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1.  Metastatic Malignant Melanoma of the Inguinal Lymph Node with Unknown Primary Lesion 
Case Reports in Medicine  2015;2015:879460.
Background. Malignant melanoma could present with metastasis with unknown primary (MUP) and this happens in 2-3% according to the studies. Around 90% of melanomas have cutaneous origin, but still there are melanomas that could be found in visceral organs or lymph nodes with unknown primary site. Spontaneous regression of the primary site could be an explanation. Case Report. We report a 58-year-old Caucasian male who presented with a right sided swelling in the inguinal region. Surgery was performed and biopsy showed metastatic malignant melanoma. No cutaneous lesions were identified by history or physical examination. Work up could not detect the primary lesion and patient was started on radiotherapy and immunotherapy. Conclusion. We present a case of malignant melanoma of unknown primary presenting in an unusual place which is the inguinal lymph node. Theories try to explain the pathway of development of such tumors and one of the theories mentions that it could be a spontaneous regression of the primary cutaneous lesion. Another theory is that it could be from transformation of aberrant melanocyte within the lymph node. Prognosis is postulated to be better in this case than in melanoma with a known primary.
PMCID: PMC4331473
2.  An Unusual Occurrence of Hepatic Granulomas and Secondary Sitosterolemia in Turner Syndrome 
Case Reports in Medicine  2015;2015:186718.
Although abnormal liver function tests occur in 50–80% of cases with Turner syndrome, there are no previous reports of overt hepatic disease or hepatic granulomas associated with Turner's syndrome. We report three cases of Turner syndrome associated with hepatic granulomas with a wide range of liver dysfunction. Of the three patients, first patient underwent liver transplantation; second patient remained stable on immunosuppressants; and third patient died from complications of decompensated liver cirrhosis as she declined liver transplantation due to multiple comorbidities. One patient had sitosterolemia, a rare inherited autosomal recessive disorder of cholesterol metabolism, after she ingested β-sitosterol supplement and had worsening liver function tests and lipid panel. She had remarkably abnormal lipid panel that responded to ezetimibe and by stopping the β-sitosterol supplement.
PMCID: PMC4326210
3.  Sinus Venosus Atrial Septal Defect as a Cause of Palpitations and Dyspnea in an Adult: A Diagnostic Imaging Challenge 
Case Reports in Medicine  2015;2015:128462.
Sinus venosus atrial septal defects (SV-ASD) have nonspecific clinical presentations and represent a diagnostic imaging challenge. Transthoracic echocardiography (TTE) remains the initial diagnostic imaging modality. However, detection rates have been as low as 12%. Transesophageal echocardiography (TEE) improves diagnostic accuracy though it may not detect commonly associated partial anomalous pulmonary venous return (PAPVR). Cardiac magnetic resonance (CMR) imaging provides a noninvasive, highly sensitive and specific imaging modality of SV-ASD. We describe a case of an adult male with exercise-induced, paroxysmal supraventricular tachycardia who presented with palpitations and dyspnea. Despite nondiagnostic imaging results on TTE, CMR proved to be instrumental in visualizing a hemodynamically significant SV-ASD with PAPVR that ultimately led to surgical correction.
PMCID: PMC4326212
4.  Successful and Safe Treatment of Chronic Spontaneous Urticaria with Omalizumab in a Woman during Two Consecutive Pregnancies 
Case Reports in Medicine  2015;2015:368053.
Chronic spontaneous urticaria is an itching skin disease characterised by wheals, angioedema, or both present for more than six weeks. Omalizumab is a humanized anti-IgE monoclonal antibody recently approved for treatment of chronic urticaria. Several randomised controlled trials have investigated the safety, tolerability, and efficacy of omalizumab for chronic urticaria. The safety of omalizumab in pregnancy is not known. We describe a female patient with chronic spontaneous urticaria who was treated with omalizumab continuously through two consecutive pregnancies with convincing results and no apparent toxicity.
PMCID: PMC4326346
5.  Cutaneous and Gastrointestinal Symptoms in Two Patients with Systemic Mastocytosis Successfully Treated with Omalizumab 
Case Reports in Medicine  2015;2015:903541.
The pathogenesis of mastocytosis is not well defined and thus treatment remains challenging and remains on a palliative basis. We present two cases (a 48-year-old woman and a 57-year-old man) with indolent systemic mastocytosis in whom omalizumab (anti-IgE) reduced gastrointestinal and cutaneous symptoms significantly. This observation provides additional insight into the effects of omalizumab on systemic mastocytosis.
PMCID: PMC4324745
6.  Fatal Retroperitoneal Bleeding Caused by Neurofibromatosis: A Case Report and Review of the Literature 
Case Reports in Medicine  2015;2015:965704.
A young female was brought into the emergency department with pulseless electrical activity (PEA) after local resection of neurofibromateous lesions. Chest ultrasonography was normal. Abdominal ultrasonography was not performed. After successful resuscitation a total body CT-scan was performed to rule out potential bleeding sources. However, haemodynamic instability reoccurred and the scan had to be aborted at the thoracoabdominal level. No thoracic abnormalities were found. Resuscitation was reinitiated and abdominal ultrasonography was performed, showing a large amount of abdominal fluid. A progressive fall in haemoglobin was noted. Emergency laparotomy was performed, revealing a large retroperitoneal haematoma. Despite ligation and packing, bleeding continued. Postoperative angiography showed active bleeding from a branch of the left internal iliac artery, which could be successfully coiled. Unfortunately, the patient died five days later due to irreversible brain damage. Revision of an MRI scan made one year earlier showed a 10 cm large retroperitoneal neurofibromatous lesion exactly at the location of the current bleeding. This case shows that patients with neurofibromatosis might develop spontaneous life-threatening bleeding from retroperitoneal located lesions. Furthermore, it points out the necessity of focused assessment with ultrasonography of the abdomen in all patients with PEA of unknown origin.
PMCID: PMC4321078
7.  Giant Polypoid Tumor Expressing on the Pyloric Ring 
Case Reports in Medicine  2015;2015:986971.
A 66-year-old Japanese man was referred to our hospital because of suspected duodenal cancer. Upper gastric endoscopy revealed a giant polypoid-type tumor that extended from the duodenum bulb to the pyloric ring. A computed tomography scan revealed a slightly enhanced lobular tumor protruding into the duodenum bulb. Positron emission tomography showed an accumulation of 18F-fluorodeoxyglucose in the area extending from the antrum of the stomach to the duodenum bulb. Since an endoscopic ultrasound test suggested that the tumor might invade the muscular tunic, indications of endoscopic mucosal resection were not favored, and the tumor was curatively removed via distal gastrectomy. The histopathologic diagnosis was papillary adenocarcinoma, and the invasion depth was the mucosal layer without vascular invasion, which was different from the preoperative diagnosis. Our case suggests the difficulties in precise diagnosis of the invasion depth of the giant polypoid cancer.
PMCID: PMC4320937
8.  A Case of IFAP Syndrome with Severe Atopic Dermatitis 
Case Reports in Medicine  2015;2015:450937.
Introduction. The IFAP syndrome is a rare X-linked genetic disorder characterized by the triad of follicular ichthyosis, atrichia, and photophobia. Case Report. A three-month-old Caucasian, male patient was observed with noncicatricial universal alopecia and persistent eczema from birth. He had dystrophic nails, spiky follicular hyperkeratosis, and photophobia which became apparent at the first year of life. Short stature and psychomotor developmental delay were also noticed. Histopathological examination of skin biopsy on left thigh showed epidermis with irregular acanthosis, lamellar orthokeratotic hyperkeratosis, and hair follicles fulfilled by parakeratotic hyperkeratosis. The chromosomal study showed a karyotype 46, XY. Total IgE was 374 IU/mL. One missense mutation c.1360G>C (p.Ala454Pro) in hemizygosity was detected on the MBTPS2 gene thus confirming the diagnosis of IFAP syndrome. Conclusions. We describe a boy with a typical clinical presentation of IFAP syndrome and severe atopic manifestations. A novel missense mutation c.1360G>C (p.Ala454Pro) in MBTPS2 gene was observed. The phenotypic expression of disease is quantitatively related to a reduced function of a key cellular regulatory system affecting cholesterol and endoplasmic reticulum homeostasis. It can cause epithelial disturbance with failure in differentiation of epidermal structures and abnormal skin permeability barrier. However, no correlation phenotype/genotype could be established.
PMCID: PMC4320795
9.  Acute Obstructive Suppurative Pancreatic Ductitis in an Asymptomatic Patient 
Case Reports in Medicine  2015;2015:919452.
Acute obstructive suppurative pancreatic ductitis (AOSPD), defined as suppuration from the pancreatic duct without associated pseudocyst, abscess, or necrosis, is a rare complication of chronic pancreatitis. We present the first case of AOSPD in an asymptomatic patient with a polymicrobial infection and review the literature on this rare clinical entity.
PMCID: PMC4320860
10.  Recurrent Syncope Attributed to Left Main Coronary Artery Severe Stenosis 
Case Reports in Medicine  2015;2015:782347.
Patients with acute coronary syndrome (ACS) rarely manifest as recurrent syncope due to malignant ventricular arrhythmia. We report a case of a 56-year-old Chinese male with complaints of paroxysmal chest burning sensation and distress for 2 weeks as well as loss of consciousness for 3 days. The electrocardiogram (ECG) revealed paroxysmal multimorphologic ventricular tachycardia during attack and normal heart rhythm during intervals. Coronary angiograph showed 90% stenosis in left main coronary artery and 80% stenosis in anterior descending artery. Two stents sized 4.0∗18 mm and 2.75∗18 mm were placed at left main coronary artery and anterior descending artery, respectively, during percutaneous coronary intervention (PCI). The patient was discharged and never had ventricular arrhythmia again during a 3-month follow-up since the PCI. This indicated that ventricular tachycardia was correlated with persistent severe myocardial ischemia. Coronary vasospasm was highly suspected to be the reason of the sudden attack and acute exacerbation. PCI is recommended in patients with both severe coronary artery stenosis and ventricular arrhythmia. Removing myocardial ischemia may stop or relieve ventricular arrhythmia and prevent cardiac arrest.
PMCID: PMC4312630
11.  Isolated Splenic Tuberculosis without Any Radiological Focal Lesion 
Case Reports in Medicine  2015;2015:130209.
Incidence of tuberculosis (TB) of spleen is a rare entity and isolated splenic tuberculosis is an unusual phenomenon, especially in immunocompetent individuals. We came across a case of 63-year-old male who presented with high grade fever, loss of weight, and generalized weakness of one-month duration. When physically examined, he had pallor and moderate nontender splenomegaly without any other significant clinical findings. He had pancytopenia, elevated ESR, and positive Mantoux test. Ultrasonography and CT scan of abdomen showed splenomegaly without any other relevant findings. Markers of connective tissue disorders and bone marrow aspiration and biopsy all were noncontributory for diagnosis. Hence splenic biopsy was done and sent for histopathological examination. Presence of caseation surrounded by epitheloid granulomas and Langerhans cells was suggestive of diagnosis as tuberculosis. And gene probe for the AFB (acid fast bacilli) came to be positive. No primary focus was present in either lungs or other organs. Patient improved clinically with antitubercular treatment.
PMCID: PMC4299791  PMID: 25628658
12.  The Incidental Finding of a Persistent Left Superior Vena Cava: Implications for Primary Care Providers—Case and Review 
Case Reports in Medicine  2015;2015:198754.
Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and is a persistent congenital remnant of the vena caval system from early cardiac development. Patients with congenital anomalous venous return are at increased risk of developing various cardiac arrhythmias, due to derangement of embryologic conductive tissue during the early development of the heart. Previously this discovery was commonly made during the placement of pacemakers or defibrillators for the treatment of the arrhythmias, when the operator encountered difficulty with proper lead deployment. However, in today's world of various easily obtainable imaging modalities, PLSVC is being discovered more and more by primary care providers during routine testing or screening for other ailments. Given the known association between anomalous venous return and the propensity for cardiac arrhythmias, we review the embryology of PLSVC and the mechanisms by which it leads to conduction abnormalities. We also provide the practitioner with recommendations for certain baseline cardiac observations and suggestions for proper surveillance in hopes that better understanding will reduce unnecessary and potentially harmful testing, premature subspecialty referral, and unneeded patient anxiety.
PMCID: PMC4302353  PMID: 25632278
13.  Neurocognitive Rehabilitation in Parkinson's Disease with Motor Imagery: A Rehabilitative Experience in a Case Report 
Case Reports in Medicine  2015;2015:670385.
A 50-year-old female with Parkinson's disease underwent a neurocognitive rehabilitation program consisting of one-hour-lasting sessions attended twice a week for three months. The balance and the risk of falls were determined using the Tinetti Balance and Gait Evaluation Scale. The pain was determined using the Visual Analog Scale and the course of the disease was examined using the Unified Parkinson's Disease Rating Scale (UPDRS). Endpoints were before the treatment, at the end of the treatment, and at a 12-week follow-up. The aim of this study is to evaluate the efficacy of neurocognitive rehabilitation in PD with motor imagery. Primary outcome is the improvement in balance and the falls risk reduction; secondary outcome is lower limb pain reduction.
PMCID: PMC4302360  PMID: 25632279
14.  Preservation of the External Jugular Vein in Bilateral Radical Neck Dissections: Technique in Two Cases and Review of the Literature 
Case Reports in Medicine  2015;2015:168474.
Context. The possibility of cephalic venous hypertension with the resultant facial edema and elevated cerebrospinal fluid pressure continues to challenge head and neck surgeons who perform bilateral radical neck dissections during simultaneous or staged procedures. Case Report. The staged procedure in patients who require bilateral neck dissections allows collateral venous drainage to develop, mainly through the internal and external vertebral plexuses, thereby minimizing the risks of deleterious consequences. Nevertheless, this procedure has disadvantages, such as a delay in definitive therapy, the need for a second hospitalization and anesthesia, and the risk of cutting lymphatic vessels and spreading viable cancer cells. In this paper, we discuss the rationale and feasibility of preserving the external jugular vein. Considering the limited number of similar reports in the literature, two cases in which this procedure was accomplished are described. The relevant anatomy and technique are reviewed and the patients' outcomes are discussed. Conclusion. Preservation of the EJV during bilateral neck dissections is technically feasible, fast, and safe, with clinically and radiologically demonstrated patency.
PMCID: PMC4302362  PMID: 25632277
15.  Management of Six Root Canals in Mandibular First Molar 
Case Reports in Medicine  2015;2015:827070.
Success in root canal treatment is achieved after thorough cleaning, shaping, and obturation of the root canal system. This clinical case describes conventional root canal treatment of an unusual mandibular first molar with six root canals. The prognosis for endodontic treatment in teeth with abnormal morphology is unfavorable if the clinician fails to recognize extra root canals.
PMCID: PMC4312998
16.  A Rare Case of Unrecognized and Uncommon Bladder Perforation after Transobturator Tape Procedure 
Case Reports in Medicine  2015;2015:731593.
The transobturator tape (TOT) procedure has become practically widespread worldwide. Complications seem to be rare, but recognizing them intraoperatively is the most significant step because some of the complications which may appear in postoperative period can be challenging for both physicians and patients. The purpose of this case, with this patient who was operated on with open surgery, is to evaluate this rarely seen unrecognized and uncommon bladder perforation after TOT procedure and thus make some contribution to the literature. Here, we present a case report about the treatment of a 48-year-old woman patient with unrecognized and uncommon bladder perforation after TOT procedure, 5 months postoperatively. Cystoscopic evaluation is not recommended routinely, but it must be performed if the patient is complicated enough to create doubt and also the surgeon's skill and ability are not sufficient enough to operate decently.
PMCID: PMC4313003
17.  Multiglandular Hormone Deficiency in a Patient with Systemic Capillary Leak Syndrome 
Case Reports in Medicine  2015;2015:958283.
Systemic capillary leak syndrome (SCLS) is a rare but potentially fatal disorder characterized by a loss of fluid and proteins into the interstitial space leading to intravascular hypovolemia up to the point of hypovolemic shock. We report the case of a 64-year-old man with SCLS and multiple hormone abnormalities (primary hypothyroidism, hypoadrenalism, and hypogonadism), deficiency of hormone binding globulins, and hypogammaglobulinemia. The patient was successfully treated with intravenous immunoglobulins, theophylline, and terbutaline. Strikingly, with the dissolution of peripheral edema, hormone levels improved. To our knowledge, this is the first reported case of SCLS associated with polyglandular abnormalities.
PMCID: PMC4313677
18.  Guide Catheter-Induced Aortic Dissection Complicated by Pericardial Effusion with Pulsus Paradoxus: A Case Report of Successful Medical Management 
Case Reports in Medicine  2015;2015:480242.
Aortic dissection is a rare but potentially fatal complication of percutaneous coronary intervention (PCI). Management strategies of PCI induced dissection are not clearly identified in literature; such occurrences often mandate surgical repair of the aortic root with reimplantation of the coronary arteries. Another trend seen in case reports is the use of coronary-aortic stenting if such lesions permit. Several factors impact the management decision including the hemodynamic stability of the patient; mechanism of aortic injury; size, severity, and direction of propagation of the dissection; presence of an intimal flap; and preexisting atherosclerotic disease. We describe a case of a 65-year-old woman who underwent PCI for a chronic right coronary artery (RCA) occlusion, which was complicated by aortic dissection and pericardial effusion. Our case report suggests that nonsurgical management may also be appropriate for PCI induced dissections, and potentially even those associated with new pericardial effusion.
PMCID: PMC4313002
19.  Metastasis to Sartorius Muscle from a Muscle Invasive Bladder Cancer 
Case Reports in Medicine  2014;2014:524757.
Bladder cancer constitutes the ninth most common cancer worldwide and approximately only 30% of cases are muscle invasive at initial diagnosis. Regional lymph nodes, bones, lung, and liver are the most common metastases from bladder cancer and generally from genitourinary malignancies. Muscles constitute a rare site of metastases from distant primary lesions even though they represent 50% of total body mass and receive a large blood flow. Skeletal muscles from urothelial carcinoma are very rare and up to date only few cases have been reported in the literature. We present a rare case of 51-year-old patient with metastases to sartorius muscle 8 months after the radical cystectomy performed for a muscle invasive bladder cancer.
PMCID: PMC4283260  PMID: 25587283
20.  Maraviroc Failed to Control Progressive Multifocal Leukoencephalopathy-Associated IRIS in a Patient with Advanced HIV Infection 
Case Reports in Medicine  2014;2014:381480.
Due to the lack of therapeutic options for patients with progressive multifocal leukoencephalopathy-associated immune reconstitution inflammatory syndrome (PML-associated IRIS), maraviroc has generated expectations among the medical community. However, we report a patient with advanced HIV infection, who developed PML-associated IRIS and had a fatal outcome despite the addition of maraviroc to suppressive ART. Future studies are required to define the therapeutic role of maraviroc in PML-associated IRIS and differentiate individuals who may benefit from maraviroc from those who may develop neurological deterioration.
PMCID: PMC4284930  PMID: 25587282
21.  Chronic Pulmonary Aspergillosis Complicating Bronchial Atresia 
Case Reports in Medicine  2014;2014:208963.
Bronchial atresia is a rare pulmonary developmental anomaly characterized by the presence of a focal obliteration of a segmental or lobar bronchial lumen. The lung distal to the atretic bronchus is typically emphysematous along with the presence of mucus filled ectatic bronchi (mucoceles). BA is usually asymptomatic but pulmonary infections can rarely develop in the emphysematous lung distal to the atretic bronchus. We present a unique case of chronic pulmonary aspergillosis (CPA) in a patient with BA with no evidence of immune dysfunction. The patient was treated initially with voriconazole and subsequently underwent surgical excision of the involved area. On follow-up, she has done extremely well with no evidence for recurrence. In summary, we describe the first case of chronic pulmonary aspergillosis in an immunocompetent patient with bronchial atresia.
PMCID: PMC4283422  PMID: 25587281
22.  Efficient and Cost-Effective Alternative Treatment for Recurrent Urinary Tract Infections and Interstitial Cystitis in Women: A Two-Case Report 
Case Reports in Medicine  2014;2014:698758.
Urinary tract infections (UTIs) are among the most common bacterial infections affecting women. UTIs are primarily caused by Escherichia coli, which increases the likelihood of a recurrent infection. We encountered two cases of recurrent UTIs (rUTIs) with a positive E. coli culture, not improving with antibiotics due to the development of antibiotic resistance. An alternative therapeutic regimen based on parsley and garlic, L-arginine, probiotics, and cranberry tablets has been given. This regimen showed a significant health improvement and symptoms relief without recurrence for more than 12 months. In conclusion, the case supports the concept of using alternative medicine in treating rUTI and as a prophylaxis or in patients who had developed antibiotic resistance.
PMCID: PMC4283390  PMID: 25587284
23.  A Giant Left Atrial Myxoma 
Case Reports in Medicine  2014;2014:819052.
Atrial myxomas are the most common primary cardiac tumors. Patients with left atrial myxomas generally present with mechanical obstruction of blood flow, systemic embolization, and constitutional symptoms. We present a case of an unusually large left atrial myxoma discovered incidentally in a patient with longstanding dyspnea being managed as bronchial asthma.
PMCID: PMC4283415  PMID: 25587285
24.  Successful Use of Extracorporeal Membrane Oxygenation for Respiratory Failure Caused by Mediastinal Precursor T Lymphoblastic Lymphoma 
Case Reports in Medicine  2014;2014:804917.
Precursor T lymphoblastic lymphoma (T-LBL) often manifests as a mediastinal mass sometimes compressing vital structures like vessels or large airways. This case was a 40-year-old male who developed T-LBL presenting as respiratory failure caused by mediastinal T-LBL. He presented with persistent life threatening hypoxia despite tracheal intubation. We successfully managed this respiratory failure using venovenous (VV) ECMO. Induction chemotherapy was started after stabilizing oxygenation and the mediastinal lesion shrank rapidly. Respiratory failure caused by compression of the central airway by tumor is an oncologic emergency. VV ECMO may be an effective way to manage this type of respiratory failure as a bridge to chemotherapy.
PMCID: PMC4280498  PMID: 25580133
25.  Malignant Pediatric Gliosarcoma Defies General Survival Data 
Case Reports in Medicine  2014;2014:175679.
Gliosarcoma, a variant of glioblastoma multiforme, is a dimorphic tumor known for its intra-axial occurrence and poor survival of less than a year. Here is an 11-year-old boy with gliosarcoma. He had a near total excision and postoperative chemoradiotherapy. He has lived through the disease for over 34 months with a residual disease.This case report is to report an unusual long survival of gliosarcoma in a teenager (Ravisankar et al., 2012).
PMCID: PMC4281457  PMID: 25580128

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