Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. A Palpable Painless Axillary Mass as the Clinical Manifestation of Castleman’s Disease in a Patient with Hepatitis C Disease Sun, 22 May 2016 11:23:32 +0000 Introduction. Castleman’s disease (CD) is a rare lymphoproliferative disorder. CD is divided into two clinical subtypes: the most common unicentric and the less usual multicentric subtype. The majority of unicentric CD affects the mediastinum, while neck, abdomen, and axilla are less common locations. Case Presentation. Herein, we describe a rare case of unicentric CD in the right axilla in a 36-year-old white male with a medical history of hepatitis C virus infection admitted to our hospital due to palpation of a painless mass in the right axilla. Complete excision of the lesion was performed and, one year after the diagnosis, patient was free of the disease. Conclusions. Although infrequent, it is important to include CD in the differential diagnosis when evaluating axillary lymphadenopathy particularly in young patients with a low-grade inflammation process and chronic disease even in the absence of an abnormal blood picture or organomegaly. Athanasia K. Papazafiropoulou, Angeliki M. Angelidi, Antonis A. Kousoulis, Georgios Christofilidis, Chariklia Sagia, Liountmila Kaftanidou, Kassiani Manoloudaki, Aikaterini Tsavari, Georgios Kranidiotis, Alexandros Kamaratos, and Andreas Melidonis Copyright © 2016 Athanasia K. Papazafiropoulou et al. All rights reserved. Quinine-Induced Disseminated Intravascular Coagulation Mon, 16 May 2016 08:28:17 +0000 Every drug comes with some side effect. It is the benefit/risk ratio that determines the medical use of the drug. Quinine, a known antimalarial drug, has been used for nocturnal leg cramps since the 1930s; it is associated with severe life-threatening hematological and cardiovascular side effects. Disseminated intravascular coagulation (DIC), albeit rare, is a known coagulopathy associated with Quinine. It is imperative to inquire about the Quinine intake in medication history in patients with coagulopathy, as most patients still consider it a harmless home remedy for nocturnal leg cramps. In this report, we present a case of coagulopathy in a middle-aged woman, who gave a history of taking Quinine for nocturnal leg cramps, as her home remedy. Early identification of the offending agent led to the diagnosis, prompt discontinuation of the medication, and complete recovery and prevented the future possibility of recurrence. Firas Abed, Ramkaji Baniya, and Ghassan Bachuwa Copyright © 2016 Firas Abed et al. All rights reserved. Impacted and Fractured Biliary Basket: A Second Basket Rescue Technique Wed, 11 May 2016 14:30:28 +0000 A 59-year-old woman was treated with ERCP, ES, and biliary plastic stent, for large and multiple common bile duct stones. During a second ERCP basket extraction was impacted with a round entrapped stone. The basket handle was cut off; a metal sheath of extraendoscopic lithotriptor was advanced over the basket. The mechanical lithotripsy was complicated with basket traction wires fracturing, without breakage of the stone. A rescue standard basket was pushed until it caught the basket/stone complex. Using this method disengagement of the whole fractured basket/stone complex was achieved without need of surgery. It is the third case reported in the English literature. Mohammed Amine Benatta, Ariane Desjeux, Marc Barthet, Jean Charles Grimaud, and Mohamed Gasmi Copyright © 2016 Mohammed Amine Benatta et al. All rights reserved. Idiopathic Pulmonary Vein Thrombus Extending into Left Atrium: A Case Report and Review of the Literature Thu, 05 May 2016 12:01:10 +0000 Pulmonary vein thrombosis (PVT) is rather an uncommon condition which presents nonspecifically and is usually associated with lung malignancy and major pulmonary surgery. Rarely could no cause be found. It causes increased pulmonary venous pressure leading to pulmonary arterial vasoconstriction and subsequent pulmonary arterial hypertension and subsequently can cause cor pulmonale if not addressed in timely fashion. Other associated complications like peripheral embolization and stroke have also been reported. This case emphasizes the importance of maintaining high index of clinical suspicion especially when CT pulmonary angiogram is negative for pulmonary embolism. Muhammad Asim Rana, Nicholas Tilbury, Yashwant Kumar, Habib Ahmad, Kamal Naser, Ahmed F. Mady, and Awani Patel Copyright © 2016 Muhammad Asim Rana et al. All rights reserved. Bone Cutting Forceps: A Safe Approach for Saving Strangulated Penis Thu, 28 Apr 2016 14:03:32 +0000 Penile strangulation is considered a rare andrological emergency that may lead to a wide range of complications. Penile strangulation may be related to mental retardation in children or hypersexuality, abnormal sexual preferences in adults. This case report shows a 23-year-old male who presented to the emergency room with agonizing pain related to a metallic ring placed at the base of the penis for more than 8 hours during an attempt of masturbation. Removing this metallic ring and saving the patient’s penis from gangrene without causing injury were very challenging. Patient was successfully managed and had an uneventful recovery. Mohamed Ahmed Abd El Salam, Ahmed Gamal, and Hossam Elenany Copyright © 2016 Mohamed Ahmed Abd El Salam et al. All rights reserved. The Side Effects of Facial Implants Tue, 26 Apr 2016 14:24:29 +0000 This case report is about a 64-year-old woman who presented at the Emergency Walk-in Center with palpebral edema as well as various erythematous plaques in supraciliary and malar areas that have been gradually worsening a couple of days prior to presentation. While talking about history, the patient mentioned she was attending, for about four months, an Esthetic Private Clinic, where she was injected in various sessions with Metacrill®, as a facial lift, for beauty purpose. Due to suspecting an allergic reaction to the Metacrill and the failure of the initial treatments, she was referred to the dermatologist. After failed attempts to treat the patient with corticosteroids and antibiotics, the patient was sent for autoimmunity consultation at the hospital where she received an immunosuppressive treatment with Tacrolimus and was not presenting new symptoms ever since. Adela Ioana Uta, Claudia Elena Uta, Lia Anguelova Valentinova, and Carlos Isanta Pomar Copyright © 2016 Adela Ioana Uta et al. All rights reserved. Fixation Improvement through Biofeedback Rehabilitation in Stargardt Disease Sun, 24 Apr 2016 09:24:35 +0000 Stargardt disease is the most common hereditary macular degeneration in juveniles. It is characterized by macular dystrophy associated with loss of central vision in the first or second decade of life, a “beaten-metal” appearance in the fovea or parafoveal region, yellowish flecks around the macula or in posterior area of the retina, progressive atrophy of the bilateral foveal retinal pigment epithelium, and the “dark choroid” sign on fundus fluorescein angiography in most cases. We report a case of Stargardt disease in a 26-year-old Caucasian female submitted to rehabilitative training with microperimetry MP-1 to find a new preferred retinal locus (PRL) and to train her to better her quality of life. Best corrected visual acuity, mean retinal sensitivity, fixation, bivariate contour ellipse area, and speed reading were evaluated before and after the training and results were discussed. G. Scuderi, F. Verboschi, D. Domanico, and L. Spadea Copyright © 2016 G. Scuderi et al. All rights reserved. Bronchiolitis Obliterans Organizing Pneumonia as an Initial Presentation of Systemic Lupus Erythematosus: A Rare Case Report and Literature Review Thu, 21 Apr 2016 07:55:09 +0000 The etiology of bronchiolitis obliterans organizing pneumonia (BOOP) remains controversial. While it has been reportedly associated with several connective tissue disorders, there are only rare reports of BOOP associated with systemic lupus erythematosus (SLE). Herein, we report a 56-year-old female patient who presented with dyspnea on exertion, cough, fever, and joint pain of her left wrist and fingers as initial symptoms. Laboratory tests revealed positivity for anti-nuclear antibody, anti-Ro, and anti-double strand DNA antibody. In this case, the patient with SLE had respiratory illness as the initial symptom due to BOOP in the absence of clear etiology. The diagnosis of BOOP was confirmed by thoracic surgery biopsy. Her respiratory symptoms and radiologic findings significantly improved following prednisolone treatment. Hung-Ping Wang, Chun-Ming Chen, Yih-Yuan Chen, and Wei Chen Copyright © 2016 Hung-Ping Wang et al. All rights reserved. Pericardial Metastasis Induced Tamponade from Urothelial Carcinoma: A Rare Entity Mon, 11 Apr 2016 09:56:14 +0000 Urothelial carcinoma in a few cases may result in cardiac metastasis. A rare presentation of this condition is its diagnosis as a result of cardiac tamponade. Tamponade is an unusual entity as a result of urothelial carcinoma and has only been reported in four cases. There have also been only a total of fifteen cases of cardiac metastasis from this form of malignancy. It is through this discussion that we emphasize the importance of early detection and monitoring of cardiac symptoms with the implementation of echocardiogram imaging. Although not feasible in all patients it may be considered in those presenting with cardiac and pulmonary symptoms. In this case we discuss the presentation of a 71-year-old gentleman with a history of urothelial carcinoma after cystectomy and while on chemotherapy presented with new onset atrial fibrillation and later was diagnosed with cardiac tamponade as a result of malignant metastasis. Rafay Khan, Waqas Jehangir, Sunil Tulpule, Mohamed Osman, Shilpi Singh, and Shuvendu Sen Copyright © 2016 Rafay Khan et al. All rights reserved. A Case of Atrial Tachycardia Circulating around a Left Atrial Roof Scar with Diabetes Mellitus and Renal Failure on Hemodialysis Mon, 11 Apr 2016 09:47:58 +0000 Introduction. Little is known about the effects of volume change by hemodialysis (HD) and mechanical stress caused by an anatomical structure being in contact with the left atrium on the progression of atrial remodeling. We experienced a case of atrial tachycardia (AT) in a patient who had left atrial (LA) scarring at the LA roof and a low-voltage area with slow conduction around the LA scar as components of AT circuit. Here, we present the conceivable hypothesis of the LA scar and the low-voltage area formation. Our concept can be useful in developing a strategy for ablation in a patient with chronic renal failure (CRF) on HD. Case Report. A 65-year-old man with CRF on HD was referred for AT ablation. Three-dimensional electroanatomical mapping revealed that the AT conducted around an LA scar in a counterclockwise fashion. There was a slow conduction area at the superior side of the LA scar, where the AT was terminated during the ablation. Computed tomography indicated a close relationship between the LA and the anatomical structures (ascending aorta and pulmonary artery). Conclusion. Volume change by HD and close contact of anatomical structures to the LA can promote atrial remodeling, resulting in AT occurrence. Naoko Hijioka, Masashi Kamioka, Hitoshi Suzuki, and Yasuchika Takeishi Copyright © 2016 Naoko Hijioka et al. All rights reserved. Poststernotomy Osteomyelitis Presenting with Severe Sepsis and Rhabdomyolysis Sun, 10 Apr 2016 08:21:06 +0000 A 39-year-old male, who recently underwent a composite valve graft of the aortic root and ascending aorta for bicuspid aortic valve and aortic root aneurysm, was hospitalized for severe sepsis, rhabdomyolysis (creatine kinase 29000 U/L), and severe liver dysfunction (AST > 7000 U/L, ALT 4228 U/L, and INR > 10). Cardiac magnetic resonance imaging (MRI) findings were consistent with sternal osteomyelitis with a 1.5 cm abscess at the inferior sternotomy margin, which was contiguous with pericardial thickening. Aspiration and culture of this abscess did not yield any organisms, so he was treated with vancomycin and cefepime empirically for 4 weeks. Because this patient was improving clinically on antibiotics and did not show external signs of wound infection, there was no compelling indication for sternectomy. This patient’s unusual presentation with osteomyelitis and rhabdomyolysis has never been reported and is crucial for clinicians to recognize in order to prevent delays in diagnosis. Eugene M. Tan, Melissa Lyle, Kelly Cawcutt, and Zelalem Temesgen Copyright © 2016 Eugene M. Tan et al. All rights reserved. Sacroiliitis and Polyarteritis Nodosa in a Patient with Familial Mediterranean Fever Thu, 07 Apr 2016 11:08:26 +0000 Familial Mediterranean fever (FMF) is an autoinflammatory disorder with autosomal recessive inheritance, characterized by recurrent fever and episodes of serositis. The condition is known to be caused by mutations in the MEFV (Mediterranean FeVer) gene, located in the short arm of chromosome 16. While more than 310 sequence variants in the MEFV gene have been described to date, the diagnosis is still established clinically. FMF may be accompanied by sacroiliitis and various forms of vasculitis. The most common forms of associated vasculitis are Henoch-Schonlein purpura and polyarteritis nodosa (PAN). We have presented here a fairly rare case of FMF, accompanied by both sacroiliitis and PAN. Yunus Ugan, Atalay Doğru, Hüseyin Şencan, Mehmet Şahin, and Şevket Ercan Tunç Copyright © 2016 Yunus Ugan et al. All rights reserved. An Extraordinary Cause of the Sucking Difficulty: Ecthyma Gangrenosum Wed, 06 Apr 2016 12:44:19 +0000 Ecthyma gangrenosum is a cutaneous lesion often associated with pseudomonas aeruginosa bacteremia, even though it may develop without bacteremia and may originate from other bacterial and fungal organisms. Pseudomonas aeruginosa bacteremia or sepsis, which mainly affects immunocompromised patients, frequently occurs in hospitals. This lesion typically occurs on the extremities and gluteal and perineal regions. In this report we present a case of ecthyma gangrenosum in a premature newborn occurring secondary to pseudomonas sepsis causing sucking dysfunction due to tissue loss in the lip, soft palate, and tongue. Nesrin Ceylan, Nihat Demir, Selami Kocaman, Erdal Peker, and Oğuz Tuncer Copyright © 2016 Nesrin Ceylan et al. All rights reserved. Encephalopathy Associated with Autoimmune Thyroid Disease: A Potentially Reversible Condition Tue, 05 Apr 2016 13:39:20 +0000 Autoimmune thyroid disease may occasionally associate with unspecific neurological symptoms, which are more commonly insidious, include cognitive or behavioural symptoms, and may associate with tremor, myoclonus, or ataxia. We report a 61-year-old female patient who presented with chronic headache, insidious mood, and cognitive disturbance which evolved in a few months to dementia associated with exuberant limb myoclonus. Diagnostic workup revealed high anti-thyroid peroxidase antibody titers and an inflammatory CSF profile, and it was negative for other possible etiologies. Treatment with steroids induced significant improvement. The diagnosis of encephalopathy associated with autoimmune thyroid disease is still controversial given the fact that the clinical presentation and diagnostic workup are unspecific, the pathophysiology is still undetermined, and the diagnosis is mostly of exclusion. No direct correlation is found between anti-thyroid antibody titers and clinical presentation, and it is currently speculated that other still unrecognized antibodies may be responsible for this clinical entity. It is extremely important to recognize this entity because it is potentially treatable with immunotherapies. It is also increasingly recognized that clinical improvement with first-line treatment with steroids may be absent or incomplete, and other immunotherapies as immunosuppressants, intravenous immunoglobulin, or plasma exchange must be attempted in the clinical suspicion of EEAT. Inês Correia, Inês B. Marques, Rogério Ferreira, and Lívia Sousa Copyright © 2016 Inês Correia et al. All rights reserved. A Giant Intrathoracic Malignant Schwannoma Causing Respiratory Failure in a Patient without von Recklinghausen’s Disease Mon, 28 Mar 2016 14:09:39 +0000 We report an unusual case of a thoracic opacity due to a huge mediastinal malignant schwannoma which compressed the whole left lung and the mediastinum causing respiratory failure in a 73-year-old woman without von Recklinghausen’s disease. Although the tumor was resected, the patient failed to wean from mechanical ventilation and died one month later because of multiple organ dysfunction syndrome. Epameinondas Angelopoulos, Konstantinos Eleftheriou, Georgios Kyriakopoulos, Kalliopi Athanassiadi, Dimitra Rontogianni, and Christina Routsi Copyright © 2016 Epameinondas Angelopoulos et al. All rights reserved. Thyroid Carcinoma Showing Thymic-Like Differentiation Causing Fracture of the Trachea Sun, 27 Mar 2016 13:52:28 +0000 Thyroid carcinoma showing thymic-like differentiation (CASTLE) comprises a rare neoplasm of the thyroid gland which arises from ectopic thymic tissue or remnants of brachial pouches. CASTLE is regarded as an indolent neoplasm with a favorable prognosis, irrespective of its metastatic potential. Diagnosis is difficult as clinicopathological features have not been yet well-defined. Radiological findings are not specific and only immunohistochemical positivity for CD5 and CD117 staining is highly suggestive of CASTLE. Despite lack of universally accepted treatment recommendations, the mainstay treatment includes thyroidectomy and systematic lymph node dissection. We report a case of CASTLE tumour with very uncommon characteristics developed in a 76-year-old man, who presented with rapidly deteriorating dyspnea and severe cough, resulting in respiratory failure. At surgery, a suspicious looking tumour arising from the upper pole of the right lobe of the thyroid gland, surrounding the trachea and displacing the right common carotid artery, was identified. The patient underwent en bloc resection of the tumour with the thyroid gland and regional lymph node dissection. This is the first reported case of CASTLE causing tracheal ring fracture. Aikaterini Marini, Meletios Kanakis, Konstantinos Valakis, Nikolaos Laschos, Maria Chorti, and Achilleas Lioulias Copyright © 2016 Aikaterini Marini et al. All rights reserved. Repair of Postoperative Abdominal Hernia in a Child with Congenital Omphalocele Using Porcine Dermal Matrix Thu, 24 Mar 2016 13:21:02 +0000 Introduction. Incisional hernias are a common complication appearing after abdominal wall defects reconstruction, with omphalocele and gastroschisis being the most common etiologies in children. Abdominal closure of these defects represents a real challenge for pediatric surgeons with many surgical techniques and various prosthetic materials being used for this purpose. Case Report. We present a case of repair of a postoperative ventral hernia occurring after congenital omphalocele reconstruction in a three-and-a-half-year-old child using an acellular, sterile, porcine dermal mesh. Conclusion. Non-cross-linked acellular porcine dermal matrix is an appropriate mesh used for the reconstruction of abdominal wall defects and their postoperative complications like large ventral hernias with success and preventing their recurrence. V. Lambropoulos, E. Mylona, V. Mouravas, C. Tsakalidis, I. Spyridakis, G. Mitsiakos, and P. Karagianni Copyright © 2016 V. Lambropoulos et al. All rights reserved. A Case of Wegener’s Granulomatosis Presenting with Unilateral Facial Nerve Palsy Thu, 24 Mar 2016 13:20:12 +0000 Wegener’s granulomatosis or granulomatosis with polyangiitis is a necrotizing vasculitis affecting both arterioles and venules. The disease is characterized by the classical triad involving acute inflammation of the upper and lower respiratory tracts with renal involvement. However, the disease pathology can affect any organ system. This case presents Wegener’s granulomatosis presenting with facial nerve palsy as the first manifestation of the disease, which is rarely reported in medical literature. Roy Ujjawal, Pan Koushik, Panwar Ajay, and Chakrabarti Subrata Copyright © 2016 Roy Ujjawal et al. All rights reserved. A Tongue Lesion as a Sign of a Systemic Disease Tue, 22 Mar 2016 14:22:30 +0000 Amyloidosis is the extracellular fibril deposition of a variety of proteins, many of which circulate as plasma ingredients. It is a disease difficult to identify due to its nonspecific symptoms and manifestations. Amyloidosis of the tongue, either isolated or part of the systemic disease, is rare and its features resemble those of a tumor. We report the case of a patient with amyloidosis who presented with a tongue lesion, weakness, nonspecific arthritis, and dyspnea on exertion that resulted in multiorgan system failure. Chrysoula I. Liakou, Joan Koh, Antonios Tsimpidakis, Katrina Rios, Charalabos Paskalis, Athanasios Pipilis, Dimitrios Kantianis, Thomas Georgiadis, and Evangelia Razis Copyright © 2016 Chrysoula I. Liakou et al. All rights reserved. Thyroid, Renal, and Breast Carcinomas, Chondrosarcoma, Colon Adenomas, and Ganglioneuroma: A New Cancer Syndrome, FAP, or Just Coincidence Sun, 20 Mar 2016 09:56:47 +0000 We are presenting a case associated with papillary thyroid carcinoma, renal cell carcinoma, invasive mammary carcinoma, chondrosarcoma, benign ganglioneuroma, and numerous colon adenomas. The patient had a family history of colon cancer, kidney and bladder cancers, lung cancer, thyroid cancer, leukemia, and throat and mouth cancers. She was diagnosed with colonic villous adenoma at the age of 41 followed by thyroid, renal, and breast cancers and chondrosarcoma at the ages of 48, 64, 71, and 74, respectively. Additionally, we included a table with the most common familial cancer syndromes with one or more benign or malignant tumors diagnosed in our case, namely, FAP, HNPCC, Cowden, Peutz-Jeghers, renal cancer, tuberous sclerosis, VHL, breast/other, breast/ovarian, Carney, Werner’s, Bloom, Li-Fraumeni, xeroderma pigmentosum, ataxia-telangiectasia, osteochondromatosis, retinoblastoma, and MEN2A. Ihab Shafek Atta and Fahd Nasser AlQahtani Copyright © 2016 Ihab Shafek Atta and Fahd Nasser AlQahtani. All rights reserved. A Rare Case of Tolosa-Hunt-Like Syndrome in a Poorly Controlled Diabetes Mellitus Sun, 20 Mar 2016 09:48:49 +0000 We report a case of a 50-year-old female with diabetes mellitus who presented with progressive second, third, fifth, sixth, and eighth cranial nerve palsy. Diagnostic investigation revealed hyperglycemic state, and brain imaging showed a right cavernous sinus enhancement suggestive of and consistent with Tolosa-Hunt syndrome. The patient was started on steroids with tight glycemic control for eight weeks; subsequently, the cranial nerve palsies resolved as well as documented resolution of the right cavernous sinus enhancement. Glenmore Lasam and Sakshi Kapur Copyright © 2016 Glenmore Lasam and Sakshi Kapur. All rights reserved. Reduction of Behavioral Psychological Symptoms of Dementia by Multimodal Comprehensive Care for Vulnerable Geriatric Patients in an Acute Care Hospital: A Case Series Wed, 16 Mar 2016 12:10:04 +0000 Management of Behavioral and Psychological Symptoms of Dementia (BPSD) is a key challenge in geriatric dementia care. A multimodal comprehensive care methodology, Humanitude, with eye contact, verbal communication, and touch as its elements, was provided to three geriatric dementia patients for whom conventional nursing care failed in an acute care hospital. Each episode was evaluated by video analysis. All patients had advanced dementia with BPSD. Failure of care was identified by patient’s shouting, screaming, or abrupt movements of limbs. In this case series, conventional care failed for all three patients. Each element of care communication was much shorter than in Humanitude care, which was accepted by the patients. The average of the elements performed during the care was eye contact 0.6%, verbal communication 15.7%, and touch 0.1% in conventional care and 12.5%, 54.8%, and 44.5% in Humanitude care, respectively. The duration of aggressive behavior of each patient during care was 25.0%, 25.4%, and 66.3% in conventional care and 0%, 0%, and 0.3% in Humanitude, respectively. In our case series, conventional care was provided by less eye contact, verbal communication, and touch. The multimodal comprehensive care approach, Humanitude, decreased BPSD and showed success by patients’ acceptance of care. Miwako Honda, Mio Ito, Shogo Ishikawa, Yoichi Takebayashi, and Lawrence Tierney Jr. Copyright © 2016 Miwako Honda et al. All rights reserved. Hiatus Hernia: A Rare Cause of Acute Pancreatitis Tue, 15 Mar 2016 11:51:38 +0000 Hiatal hernia (HH) is the herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. A giant HH with pancreatic prolapse is very rare and its causing pancreatitis is an even more extraordinary condition. We describe a case of a 65-year-old man diagnosed with acute pancreatitis secondary to pancreatic herniation. In these cases, acute pancreatitis may be caused by the diaphragmatic crura impinging upon the pancreas and leading to repetitive trauma as it crosses the hernia; intermittent folding of the main pancreatic duct; ischemia associated with stretching at its vascular pedicle; or total pancreatic incarceration. Asymptomatic hernia may not require any treatment, while multiple studies have supported the recommendation of early elective repair as a safer route in symptomatic patients. In summary, though rare, pancreatic herniation should be considered as a cause of acute pancreatitis. A high index of suspicion for complications is warranted in cases like these. Shruti Patel, Ghulamullah Shahzad, Mahreema Jawairia, Krishnaiyer Subramani, Prakash Viswanathan, and Paul Mustacchia Copyright © 2016 Shruti Patel et al. All rights reserved. Atypical Presenting Symptoms of Acute Onset Systemic Lupus Erythematosus with Enteritis and Cystitis Tue, 15 Mar 2016 09:36:01 +0000 Lupus enteritis and lupus cystitis are relatively rare manifestations of systemic lupus erythematosus. Some patients develop severe complications such as bowel perforation, infarction, obstruction, or irreversible bladder dysfunction. Early diagnosis is critical for management of lupus enteritis and cystitis. We report a 48-year-old Japanese man who presented with initial manifestations of abdominal pain, severe diarrhea, and bloody feces. The diagnosis was delayed due to atypical initial symptoms, resulting in clinical worsening. Physicians should be aware of typical computed tomography findings of lupus enteritis and lupus cystitis. Mayu Yagita, Kohei Tsujimoto, Masato Yagita, and Masaaki Fujita Copyright © 2016 Mayu Yagita et al. All rights reserved. Absence of Flexor Carpi Radialis during an Elective Carpometacarpal Arthroplasty of the Thumb: A Rare Anatomical Variation Mon, 14 Mar 2016 07:19:28 +0000 Purpose. We present an extremely rare anatomical variation of unilateral flexor carpi radialis (FCR) absence. This rare anatomical variation posed a clinical dilemma to us and we highlight the importance of the surgeon being aware of this anatomical variation of an important structure both as a reconstruction tool and as an anatomical landmark. Methods. This anatomical variation of the unilaterally absent FCR was found upon dissection during a carpometacarpal arthroplasty of the thumb. Results. Upon the discovery of an absent FCR tendon, we proceeded with a simple trapeziectomy. Conclusions. We present an extremely rare anatomical variation of unilateral FCR absence. This rare anatomical variation may pose clinical dilemmas to the operating surgeon who aims to utilise the FCR either for tendon transfer, for tendon graft, or, as seen in our case, in the reconstruction of a carpometacarpal excision at the thumb. We highlight this diagnosis of suspicion, which may influence the clinical procedure. Stratos S. Sofos and Muhammad Riaz Copyright © 2016 Stratos S. Sofos and Muhammad Riaz. All rights reserved. Understanding the Impact of Omega-3 Rich Diet on the Gut Microbiota Mon, 14 Mar 2016 06:59:20 +0000 Background. Recently, the importance of the gut microbiota in the pathogenesis of several disorders has gained clinical interests. Among exogenous factors affecting gut microbiome, diet appears to have the largest effect. Fatty acids, especially omega-3 polyunsaturated, ameliorate a range of several diseases, including cardiometabolic and inflammatory and cancer. Fatty acids associated beneficial effects may be mediated, to an important extent, through changes in gut microbiota composition. We sought to understand the changes of the gut microbiota in response to an omega-3 rich diet. Case Presentation. This case study investigated changes of gut microbiota with an omega-3 rich diet. Fecal samples were collected from a 45-year-old male who consumed 600 mg of omega-3 daily for 14 days. After the intervention, species diversity was decreased, but several butyrate-producing bacteria increased. There was an important decrease in Faecalibacterium prausnitzii and Akkermansia spp. Gut microbiota changes were reverted after the 14-day washout. Conclusion. Some of the health-related benefits of omega-3 may be due, in part, to increases in butyrate-producing bacteria. These findings may shed light on the mechanisms explaining the effects of omega-3 in several chronic diseases and may also serve as an existing foundation for tailoring personalized medical treatments. Blanca S. Noriega, Marcos A. Sanchez-Gonzalez, Daria Salyakina, and Jonathan Coffman Copyright © 2016 Blanca S. Noriega et al. All rights reserved. B-Cell Chronic Lymphocytic Leukemia with 11q22.3 Rearrangement in Patient with Chronic Myeloid Leukemia Treated with Imatinib Thu, 03 Mar 2016 07:05:56 +0000 The coexistence of two diseases chronic myeloid leukemia (CML) and B-cell chronic lymphocytic leukemia (B-CLL) is a rare phenomenon. Both neoplastic disorders have several common epidemiological denominators (they occur more often in men over 50 years of age) but different origin and long term prognosis. In this paper we described the clinical and pathological findings in patient with CML in major molecular response who developed B-CLL with 11q22.3 rearrangement and Coombs positive hemolytic anemia during the imatinib treatment. Due to the presence of the symptoms of autoimmune hemolytic anemia and optimal CML response to the imatinib treatment, the decision about combined therapy with prednisone and imatinib was made. During the follow-up, the normalization of complete blood count and resolution of peripheral lymphadenopathy were noted. The hematologic response of B-CLL was diagnosed. The repeated FISH analysis of cultured peripheral blood lymphocytes showed 2% of cells carrying 11q22.3 rearrangement. At the same time, molecular monitoring confirmed the deep molecular response of CML. The effectiveness of such combination in the described case raises the question about the best therapeutic option in such situation, especially in patients with good imatinib tolerance and optimal response. Krzysztof Lewandowski, Michał Gniot, Maria Lewandowska, Anna Wache, Błażej Ratajczak, Anna Czyż, Małgorzata Jarmuż-Szymczak, and Mieczysław Komarnicki Copyright © 2016 Krzysztof Lewandowski et al. All rights reserved. Fulminant Pseudomembranous Colitis Presenting as Sigmoid Stricture and Severe Polyposis with Clinical Response to Intracolonic Vancomycin Mon, 29 Feb 2016 17:05:22 +0000 Clostridium difficile infection (CDI) is the most common cause of antibiotic-associated diarrhea. Severe diseases carry significant morbidities such as septic shock, acute kidney injury, bowel perforation, and mortality. Immunocompromising conditions increase the risk of developing the disease but whether these individuals suffer a more fulminant course or warrant a more potent first-line treatment is still controversial issue. Hereby we report a case of a cirrhotic patient with life-threatening pseudomembranous colitis complicated by colonic stricture, initially refractory to standard treatment but with subsequent improvement on intracolonic vancomycin. Sai Wah Cheung and Kin Kong Li Copyright © 2016 Sai Wah Cheung and Kin Kong Li. All rights reserved. Combining Body Mass and Shape Indices in Clinical Practice Mon, 29 Feb 2016 16:38:06 +0000 We present preliminary clinical experience with combined consideration of the commonly used BMI (body mass index) and the newly developed ABSI (a body shape index) using a point of care anthropometric calculator for comparisons of index values and associated relative risks to population normals. In a series of 282 patients, BMI and ABSI were close to being independently distributed, supporting the value of considering both indices. Three selected cases illustrate scenarios where assessment of ABSI together with BMI could inform patient care and counseling. These data suggest that combined assessment of BMI and ABSI may prove useful in clinical practice. Jesse C. Krakauer and Nir Y. Krakauer Copyright © 2016 Jesse C. Krakauer and Nir Y. Krakauer. All rights reserved. Paroxysmal Amnesia Attacks due to Hashimoto’s Encephalopathy Mon, 29 Feb 2016 06:41:23 +0000 Hashimoto’s encephalopathy is a rare disease which is thought to be autoimmune and steroid responsive. The syndrome is characterized by cognitive impairment, encephalopathy, psychiatric symptoms, and seizures associated with increased level of anti-thyroid antibodies. The exact pathophysiology underlying cerebral involvement is still lesser known. Although symptoms suggest a nonlesional encephalopathy in most of the cases, sometimes the clinical appearance can be subtle and may not respond to immunosuppressants or immunomodulatory agents. Here we report a case who presented with drowsiness and amnestic complaints associated with paroxysmal electroencephalography (EEG) abnormalities which could be treated only with an antiepileptic drug. Pelin Nar Senol, Aylin Bican Demir, Ibrahim Bora, and Mustafa Bakar Copyright © 2016 Pelin Nar Senol et al. All rights reserved.