hematoma extending to the greater and lesser gastric curvature. The other abdominal organs and viscera were normal. Despite all these investigations, the patient did not complete his treatment because he had rejected the operation at that time. During the last month prior to current admission, the patient complained of fever, chills, and sweating without other complaints. The symptoms were treated with antibiotics and resolved within a week. | 3.71875 | 0.986816 | sec[1]/p[1] | en | 0.999997 | 39093788 | https://doi.org/10.1097/MD.0000000000039159 |
So, an exploratory laparotomy without any further investigations was done, due to the life-threatening condition. A midline laparotomy incision was performed. A large pulsating mass was detected occupying the epigastrium and the left hypochondrium with severe adhesions between the stomach, colon, omentum, and the pulsating mass. Due to the inability to control the subdiaphragmatic aorta, we resorted to a left anterolateral thoracotomy to control the thoracic aorta just above the diaphragm. After entering the lesser sac, a purulent collection mixed with clots; hiding a gastric perforation on the posterior gastric wall and a transverse colon perforation with fibrous edges, was detected . Then the aneurysm was opened and large amounts of clots were removed until we exposed the splenic artery defect. The splenic artery and vein were ligated, the stomach and colon perforation were closed, then splenectomy was performed. During the surgical exposure, it was detected that the omentum was stained with bile, which indicates an old leakage mostly resulted from the compressive effect of the aneurysm and the large hematoma surrounding it on the duodenum leading to bile passage from the gastric perforation. | 3.777344 | 0.980957 | sec[1]/p[3] | en | 0.999994 | 39093788 | https://doi.org/10.1097/MD.0000000000039159 |
Experts have suggested that patients with overlapping IBD and AIH are more prone to relapse and progression to cirrhosis, and anti-tumor necrosis factor (TNF) agents can be used in patients with IBD who also have liver disease. However, the challenge in treating both conditions with immunosuppressive drugs or biological therapy is the risk of developing serious infections associated with advanced liver disease. Considering the rarity of the case and its implications for therapeutic management, this study aims to present a case of a patient with liver cirrhosis due to AIH and UC refractory to conventional treatment and discuss the risks and benefits of using anti-TNF therapy for these conditions. | 4.105469 | 0.812988 | sec[0]/p[3] | en | 0.999999 | 39093785 | https://doi.org/10.1097/MD.0000000000039095 |
A 28-year-old female was admitted to the hospital in July 2016, with a history of diarrhea, 5 to 6 bowel movements per day, liquid stools without blood or mucus, associated with diffuse abdominal pain, asthenia, and lack of appetite for 9 months. Physical examination revealed collateral circulation in the abdomen. Laboratory tests showed changes in liver enzymes, anemia, and pro-inflammatory markers (Table 1 ). Serological tests for chronic viral hepatitis were negative, and ANA levels were 1/320 units/EU. A liver biopsy revealed active chronic hepatitis, stage 4 lymphohistiocytic infiltrate, and piecemeal necrosis. The patient was diagnosed with AIH based on the International Autoimmune Hepatitis Group score (11 points), and liver cirrhosis. Ultrasonography showed signs of chronic liver disease and portal hypertension, upper digestive endoscopy showed medium- to large-caliber esophageal varices, and rubber band ligation was performed. | 3.916016 | 0.982422 | sec[1]/p[0] | en | 0.999997 | 39093785 | https://doi.org/10.1097/MD.0000000000039095 |
Azathioprine and prednisone were initiated in July 2016 for AIH treatment. In March 2017, she presented with ascites and worsening pancytopenia, and azathioprine was discontinued. However, she also presented with bloody diarrhea and abdominal pain. Faced with the return of intestinal symptoms, she underwent a colonoscopy for investigation, and the colonoscopic lesions were consistent with UC with moderate activity. Treatment with low-dose azathioprine was restarted with mesalazine (4 g/day) and the patient showed a clinical response. The patient underwent a second liver biopsy that maintained the characteristics of the first biopsy, with no histological pattern of overlap with PSC. | 3.664063 | 0.986328 | sec[1]/p[1] | en | 0.999996 | 39093785 | https://doi.org/10.1097/MD.0000000000039095 |
Between 2017 and 2018, the patient had periods of clinical UC activity requiring corticosteroid use, and azathioprine was discontinued because of worsening pancytopenia. In July 2018, the patient was asymptomatic and pregnant. She was maintained on mesalazine. In March 2019, she underwent cesarean delivery and was still maintained on mesalazine. In July and August 2019, she required hospital admission due to UC activity, as evidenced by sigmoidoscopy, with lesions compatible with severe active pancolitis (Mayo endoscopic score 3) . The patient was treated with oral prednisone (60 mg/day), with improvement in intestinal symptoms. | 3.365234 | 0.98877 | sec[1]/p[2] | en | 0.999998 | 39093785 | https://doi.org/10.1097/MD.0000000000039095 |
In 2020, she presented with UC recurrence, bloody diarrhea, fever, asthenia, and decompensation of liver cirrhosis. She required blood transfusion, antibiotic therapy, and the use of vasoactive drugs. The patient continued using mesalazine 4 g/day and diuretics (furosemide and spironolactone) to treat ascites. In September 2020, she was hospitalized with abdominal septic shock. She was discharged on mesalazine and prednisone (60 mg/day), and diuretics were continued. Sigmoidoscopy showed mild UC activity (Mayo endoscopic score 1) and upper digestive endoscopy revealed esophageal moniliasis (Kodsi III) which was treated with fluconazole for 14 days. | 3.388672 | 0.98877 | sec[1]/p[3] | en | 0.999998 | 39093785 | https://doi.org/10.1097/MD.0000000000039095 |
Due to multiple hospitalizations with refractoriness to treatment with mesalazine, hematological side effects of azathioprine, side effects of corticosteroid use, and the risk of serious infection in patients with cirrhosis, we opted for the use of infliximab, an anti-TNF biological therapy. This was considered because the patient had no liver transplantation scheduled due to low therapeutic adherence and no family support to ensure posttransplantation follow-up. After evaluating the risks and benefits with the hepatology team, induction therapy with the drug was started in February 2021, with symptomatic improvement. Colonoscopy showed UC with mild activity (Mayo endoscopic score of 1). Biochemical tests showed normalization of the transaminase levels (Table 1 ). | 3.828125 | 0.949219 | sec[1]/p[4] | en | 0.999997 | 39093785 | https://doi.org/10.1097/MD.0000000000039095 |
In October 2021, the patient was hospitalized with pneumonia evidenced by diffuse pulmonary infiltrates on chest radiography and received antibiotic therapy with ceftriaxone and azithromycin, in addition to blood transfusions. The patient developed worsening liver function and disseminated intravascular coagulation. Despite treatment, the patient developed acute respiratory failure and cardiorespiratory arrest 24 hours after hospital admission. | 3.056641 | 0.98877 | sec[1]/p[5] | en | 0.999997 | 39093785 | https://doi.org/10.1097/MD.0000000000039095 |
In this case report, we described a patient with liver cirrhosis due to AIH and UC refractory to conventional therapy who had fatal complications related to the infection due to immunosuppression. Despite the risks of immunosuppression, patients need to be treated for their underlying disease to avoid the risk of complications, always weighing the risk and benefits of immunosuppressive therapy in critical patients. | 3.759766 | 0.972168 | sec[2]/p[0] | en | 0.999997 | 39093785 | https://doi.org/10.1097/MD.0000000000039095 |
TAFRO syndrome is a systemic inflammatory disorder, manifesting as thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal insufficiency/reticulin fibrosis, and organomegaly, and considered as a unique clinical subtype of idiopathic multicentric Castleman disease (iMCD). Such syndrome gave rise to a clinical picture similar to that of either a connective tissue disease or an autoimmune disease. Here we reported a delayed diagnosis of TAFRO syndrome in a Chinese young female initially presenting with symptoms of arthralgia, Raynaud phenomenon, generalized edema, and a positive anti-small nuclear ribonucleoprotein particle (snRNP) antibody. | 3.941406 | 0.858887 | sec[0]/p[0] | en | 0.999998 | 39093747 | https://doi.org/10.1097/MD.0000000000039148 |
A 39-year-old Chinese woman who had a 3-year history of arthralgia, Raynaud phenomenon, and generalized edema was admitted to our division because of a recent onset of fever, hypertension, thrombocytopenia, hematuria, and proteinuria. Three years prior to her admission, she was diagnosed as mixed connective tissue disease (MCTD) in a local hospital, presenting with arthralgia, Raynaud phenomenon, superficial lymphadenopathy, and anasarca. The clinical manifestations combined with positive antinuclear antibodies and antibodies targeting the snRNP fulfilled the criteria of MCTD. Steroid therapy (40 mg/day of intravenous methylprednisolone) was initiated for a week and tapered gradually to medroxol 4 mg Qd. Her symptoms resolved until dyeing hair 7 months ago. Due to the above symptoms, the patient went to the local hospital. Immunosuppressive treatment initiated with intravenous methylprednisolone 40 mg QD and cyclosporine A 50 mg BID. Supportive therapy was given simultaneously including antihypertension, plasmapheresis and immunoglobulin infusion due to persistent hypertension, low fever, and purpura. Specific treatment was shown in Figure 1 . Her temperature and blood pressure restored to normal but thrombocytopenia and chronic glomerulonephritis persisted. Therefore, she was transferred to our hospital. She had a medical history of hypothyroidism due to Hashimoto thyroiditis and received substitutional treatment with thyroid hormone. She was accidentally diagnosed with lung adenocarcinoma (T1N0M0) of the right inferior pulmonary lobe in 2017 and underwent surgical resection without chemotherapy and radiotherapy. | 3.859375 | 0.984863 | sec[1]/p[0] | en | 0.999996 | 39093747 | https://doi.org/10.1097/MD.0000000000039148 |
On admission, her vital signs were normal. A physical examination revealed multiple lymphadenopathies in the bilateral neck, supraclavicular fossa and axilla, and multiple purpuras on the neck and limbs. Laboratory investigations in our hospital revealed the following abnormalities (Table 1 ): platelet count of 57 * 10 9 /L; microscopic hematuria: 15 to 20/HP; urinary protein: 3+; 24-h urinary protein: 2.42 g/2200 mL, decreased serum complement level: C3 0.588 g/L and C4 level 0.11 g/L; positive antinuclear antibodies 1:1000 (speckled patterns), and positive anti-snRNP antibody 165 IU/mL, but negative anti-dsDNA antibody. She had a normal renal and hepatic function, with normal hemoglobulin, immunoglobulin, CRP, and procalcitonin levels. No monoclonal gammopathy was observed. Ultrasound scan of lymph nodes revealed multiple lymphadenopathies in the bilateral neck, supraclavicular fossa, and axilla, and these enlarged lymph nodes had slightly increased SUV values on PET-CT scan. Combined with these symptoms, signs and laboratory tests, autoimmune diseases especially systemic lupus erythematosus (SLE) were suspected. | 3.892578 | 0.963379 | sec[1]/p[1] | en | 0.999997 | 39093747 | https://doi.org/10.1097/MD.0000000000039148 |
Thrombocytopenia and proteinuria relieved after subcutaneous thrombopoietin, intravenous methylprednisolone at 40 mg QD and immunoglobulin treatments . Kidney biopsy was performed and the pathology was, to our surprise, consistent with thrombotic microangiopathy (TMA)-like lesions (capillary endothelial disease) . Immunofluorescence showed scarce immunoglobulin deposition (IgA+, IgM+, Ig G‐, C1q‐, FRA‐, Kappa+, Lambda+) but a strong deposition of C3++ along the sclerotic region and segmental mesangial region. Histopathology showed 61 glomeruli, in which diffuse endothelial proliferation and swelling along with obliteration of capillary lumen. Basement membrane thickening with double track sign. Electron microscope showed diffuse and marked thickening in the inner loose layer of glomerular basement membrane with fragmented red cells and without dense deposit. | 4.046875 | 0.758301 | sec[1]/p[2] | en | 0.999997 | 39093747 | https://doi.org/10.1097/MD.0000000000039148 |
We further completed TMA-related laboratory workup and revealed normal IL-6 level; elevated vascular endothelial growth factor (VEGF): 615.09 pg/mL (0–142.2 pg/mL); negative cryoglobulinemia; decreased complement factor H (CFH): 244.4 mg/L and negative CFH antibody. Broken red blood cells were not observed on the peripheral blood smear. ADAMTS-13 activity was within normal range. Bone marrow smear showed bone marrow hyperplasia and biopsy revealed suspected light chain restricted expression, megakaryocyte proliferation, and moderate to severe bone marrow fibrosis. A lymph node biopsy was conducted and the histopathological findings were consistent with the subtype of mixed Castleman disease. The HHV-8 and HIV were negative, so a diagnosis of iMCD was made. Based on her clinical manifestations (thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal insufficiency, lymphadenopathy) and lymph node biopsy which was consistent with iMCD, we diagnosed the patient with TAFRO syndrome after a multidisciplinary consultation. | 4.042969 | 0.952637 | sec[1]/p[3] | en | 0.999996 | 39093747 | https://doi.org/10.1097/MD.0000000000039148 |
TAFRO syndrome, a rare subtype of iMCD with an estimated annual incidence rate of 0.9–4.9 per million was first reported by Takai et al in 2010. Diagnosing TAFRO syndrome requires all 3 of the following major criteria along with at least one minor criterion, and exclusion of other diseases (Table 2 ). However, TAFRO symptoms could mimic the features of connective tissue disease, making the diagnosis difficult. Our patient presented with symptoms of arthralgia, Raynaud phenomenon, generalized edema, and a positive anti-snRNP antibody at the disease onset, fulfilled the diagnostic criteria of mixed CTD (High titer anti-RNP antibody accompanied by Raynaud phenomenon and 2 or more of the 3 remaining clinical criteria [swollen fingers, synovitis, and myositis].) and responded well to glucocorticoids therapy at first. After about 3 years of stable condition, the patient gradually presented with skin purpura, fever, hypertension, thrombocytopenia, hypocomplementemia, and nephritic syndrome. Taken together, a diagnosis of SLE was suspected. The re-induction therapy combined with corticosteroids and cyclosporin A achieved a partial remission of thrombocytopenia, but not lasting. The kidney biopsy revealed TMA-like lesions, bone marrow biopsy revealed myelofibrosis, and lymph node biopsy HHV-8 negative Castleman disease. After that, the diagnosis was revised to the iMCD-TAFRO syndrome. | 4.160156 | 0.848145 | sec[2]/p[0] | en | 0.999998 | 39093747 | https://doi.org/10.1097/MD.0000000000039148 |
To our knowledge, it is the first case reported with shared characteristics of MCTD and iMCD-TAFRO syndrome. As the overlapping symptoms between TAFRO syndrome and the systemic autoimmune disorder usually lead to misdiagnosis, indicating a shared pathogenesis between both diseases. Cytokines other than IL-6 may play a role in the shared pathogenicity of the iMCD-TAFRO syndrome and systemic autoimmune diseases. | 3.478516 | 0.921875 | sec[2]/p[5] | en | 0.999996 | 39093747 | https://doi.org/10.1097/MD.0000000000039148 |
Labial fusion, also known as labial adhesion, labial agglutination, or labial synechiae, is the fusion of either the labia majora or minora frequently around the clitoris . It is typically found in young girls before puberty, but may also arise during adolescence. In this case report, we present a pubertal girl with labial fusion and discuss the critical aspects of her diagnosis, treatment, and outcomes. Painful or difficulty urinating and the passage of menstrual blood are indications that a patient might have labial fusion. For these reasons, early detection and treatment are important. The application of estrogen cream may help separate fused labia, or surgery is part of its treatment choices. In a few cases, a biopsy might be done to rule out other conditions. The treatment outcome depends on the severity of the condition and the patient’s age. With early diagnosis and treatment, most patients achieve a full recovery and can go on to lead a normal, healthy life. | 4.027344 | 0.953613 | sec[0]/p[0] | en | 0.999995 | PMC11296960 | https://doi.org/10.7759/cureus.63773 |
Routine laboratory investigations were done to evaluate for other endocrine abnormalities and rule out infectious etiologies. A complete blood count, liver function test, kidney function test, fasting and postprandial blood sugar, urine routine, and microscopy were within normal limits. Imaging showed a normal-sized uterus and ovaries with no collection in the vaginal cavity or intrauterine cavity. However, there was dilatation of the pelvicalyceal system. | 3.296875 | 0.934082 | sec[1]/p[3] | en | 0.999995 | PMC11296960 | https://doi.org/10.7759/cureus.63773 |
Labial fusion in pubertal girls warrants prompt recognition and tailored management to mitigate associated complications and optimize patient well-being. This comprehensive case report underscores the importance of a multidisciplinary approach, incorporating hormonal therapy and patient education, in the management of pubertal labial fusion. Early intervention and vigilant follow-up are essential for achieving successful outcomes and enhancing the quality of life for affected individuals. | 3.882813 | 0.896484 | sec[3]/p[0] | en | 0.999996 | PMC11296960 | https://doi.org/10.7759/cureus.63773 |
A 4-year-old female neutered Scottish Fold shorthair cat was presented with a history of reduced general condition in the past week, and acute progressive onset of circling towards the right side. General physical examination was unremarkable. Neurological examination revealed intermittent, non-compulsive circling towards the right, mild ataxic gait and straddled forelimbs when sitting. Proprioception, cranial nerves and dazzle reaction were unremarkable. In addition, there was no pathologic nystagmus. The cat was reduced, but alert and responsive. Complete blood count was within the reference intervals (RIs). Serum biochemistry showed a mild hyperproteinaemia (85 g/l; RI 64–80) and a mild hypercholesterinaemia (8.7 mmol/l; RI 2.6–6.8). Before presentation, the cat was treated with meloxicam (Metacam; Boehringer Ingelheim) and cannabidiol (Calmin 5%; Inuvet) on suspicion of joint pain. The cat also had a history of breed-related osteochondrodysplasia. Furthermore, she had never been outside of Switzerland and was regularly vaccinated and dewormed. Differential diagnoses at that time included a metabolic or inflammatory/infectious disease, an unobserved trauma, a neoplastic process and a vascular anomaly or insult. | 3.925781 | 0.980469 | sec[0]/p[0] | en | 0.999996 | 39099734 | https://doi.org/10.1177/20551169241264134 |
An MRI examination revealed a right-sided, diffuse swelling of the cerebral grey matter that formed a focal, ill-defined mass lesion at the level of the right piriform lobe (intra-axial) . The lesion was iso- to mildly hyperintense in the fluid sensitive sequences and T1W iso- to mildly hypointense compared with the cerebral grey matter. The mass was partially surrounded by an irregularly shaped and focally discontinuous, thick T2W and FLAIR hyperintensity that affected the pachy- and leptomeninges (extra-axial). A dural tail sign with leptomeningeal enhancement and widening of the sulci could be observed after contrast administration . There was mild perilesional and moderate distant hyperintensity in the fluid sensitive sequenced without signs of restricted diffusion in the region of the white matter, consistent with a vasogenic oedema. The lesion caused a marked mass effect with left-sided shift of the cerebral falx (subfalcine herniation) and compression of the right lateral, third and fourth ventricle. The thalamus, brainstem and the cerebellum were caudally displaced and compressed with resulting caudal transtentorial forebrain herniation and transforaminal herniation of the cerebellum . The cervical spinal cord was diffusely swollen and had a parenchymal T2W hyperintensity and T1W hypointense central cavity extending from C2 to C5, consistent with a syringomyelia and spinal cord oedema, most likely secondary to flow disturbances of the cerebrospinal fluid (CSF) at the level of the mesencephalic aqueduct and foramen magnum. At the level of the right frontotemporal lobe, the calvarium was severely irregular defined and osteolytic. The right temporal muscle was moderately swollen and markedly contrast enhancing. The unstructured hyperintensity along the calvarium was indistinguishable from the above muscular lesion . The right parotid, right lateral retropharyngeal and both medial retropharyngeal lymph nodes were moderately enlarged and had strong contrast enhancement . | 4.269531 | 0.801758 | sec[0]/p[2] | en | 0.999999 | 39099734 | https://doi.org/10.1177/20551169241264134 |
The imaging summary included an intra-axial right-sided space-occupying lesion at the level of the piriform lobe with diffuse regional and distant extra-axial infiltration, mild perilesional- and moderate distant vasogenic oedema. In addition, there were aggressive calvarial osteolysis, and infiltration of the frontotemporal bone as well as of the right temporal muscle, and finally, enlarged, contrast-enhancing regional lymph nodes. Based on these imaging findings, main differentials included neoplasia such as histiocytic sarcoma (HS) or T-cell lymphoma. Aggressive meningioma or glioma had to be considered. Owing to the involvement of bone and muscle, a primary bone tumour, such as osteochondrosarcoma or other sarcoma, was included. Other neoplastic diseases, such as granular cell tumour or meningeal carcinomatosis, were considered less likely. Because of the geographical location (Switzerland) and no travel history, a fungal disease was considered unlikely. The enlarged lymph nodes most likely represented metastases of any of the above suggested neoplastic processes, as non-neoplastic diseases such as granuloma, abscess formation secondary to fungal or bacterial infection and thus reactive lymphadenopathy appeared less likely. | 4.136719 | 0.917969 | sec[0]/p[3] | en | 0.999997 | 39099734 | https://doi.org/10.1177/20551169241264134 |
The intracranial component of the present case had similar MRI features as previously described in dogs and in few case reports of cats. 3 , 4 , 9 – 13 There was a diffuse leptomeningeal extension and contrast enhancement with concurrent widening of the sulci and an additional focal, ill-defined, non-enhancing mass in the right piriform lobe, as well as perilesional and distant oedema formation. | 3.912109 | 0.543945 | sec[1]/p[2] | en | 0.999995 | 39099734 | https://doi.org/10.1177/20551169241264134 |
In the cat presented in this case report, the muscular lesion had similar signal intensities when compared with the diffuse meningeal lesion and were almost indistinct or non-separable from it. This finding could suggest a primary muscular neoplasm with infiltration of the bone and meninges, possibly mirroring an aggressive biological behaviour as mentioned above. However, as the MRI characteristics of the mass lesion at the level of the right piriform lobe were, apart from the lack of contrast enhancement, almost identical to the features described in CNS HS in dogs and cats, a primary CNS tumour with secondary osteolysis and muscular invasion was considered the most likely differential diagnosis. 3 , 4 , 9 – 13 Unfortunately, a post-mortem histopathological evaluation of the brain was not performed; therefore, it remains open whether a necropsy could clarify if the brain mass was primary or secondary in nature. | 4.125 | 0.786133 | sec[1]/p[4] | en | 0.999996 | 39099734 | https://doi.org/10.1177/20551169241264134 |
Regardless of the origin of the primary tumour, if muscular or intra-/extra-axial, the cat presented in this case report most likely had a local form of HS as, to the best of our knowledge, the extensive lesion at the level of the right piriform lobe with local invasion and metastases into the regional lymph nodes was the only one identified. | 3.199219 | 0.933594 | sec[1]/p[5] | en | 0.999996 | 39099734 | https://doi.org/10.1177/20551169241264134 |
This case report adds novel MRI features of HS involving the CNS in cats with extensive aggressive calvarial osteolysis and regional muscular invasion, which were not previously described. The intracranial component of the HS in our cat shared similar MRI features as those published in the veterinary literature to date. A diagnosis was achieved via cytology and cytology should be taken into account in such cases. HS should be considered as a differential diagnosis for an intra-axial mass with additional diffuse meningeal infiltration (extra-axial), regional aggressive bone lysis, adjacent muscular invasion and regional lymphadenopathy. | 4.078125 | 0.933105 | sec[2]/p[0] | en | 0.999996 | 39099734 | https://doi.org/10.1177/20551169241264134 |
Gastric and duodenal ulcers together are called peptic ulcer diseases, with an estimated lifetime prevalence of 5-10% and an annual incidence of 0.1-0.3% . Bleeding is the most frequent complication of peptic ulcer disease and occurs in approximately 15-20% of patients . Endoscopy is recommended for the diagnosis and treatment of peptic ulcer disease, whereas transcatheter arterial embolization (TAE) is recommended when endoscopy is not feasible . In cases of TAE, the most common causative artery is the gastroduodenal artery . Hemorrhage of the proper hepatic artery is rare. In previous case reports, bleeding from the proper hepatic artery was not controlled by endoscopy, and TAE or surgical treatment was required . Herein, we report a case of proper hepatic artery bleeding caused by a duodenal ulcer that was successfully treated with TAE. | 4.09375 | 0.920898 | sec[0]/p[0] | en | 0.999998 | 39099971 | https://doi.org/10.7759/cureus.63822 |
An 87-year-old woman called an ambulance because of melena. She had been prescribed oral non-steroidal anti-inflammatory drugs (NSAIDs) for one month after a lumbar compression fracture from a fall. Notably, she had experienced an episode of melena two weeks prior, although she had not sought medical attention at that time. She had a history of untreated type 2 diabetes, hypertension, and osteoporosis, but no history of surgery. At the time of emergency medical service contact, her level of consciousness was clear, and her vital signs were within normal limits. Immediately after arrival at the hospital, she vomited a large amount of blood, and her systolic blood pressure decreased to 80 mmHg. Her vital signs recovered in response to a 1 L fluid infusion. Blood tests revealed anemia and elevated levels of inflammatory markers (Table 1 ). | 3.574219 | 0.987793 | sec[1]/p[0] | en | 0.999997 | 39099971 | https://doi.org/10.7759/cureus.63822 |
Despite using high-frequency forceps and hemostatic clips, complete hemostasis was not achieved because of intense bleeding. Therefore, we decided to perform a TAE to stop the bleeding. Six units of red blood cells were transfused during the endoscopy. A meticulous assessment of contrast-enhanced CT before TAE revealed that the proper hepatic artery ran along the bottom of the duodenal ulcer and narrowed at the bottom of the ulcer , indicating bleeding from the proper hepatic artery. A 3D reconstruction of the hepatic artery using arterial-phase CT data demonstrates a severe stenosis (arrow) in the proper hepatic artery . The site of stenosis was located at the base of the duodenal ulcer. | 3.792969 | 0.94043 | sec[1]/p[2] | en | 0.999997 | 39099971 | https://doi.org/10.7759/cureus.63822 |
At the start of the embolization procedure, the patient was restless and hypotensive, and the procedure was performed under local anesthesia with a rapid transfusion of red blood cells. The right femoral artery was punctured, and a 4-F sheath was placed. A 4-F curved catheter (Rosch Celiac) was advanced through the sheath to catheterize the celiac artery. Angiography of the proper hepatic artery conducted using a microcatheter revealed severe stenosis in the proper hepatic artery, and the clips used for upper endoscopy were located close to the stenosis . | 3.769531 | 0.960938 | sec[1]/p[3] | en | 0.999997 | 39099971 | https://doi.org/10.7759/cureus.63822 |
After the procedure, the patient's restlessness improved, consciousness became clear, and vital signs stabilized. Oral intake was initiated the following day, and the patient did not experience recurrent hematemesis or abdominal pain. Blood tests conducted on the same day revealed elevated liver enzyme levels: aspartate transaminase/alanine transaminase (AST/ALT): 220/117 IU/L. However, blood tests conducted one week later demonstrated normalization of liver enzyme levels and no progression of anemia. One week after TAE, contrast-enhanced CT showed no signs of hepatic infarction, and upper endoscopy revealed an ulcer on the anterior wall of the duodenal bulb, categorized as stage A2, with signs of healing . | 3.804688 | 0.978516 | sec[1]/p[6] | en | 0.999999 | 39099971 | https://doi.org/10.7759/cureus.63822 |
The proper hepatic artery is a rare site of arterial bleeding caused by peptic ulcers. Only a few cases of proper hepatic artery bleeding caused by peptic ulcers have been reported . The majority of the reported cases involved bleeding at the anastomotic site of the hepatic artery after liver transplantation with a right lobe liver graft . The possible mechanisms of proper hepatic artery bleeding in recipients of right lobe liver grafts include dissection around the porta hepatis, anatomical proximity of the hepatic artery anastomosis to the duodenal bulb, and exposure of the arterial anastomosis to duodenal fluid contained by the post-operative adhesions . In contrast, the present patient had no history of abdominal surgery, which is unusual. In the present case, long-term use of NSAIDs was thought to have caused a duodenal ulcer. In all the previous cases, bleeding from the hepatic artery was not controlled by endoscopy alone and required TAE and/or surgical intervention. Endovascular treatment is more suitable than endoscopic hemostasis for hepatic arterial bleeding caused by duodenal ulcers. In patients with bleeding peptic ulcer disease, contrast-enhanced CT images should be carefully evaluated to identify the vessels that cause bleeding. If bleeding from a large artery, such as the proper hepatic artery, is suspected, we suggest endovascular treatment instead of endoscopy. | 4.199219 | 0.515137 | sec[2]/p[0] | en | 0.999995 | 39099971 | https://doi.org/10.7759/cureus.63822 |
Here, we report a case of proper hepatic artery bleeding caused by a duodenal ulcer. The bleeding was not controlled by endoscopy, and TAE was performed for hemostasis. In patients with bleeding peptic ulcer disease, it is important to carefully read contrast-enhanced CT scans to identify the source of bleeding. Endovascular treatment, rather than endoscopy, should be the first choice of treatment for bleeding from large arteries. | 3.794922 | 0.97168 | sec[3]/p[0] | en | 0.999996 | 39099971 | https://doi.org/10.7759/cureus.63822 |
Cocaine has been linked with Brugada syndrome in a few case studies to date. In a previous case report following the prognosis of a 32-year-old male with a history of cocaine and nicotine abuse presenting with a Brugada ECG pattern unmasked by cocaine use, the authors propose that cocaine's sympathomimetic effects and sodium channel blocking properties can induce transient Brugada-like patterns in individuals without a genetic predisposition to Brugada syndrome . These patterns, observed after cocaine use, highlight the importance of distinguishing drug-induced ECG changes from genuine Brugada syndrome to ensure appropriate management. While treatments for cocaine-related cardiac complications exist, the long-term consequences and outcomes of drug-induced Brugada-like patterns remain uncertain . | 4.039063 | 0.763184 | sec[0]/p[2] | en | 0.999997 | 39099899 | https://doi.org/10.7759/cureus.63861 |
In this study, we aimed to present the unique ECG findings that are consistent with those of type 1 Brugada in a 31-year-old female who was brought to the ED unresponsive with positive lab findings for cocaine, fentanyl, benzodiazepines, and tetrahydrocannabinol (THC). On initial evaluation, the patient was severely acidotic and had findings of bidirectional ventricular tachycardia which was resolved with electrolyte replacement and treatment. However, after being admitted to the ICU, the patient developed Brugada syndrome ECG patterns approximately 9 h after the resolution of her bidirectional ventricular tachycardia. We aimed to use this case to investigate potential mechanisms relating cocaine use with the induction of Brugada syndrome, as well as its implications for treatment. | 4.03125 | 0.914551 | sec[0]/p[3] | en | 0.999996 | 39099899 | https://doi.org/10.7759/cureus.63861 |
The patient was a 31-year-old female who arrived at the emergency department after being found unresponsive following an episode where she and a friend lost consciousness after using an unknown substance. The family denies any known hereditary diseases. Upon arrival, she required immediate intubation and cardiopulmonary resuscitation (CPR). Her initial ECG findings after the return of spontaneous circulation were consistent with bidirectional ventricular tachycardia, right axis deviation, terminal R wave, elongated QT interval, and a wide QRS complex. Resuscitative efforts included CPR, epinephrine administration, IV calcium gluconate, IV magnesium sulfate, and fluid resuscitation with lactated ringers and vasopressors. Laboratory findings revealed severe acidosis, leukocytosis, elevated ammonia, lactate, glucose, and abnormal liver enzyme levels, along with a positive urine drug screen for benzodiazepines, THC, cocaine, and fentanyl. Following successful resuscitation, the patient’s physical examination findings included fixed and dilated pupils, irregular rhythm with diminished carotid pulses, respiratory distress, and unresponsiveness. A subsequent ECG performed in the emergency room showed resolution of the ventricular tachycardia but revealed a prolonged QTc interval of 521 ms and right axis deviation . CT imaging revealed cerebral edema, and the patient was transferred to the ICU for further management, including intravenous fluid resuscitation, antibiotic therapy, sedation, and vasopressor support . | 3.839844 | 0.981445 | sec[1]/p[0] | en | 0.999996 | 39099899 | https://doi.org/10.7759/cureus.63861 |
The patient was admitted to the ICU where an arterial line was inserted to enable continuous hemodynamic monitoring, while a neurology consultation prompted the initiation of continuous EEG monitoring to investigate potential subclinical seizures. Throughout the afternoon, the patient displayed persistent tachycardia, leading to the administration of Lopressor to manage heart rate. An ECG was also collected 12 h after the first ECG and was suggestive of a type 1 Brugada pattern . | 3.636719 | 0.981445 | sec[1]/p[1] | en | 0.999997 | 39099899 | https://doi.org/10.7759/cureus.63861 |
To address the cerebral edema identified on the CT brain scan, the patient received 3% hypertonic saline at a rate of 30 cc/h, alongside escalated pressor support. A CT abdominal imaging also showed an irregularity within the right groin, possibly indicating a pseudoaneurysm or hematoma . Despite these interventions, the significant cerebral edema and hypoxic injury prompted a consultation with neurosurgery, who deemed invasive interventions unlikely to improve the prognosis. Consequently, palliative care discussions ensued, culminating in a mutual decision with the family to transition the patient to a do-not-resuscitate (DNR) status. Sedation was discontinued on the second day of admission, leading to a brain death evaluation revealing no evidence of brain activity in the early afternoon. A repeat evaluation was scheduled for the following day, during which sedation remained off, and no clinical changes were observed. Another brain death evaluation, including an apnea challenge, confirmed the absence of brain activity on the third day. With the family present, mechanical and chemical support was withdrawn, with the patient entering asystole shortly thereafter, and the time of death was recorded on day three of admission, approximately 79 hours after arrival to the ED. The final diagnoses encompassed multiple contributing factors, including cardiac arrest secondary to drug overdose, accidental drug overdose, cocaine use disorder, acute respiratory failure with hypoxia and hypercapnia, anoxic brain injury, transaminitis, metabolic acidosis, acute kidney injury, and cerebral edema secondary to anoxia. | 3.837891 | 0.975098 | sec[1]/p[2] | en | 0.999995 | 39099899 | https://doi.org/10.7759/cureus.63861 |
Also of note is that the patient was severely acidotic on arrival to the ED with an initial venous blood gas pH of 6.694. For those with Brugada syndrome, severe acidosis may cause the sympathetic nervous system to become activated as a compensatory response , intended to stabilize the internal environment of the body. This can then affect cardiac electrophysiology by greatly impacting cardiac rhythm and perhaps raising the chance of arrhythmias . The myocardium may become even more unstable due to the disrupted autonomic balance, increasing its susceptibility to the usual arrhythmic episodes associated with Brugada syndrome . Autonomic tone is known to affect Brugada syndrome, therefore these alterations can affect those who have it more severely . Usually, sympathetic activity reduces the symptoms of the condition while vagal dominance worsens them . Hence, depending on the individual’s physiological reaction and the severity of the acidosis, the sympathetic response caused by the illness may either mitigate or conceal distinctive signs of Brugada syndrome . One could argue that for the patient in this case the ECG abnormalities were due to the acidosis. We doubt this is the case due to the fact that the acidosis was improving. A repeat arterial blood gas (ABG) in the ICU 2 h prior to the ECG in Figure 3 was obtained and showed a pH of 7.27. While still not a normal value, it is significantly improved from the initial 6.694. In addition, the ECG in Figure 1 was obtained while the patient was acidotic and this ECG does not show the Brugada pattern. | 4.164063 | 0.739258 | sec[2]/p[5] | en | 0.999998 | 39099899 | https://doi.org/10.7759/cureus.63861 |
This patient also had co-ingestion of other substances specifically benzodiazepines THC and fentanyl. There are reports of Brugada syndrome associated with an overdose of both THC and fentanyl. However, these reports are from patients who usually have polysubstance issues and have multiple drugs in their system at the time of evaluation. In the present case, we can not definitively say that cocaine was the sole cause of all of these abnormalities. We do feel that cocaine is the most likely culprit due to its effects on the sodium channels of the myocardium. The ECG abnormalities associated with Brugada syndrome are secondary to the genetic abnormalities of the sodium channels of the myocardium. For this case, we postulate that the patient has acquired the ECG abnormalities secondary to the ingestion of cocaine. So instead of being born with abnormal sodium channels of the myocardium, this patient acquired them by ingesting significant amounts of cocaine which caused an acute pathology of the sodium channels mimicking Brugada syndrome. While it is true that the patient may have had undiagnosed Brugada syndrome, which was revealed by ingestion of the substances, we find that less likely based on her history or lack thereof. | 4 | 0.901367 | sec[2]/p[6] | en | 0.999996 | 39099899 | https://doi.org/10.7759/cureus.63861 |
It is important to approach cases of cocaine-induced changes resembling Brugada syndrome with caution, distinguishing between actual Brugada syndrome and Brugada-like findings. While cocaine-induced alterations in cardiac physiology may mimic the characteristic ECG patterns of Brugada syndrome, the underlying mechanisms and long-term implications might differ, and further research is needed to determine the precise relationship between cocaine exposure and the development of Brugada-like findings in order to clarify whether these changes represent a true manifestation of acquired Brugada syndrome or a distinct cardiotoxic effect of cocaine. In the present case, there had been no previous extensive genetic or cardiological workups, making it difficult to determine whether or not she was genetically predisposed to Brugada syndrome. However, given that the patient did have a type 1 Brugada ECG finding in addition to experiencing ventricular arrhythmias on arrival to the ED, we believe that she did meet the criteria to be diagnosed with Brugada syndrome and that the cardiotoxic effects of her cocaine use may have contributed to unveiling it. | 4.15625 | 0.564941 | sec[2]/p[7] | en | 0.999998 | 39099899 | https://doi.org/10.7759/cureus.63861 |
While cocaine-induced changes in heart function can resemble the ECG patterns seen in Brugada syndrome, it's essential to differentiate between true Brugada syndrome and similar findings caused by cocaine. Although there are indications that cocaine might contribute to Brugada syndrome by affecting cardiac sodium channels and connexin 43, further investigation is necessary to fully grasp these mechanisms and their link to Brugada-like findings in individuals with a history of cocaine abuse. The case discussed highlights the challenges in diagnosing and managing such scenarios, especially when substance abuse is involved without prior genetic or cardiac evaluations. While this patient's clinical presentation is indicative of Brugada syndrome, further exploration is required to determine if her condition was induced by cocaine or simply unmasked by it. In conclusion, extensive research is necessary in order to better understand the mechanisms by which cocaine may lead to or unmask Brugada syndrome and to develop more effective treatment strategies for individuals affected by this complex interaction. | 4.226563 | 0.429932 | sec[3]/p[0] | en | 0.999996 | 39099899 | https://doi.org/10.7759/cureus.63861 |
Acute subdural hematomas (ASDH) are commonly observed in younger individuals. However, this condition often occurs in the elderly and tends to result in poor clinical outcomes . In elderly patients, low-velocity falls within the home environment are the primary contributors to these injuries . The incidence of ASDH has been increasing, a trend partially attributable to the increasing number of individuals undergoing more comprehensive antithrombotic and anticoagulant therapies and also due to the aging population. . Mortality following ASDH varies based on several factors, including patient age, Glasgow Coma Scale (GCS) score, extent of hemorrhage, and duration between the ASDH event and treatment initiation . Post-traumatic seizures (PTS) are also independent markers of poor functional and social outcomes . In elderly patients, the indications for surgery must be carefully determined because of low surgical tolerance. However, some patients have refractory non-convulsive status epilepticus (NCSE), and medication alone cannot resolve this situation. Here, we present an illustrative case of refractory NCSE that improved after endoscope-assisted evacuation of ASDH. | 4.210938 | 0.85791 | sec[0]/p[0] | en | 0.999998 | 39099992 | https://doi.org/10.7759/cureus.63817 |
An 88-year-old woman weighing 33 kg presented with progressive dysarthria and right hemiparesis three days after a fall. On admission, she presented with a GCS score of E4V3M5, dysarthria, and right hemiparesis (MMT 4/5). Cranial CT scan revealed a left hemispheric ASDH, 9 mm thick, without a midline shift. However, it showed a mild traumatic subarachnoid hemorrhage in the interpeduncular cistern, hydrocephalus ex vacuo and the right predominant periventricular cerebrospinal fluid (CSF) leaks . We preferred conservative therapy first because it did not fulfill the following surgical indications: ASDH less than 10 mm in thickness and mild consciousness disturbance. A nonconvulsive seizure was suspected, and lacosamide 100 mg/day was started on the same day. Although the CT scan showed no progression of ASDH, her consciousness deteriorated 4 days after admission (GCS E1V3M5). MRI revealed no other lesions such as contusions or diffuse axonal injury . Laboratory data showed no evidence of electrolyte abnormalities, glucose metabolism abnormalities, or dehydration. Five days after admission, she experienced convulsions in the right face and arm. Although the convulsions stopped after the administration of diazepam 10 mg IV and her consciousness temporarily improved (GCS E3V4M5), it worsened again 6 days after admission (GCS E1V3M5). EEG revealed an ictal pattern in the left frontoparietal region, leading to a diagnosis of NCSE . Subsequently, despite the administration of fosphenytoin sodium hydrate (750 mg on the first day and 262 mg/day on the second day) infused via IV for 30 minutes 7-8 days after admission and phenobarbital 625 mg/day infused via IV over 10 minutes 11 days after admission for NCSE, the persistent disturbance of consciousness and EEG findings remained unimproved . Therefore, considering the need for subdural hematoma drainage, the patient underwent endoscope-assisted evacuation for ASDH 13 days after admission. | 3.960938 | 0.980469 | sec[1]/p[0] | en | 0.999998 | 39099992 | https://doi.org/10.7759/cureus.63817 |
The patient underwent endoscope-assisted evacuation of ASDH under general anesthesia. We selected the site for craniotomy at the thickest part of the hematoma using neuronavigation. Then, a straight skin incision of 5 cm was made, and a 4-cm-diameter small parietal craniotomy was performed. The hematoma was jelly-like and had partially formed a capsule. The hematoma was aspirated with a suction tube while being observed with a 2.7-mm 0° and 30° rigid endoscope . The rigid endoscope was held in the left hand, the suction cannula was held in the right hand, and the suction cannula was exchanged for bipolar forceps, as needed. The hematoma was removed using a suction cannula under the guidance of a rigid endoscope. When bleeding from a vessel on the brain surface was observed, a suction cannula was placed at the bleeding point, and coagulation was performed using monopolar electrocoagulation with a suction cannula. The bridging vein, which we identified as the source of bleeding, was coagulated using bipolar forceps. It was covered with absorbable Fibrillar™ hemostat (Surgicel®; Ethicon, Tokyo, Japan) for bleeding points. Finally, the subdural space was irrigated with artificial cerebrospinal fluid(Artcereb, Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan). The dura mater was tightly closed and the bone was repositioned and stabilized using a fixture device, followed by closure of the scalp. | 3.914063 | 0.95752 | sec[1]/p[2] | en | 0.999996 | 39099992 | https://doi.org/10.7759/cureus.63817 |
Postoperatively, the postoperative course was uneventful, and the patient showed improved consciousness (GCS E4V4M6) with no neurological deficits. A CT scan performed one day after the surgery showed near-total hematoma evacuation . EEG taken 15 days after admission showed that NCSE was completely suppressed . At discharge, on postoperative day 34, the patient’s modified Rankin Scale score was 4 due to disuse atrophy. | 3.28125 | 0.989746 | sec[1]/p[4] | en | 0.999998 | 39099992 | https://doi.org/10.7759/cureus.63817 |
Table 1 Individual case description No. Age Initial disease Type of initial index Surgery/intervention Indication for reconstruction Type of Reconstruction Individual description 1 69 EGJ Carcinoma Ivor Lewis with subsequent anastomotic stenosis along with delayed gastric emptyping Pseudoachalasia Colon interposition Chronic (8 years) therapy-refractory stenosis of the oesophagogastrostomy combined with delayed gastric emptying, secondary retrosternal Colon interposition (Roux-en-Y). 2 66 Boerhaave syndrome Salvage oesophagectomy Esophageal discontinuity Gastric pull-up Emergency esophagostomy in septic multi-organ failure due to Boerhaave syndrome, secondary reconstruction with gastric pull-up. 3 70 Incarcerated upside- down stomach Merendino with subsequent leakage of oesophagojejunostomy Esophageal discontinuity Colon interposition Leakage after Merendino procedure due to incarcerated upside-down stomach years after sleeve gastrectomy, salvage oesophagectomy, secondary colon interposition onto the merendino-limb. 4 62 Long segment EGJ Carcinoma oncological D2 gastrectomy with partial oesophagectomy Stomach not available for reconstruction Colon interposition Oncological D2 Gastrectomy along with thoracal partial oesophagectomy for a long-distance longitudinally spread cardiac carcinoma after neoadjuvant treatment. Followed by reconstruction via colon interposition with distal Roux-en-Y anastomosis. 5 68 Long segment EGJ Carcinoma oncological D2 gastrectomy with partial oesophagectomy Stomach not available for reconstruction Colon interposition Oncological D2 Gastrectomy along with thoracal partial oesophagectomy for a long-distance longitudinally spread cardiac carcinoma after neoadjuvant treatment. Followed by reconstruction via colon interposition with distal Roux-en-Y anastomosis. 6 74 Hiatal hernia Fundoplication with early recurrence and incarceration of the stomach along with esophageal perforation Esophageal discontinuity Colon interposition Fundoplication with early recurrence and partial incarceration of the stomach along with esophageal perforation alio loco, salvage oesophagectomy and partial gastric resection, secondary colon interposition. 7 62 Esophageal squamous carcinoma Hybrid Ivor-Lewis with subsequent eosophago-bronchial fistula Esophageal discontinuity Colon interposition Hybrid Ivor-Lewis after neoadjuvant treated esophageal squamous carcinoma with subsequent oesophago-bronchial fistula, salvage conduit resection and treatment of bronchial fistula, secondary colon interposition onto Roux-en-Y-limb. 8 69 Achalasia Several Myotomies and hiatal revisions End-stage-achalasia with sigmoidal transformation Colon interposition Elective esophagectomy and colon interposition in end-stage-achalasie with mega-esophagus and poor QoL. 9 61 Esophageal SCC Hybrid Ivor-Lewis with subsequent eosophago-bronchial fistula Esophageal discontinuity Colon interposition Hybrid Ivor-Lewis after neoadjuvant treated esophageal squamous carcinoma with subsequent eosophago-bronchial fistula alio loco, salvage conduit resection and treatment of bronchial fistula, secondary colon interposition onto Roux-en-Y-limb 10 87 Choledocholithiasis Iatrogenic esophageal perforation during ERCP Esophageal discontinuity Gastric pull-up Iatrogenic perforation during ERCP for choledocholithiasis, salvage oesophagectomy alio loco. Secondary retrosternal gastric pull-up. 11 30 Achalasia Several Myotomies and hiatal revisions, partial esophagectomy and gastric pull-up Therapy refractory severe erosive Reflux disease, sigmoidal transformation of the gastric conduit Colon interposition End-stage achalasia; Several Myotomies and hiatal revisions, partial esophagectomy and gastric pull-up with therapy refractory severe erosive Reflux disease along with sigmoidal transformation of the gastric conduit, secondary colon interposition onto Roux-en-Y limb. 12 45 GORD Fundoplication with multiple hiatal revisions, Merendino with subsequent stenosis and stent perforation into the Merendino limb Esophageal discontinuity Colon interposition Initial Fundoplication with multiple revisions alio loco. Merendino procedure with subsequent stenosis and stent perforation into the Merendino limb Salvage oesophagectomy, Retrosternal colon interposition onto Meredino limb. Legend: EGJ: esophago-gastral-junction; SCC: squamous cell carcinoma; ERCP: endoscopic retrograde cholangio pancreaticography; GERD: gastro oesophageal reflux disease | 4.125 | 0.702148 | sec[1]/sec[0]/p[2] | en | 0.999996 | 39096348 | https://doi.org/10.1007/s00423-024-03433-6 |
The colon was completely mobilized from the retroperitoneum, starting at the caecum to the sigmoid colon. Then, the arterial vascularisation was identified followed by the occlusion of the right colic artery, the middle colic artery as well as the collateral arcades at both extremities with atraumatic vascular clamps. This manoeuvre has been carried out for at least 10 min to check for sufficient arterial blood supply from the left colonic artery origin from the inferior mesenteric artery as previously reported . During the same time, it was also ensured that there was no venous congestion. | 3.882813 | 0.451904 | sec[1]/sec[1]/p[2] | en | 0.999998 | 39096348 | https://doi.org/10.1007/s00423-024-03433-6 |
Our experience aligns with previous reports highlighting the functional superiority of the colon over the stomach as a substitute for the oesophagus, particularly in younger patients with benign conditions like end-stage achalasia . This was exemplified by a case involving a young female patient with chronic, therapy-refractory severe reflux disease post-gastric pull-up with intrathoracic esophago-gastrostomy, who underwent successful conversion to colonic interposition, yielding a favourable functional outcome. | 3.896484 | 0.797363 | sec[3]/p[7] | en | 0.999995 | 39096348 | https://doi.org/10.1007/s00423-024-03433-6 |
In our cohort one leakage of the esophgo-colonostomy occurred which was treated with subsequent EVT treatment (three cycles) without any septic events. This was well tolerated as the anastomosis was at the level of the upper thoracic aperture about seven centimetre distal to the pharynx. If EVT would not have been tolerated the cervical wound would have been opened. | 3.103516 | 0.688477 | sec[3]/p[9] | en | 0.999998 | 39096348 | https://doi.org/10.1007/s00423-024-03433-6 |
Between 2012 and 2016, she had multiple admissions but never returned to baseline. In April 2016, she was admitted for trying to jump out of a moving car, and this admission lasted until 2023. Different medication combinations were tried and adjusted according to the response, as shown in Table 1 . She also received six sessions of electroconvulsive therapy (ECT) in 2017. Despite treatment, she remained symptomatic with hallucinatory behaviour, social withdrawal, poverty of speech, psychomotor retardation, poor self-hygiene, difficulty tending to activities of daily living, and bouts of agitation and aggression, which required frequent rapid tranquilisation and a short course of regular benzodiazepines. | 3.056641 | 0.990234 | sec[1]/p[3] | en | 0.999997 | 39100027 | https://doi.org/10.7759/cureus.63871 |
This report's primary goals are to reinforce the value of antipsychotic monotherapy in the treatment of schizophrenia, particularly TRS, and to discourage the overuse of APP in cases of poor response, especially in the absence of a previous clozapine trial. This patient did not achieve remission on subtherapeutic APP dosages. The most effective treatment for TRS has been shown to be clozapine monotherapy, as it was in our instance . | 3.865234 | 0.834473 | sec[2]/p[6] | en | 0.999998 | 39100027 | https://doi.org/10.7759/cureus.63871 |
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