Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Fatal Retroperitoneal Bleeding Caused by Neurofibromatosis: A Case Report and Review of the Literature Mon, 26 Jan 2015 09:02:37 +0000 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. Patrick R. Moerbeek, Jesse M. van Buijtenen, Baukje van den Heuvel, and Arjan W. J. Hoksbergen Copyright © 2015 Patrick R. Moerbeek et al. All rights reserved. Giant Polypoid Tumor Expressing on the Pyloric Ring Thu, 22 Jan 2015 06:39:51 +0000 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. Hirofumi Sonoda, Takashi Kobayashi, Yuhei Endo, Shoichi Irie, Toru Hirata, Keisuke Minamimura, Ken-ichi Mafune, and Masaya Mori Copyright © 2015 Hirofumi Sonoda et al. All rights reserved. A Case of IFAP Syndrome with Severe Atopic Dermatitis Wed, 21 Jan 2015 11:15:01 +0000 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. Catarina Araújo, Miguel Gonçalves-Rocha, Cristina Resende, Ana Paula Vieira, and Celeste Brito Copyright © 2015 Catarina Araújo et al. All rights reserved. Acute Obstructive Suppurative Pancreatic Ductitis in an Asymptomatic Patient Tue, 20 Jan 2015 11:23:21 +0000 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. Eisha Wali, Patrick Koo, and Clifford D. Packer Copyright © 2015 Eisha Wali et al. All rights reserved. Recurrent Syncope Attributed to Left Main Coronary Artery Severe Stenosis Thu, 15 Jan 2015 11:22:01 +0000 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  mm and  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. Min Li, Xinyi Zheng, Hua Liu, and Yujie Liu Copyright © 2015 Min Li et al. All rights reserved. The Incidental Finding of a Persistent Left Superior Vena Cava: Implications for Primary Care Providers—Case and Review Tue, 06 Jan 2015 11:16:40 +0000 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. Loren Garrison Morgan, Jonathan Gardner, and Joe Calkins Copyright © 2015 Loren Garrison Morgan et al. All rights reserved. Neurocognitive Rehabilitation in Parkinson’s Disease with Motor Imagery: A Rehabilitative Experience in a Case Report Tue, 06 Jan 2015 10:01:24 +0000 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. Federico Zangrando, Giulia Piccinini, Andrea Pelliccioni, Vincenzo Maria Saraceni, and Teresa Paolucci Copyright © 2015 Federico Zangrando et al. All rights reserved. Preservation of the External Jugular Vein in Bilateral Radical Neck Dissections: Technique in Two Cases and Review of the Literature Tue, 06 Jan 2015 09:01:36 +0000 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. Rodrigo Lima Bastos da Rocha, André Del Negro, Alfio José Tincani, Maíra Soliani Del Negro, and Antonio Santos Martins Copyright © 2015 Rodrigo Lima Bastos da Rocha et al. All rights reserved. Isolated Splenic Tuberculosis without Any Radiological Focal Lesion Tue, 06 Jan 2015 07:02:09 +0000 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. Sunil Raviraj, A. Gogia, A. Kakar, and S. P. Byotra Copyright © 2015 Sunil Raviraj et al. All rights reserved. Management of Six Root Canals in Mandibular First Molar Mon, 05 Jan 2015 09:07:00 +0000 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. Claudio Maniglia-Ferreira, Fabio de Almeida Gomes, and Bruno Carvalho Sousa Copyright © 2015 Claudio Maniglia-Ferreira et al. All rights reserved. A Rare Case of Unrecognized and Uncommon Bladder Perforation after Transobturator Tape Procedure Mon, 05 Jan 2015 07:40:27 +0000 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. Ercüment Kılınç and Yaşam Kemal Akpak Copyright © 2015 Ercüment Kılınç and Yaşam Kemal Akpak. All rights reserved. Multiglandular Hormone Deficiency in a Patient with Systemic Capillary Leak Syndrome Mon, 05 Jan 2015 07:37:50 +0000 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. Cornelia Then, Katrin Ritzel, Christa Seibold, Johannes F. E. Mann, and Martin Reincke Copyright © 2015 Cornelia Then et al. All rights reserved. Guide Catheter-Induced Aortic Dissection Complicated by Pericardial Effusion with Pulsus Paradoxus: A Case Report of Successful Medical Management Thu, 01 Jan 2015 09:59:19 +0000 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. Magdalene Fiddler, Sriya A. Avadhani, and Jonathan D. Marmur Copyright © 2015 Magdalene Fiddler et al. All rights reserved. Ewing Sarcoma of the Posterior Fossa in an Adolescent Girl Mon, 29 Dec 2014 00:10:31 +0000 Medulloblastoma, astrocytoma, and ependymoma represent the most common infratentorial tumors in childhood, while Ewing sarcomas in that localization are extremely rare. A large left infratentorial space-occupying lesion was diagnosed in a 12-year-old girl with signs of increased intracranial pressure. Following total tumor resection, histological and molecular examination revealed Ewing sarcoma with rearranged EWSR-1 gene. The patient achieved complete remission following adjuvant chemotherapy and radiotherapy according to Euro-EWING 2008 treatment protocol. Intracranial Ewing sarcoma, although rare, should be an important differential diagnosis of intracranial tumors in childhood which requires aggressive multimodal treatment. Andreas M. Stark, Ivo Leuschner, H. Maximilian Mehdorn, and Alexander Claviez Copyright © 2014 Andreas M. Stark et al. All rights reserved. Cor Triatriatum Sinister Identified after New Onset Atrial Fibrillation in an Elderly Man Mon, 29 Dec 2014 00:10:30 +0000 A 73-year-old man with new onset atrial fibrillation with rapid ventricular response underwent transthoracic echocardiography that revealed an echogenic linear structure along the left atrium, suggestive of cor triatriatum sinister (CTS). CTS was confirmed with transesophageal echocardiography which demonstrated a proximal accessory atrium receiving pulmonary venous flow separated from a distal true atrium by a fibromuscular membrane with a large fenestration allowing flow between the chambers. In CTS, the left atrium is divided into proximal and distal chambers by a fenestrated fibromuscular septum. This cardiac anomaly accounts for 0.1% of cases of congenital heart disease and rarely presents in adults. CTS is primarily diagnosed with echocardiography and is associated with left atrial enlargement and development of atrial fibrillation. Treatment options depend on size of the communication between proximal and distal chambers, the gradient across the membrane, and the position of pulmonary veins. In some instances, surgical resection of the membrane that divides the left atrium is warranted. Ignacio A. Zepeda, Peter Morcos, and Luis R. Castellanos Copyright © 2014 Ignacio A. Zepeda et al. All rights reserved. Thiamine Deficiency in Self-Induced Refeeding Syndrome, an Undetected and Potentially Lethal Condition Sun, 28 Dec 2014 07:53:42 +0000 Rapid restoration of nutrients and electrolytes after prolonged starvation could result in a life threatening condition characterized by sensory and neurological dysfunction and severe metabolic imbalance that has been designated as refeeding syndrome. Its diagnosis is frequently missed resulting in severe complications and even death. We describe a 25-years-old female patient with mental disorders and severe malnutrition who developed severe clinical manifestations and biochemical abnormalities characteristic of the refeeding syndrome, after restarting oral feeding on her own. Schizophrenia was later diagnosed. Increased awareness of this condition and its complications is necessary to prevent its detrimental complications. Einat Hershkowitz, Alon Reshef, Olga Munich, Bracha Yosefi, and Arie Markel Copyright © 2014 Einat Hershkowitz et al. All rights reserved. Polymicrobial Bacteremia Involving Comamonas testosteroni Sun, 28 Dec 2014 07:20:03 +0000 Comamonas spp. are uncommon isolates in microbiology laboratories and have been rarely observed as an infectious agent in clinical practice. They have widespread environmental distribution and have been isolated from water, soil, and plants as well as from some hospital devices such as intravenous catheters and water contained in humidifier reservoirs used in respiratory treatment. The genus Comamonas originally contained the following species: acidovorans, testosteroni, kerstersii, terrigena, denitrificans, and nitrativorans. It now contains 17 species, while acidovorans spp. have been reclassified as Delftia acidovorans. In spite of its uncommon human pathogenesis, there are few reports on the aggressive manner of it as an opportunistic pathogen, mostly related to testosteroni spp. We present a case of polymicrobial bacteremia involving Comamonas testosteroni. The aim of this case report is to alert clinicians to the potential diagnosis of bloodstream infections caused by uncommon pathogens. Jose Orsini, Eric Tam, Naomi Hauser, and Salil Rajayer Copyright © 2014 Jose Orsini et al. All rights reserved. Maraviroc Failed to Control Progressive Multifocal Leukoencephalopathy-Associated IRIS in a Patient with Advanced HIV Infection Tue, 23 Dec 2014 11:21:19 +0000 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. Mónica Rodríguez, Fernando Antonio Silva-Sánchez, César Luna-Rivero, Ricardo Vega-Barrientos, Claudia Alvarado-de la Barrera, and Gustavo Reyes-Terán Copyright © 2014 Mónica Rodríguez et al. All rights reserved. Metastasis to Sartorius Muscle from a Muscle Invasive Bladder Cancer Tue, 23 Dec 2014 00:10:13 +0000 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. Ioannis Katafigiotis, Antonios Athanasiou, Panagiotis K. Levis, Evangelos Fragkiadis, Stavros Sfoungaristos, Achilles Ploumidis, Adamantios Michalinos, Christos Alamanis, Evangelos Felekouras, and Constantinos A. Constantinides Copyright © 2014 Ioannis Katafigiotis et al. All rights reserved. Chronic Pulmonary Aspergillosis Complicating Bronchial Atresia Mon, 22 Dec 2014 00:10:23 +0000 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. Mazen O. Al-Qadi, Dereddi Raja S. Reddy, Brandon T. Larsen, and Vivek N. Iyer Copyright © 2014 Mazen O. Al-Qadi et al. All rights reserved. Efficient and Cost-Effective Alternative Treatment for Recurrent Urinary Tract Infections and Interstitial Cystitis in Women: A Two-Case Report Sun, 21 Dec 2014 12:19:38 +0000 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. Anthony Mansour, Essa Hariri, Samar Shelh, Ralph Irani, and Mohamad Mroueh Copyright © 2014 Anthony Mansour et al. All rights reserved. A Giant Left Atrial Myxoma Sun, 21 Dec 2014 10:30:26 +0000 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. Medhat F. Zaher, Sharad Bajaj, Mirette Habib, Emile Doss, Michael Habib, Mahesh Bikkina, Fayez Shamoon, and Wissam N. Hoyek Copyright © 2014 Medhat F. Zaher et al. All rights reserved. Malignant Pediatric Gliosarcoma Defies General Survival Data Wed, 17 Dec 2014 12:36:59 +0000 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). Jovita Martin, Premkumar Devadoss, Kalaichelvi Kannan, and Suresh Kumar Sundarraj Copyright © 2014 Jovita Martin et al. All rights reserved. Successful Use of Extracorporeal Membrane Oxygenation for Respiratory Failure Caused by Mediastinal Precursor T Lymphoblastic Lymphoma Wed, 17 Dec 2014 06:20:08 +0000 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. Masafumi Oto, Kyoko Inadomi, Toshiyuki Chosa, Shima Uneda, Soichi Uekihara, and Minoru Yoshida Copyright © 2014 Masafumi Oto et al. All rights reserved. Actinomyces odontolyticus: Rare Etiology for Purulent Pericarditis Mon, 15 Dec 2014 11:06:56 +0000 Purulent pericarditis is one of the most common causes of cardiac tamponade and if left untreated has a mortality of 100%. Staphylococcus aureus and Streptococcus pneumonia have been implicated as the main etiology of purulent pericardial effusion followed by fungi and anaerobic sources. Actinomyces odontolyticus pericardial involvement has been reported in the literature only once. To our knowledge, this is the first fatal case of A. odontolyticus purulent pericarditis in the absence of periodontal disease. Ryan Mack, Kipp Slicker, Shekhar Ghamande, and Salim R. Surani Copyright © 2014 Ryan Mack et al. All rights reserved. Intrapericardial Bronchogenic Cyst: An Unusual Clinical Entity Mon, 15 Dec 2014 09:33:50 +0000 Mediastinal cysts are extremely rare clinical disorders. They usually have a pericardial origin. In this report, we present a 27-year-old male patient with a mediastinal bronchogenic cyst together with clinical presentation and management of the pathology. Murat Ugurlucan, Omer Ali Sayin, Matthias Felten, Didem Melis Oztas, Mehmet Semih Cakir, Mehmet Barburoglu, Murat Basaran, Ufuk Alpagut, and Enver Dayioglu Copyright © 2014 Murat Ugurlucan et al. All rights reserved. Endoscopic Stenting and Clipping for Anastomotic Stricture and Persistent Tracheoesophageal Fistula after Surgical Repair of Esophageal Atresia in an Infant Mon, 15 Dec 2014 09:10:41 +0000 Anastomotic stricture (AS) and recurrent tracheoesophageal fistula (TEF) are two complications of surgical repair of esophageal atresia (EA). Therapeutic endoscopic modalities include stenting, tissue glue, and clipping for TEF and endoscopic balloon dilation bougienage and stenting for esophageal strictures. We report herein a two-month infant with both EA and TEF who benefited from a surgical repair for EA, at the third day of life. Two months later he experienced deglutition disorders and recurrent chest infections. The esophagogram showed an AS and a TEF confirmed with blue methylene test at bronchoscopy. A partially covered self-expanding metal type biliary was endoscopically placed. Ten weeks later the stent was removed. This allows for easy passage of the endoscope in the gastric cavity but a persistent recurrent fistula was noted. Instillation of contrast demonstrated a fully dilated stricture but with a persistent TEF. Then we proceeded to placement of several endoclips at the fistula site. The esophagogram confirmed the TEF was obliterated. At 12 months of follow-up, he was asymptomatic. Stenting was effective to alleviate the stricture but failed to treat the TEF. At our knowledge this is the second case of successful use of endoclips placement to obliterate recurrent TEF after surgical repair of EA in children. Mohammed Amine Benatta, Amine Benaired, and Ahmed Khelifaoui Copyright © 2014 Mohammed Amine Benatta et al. All rights reserved. A Case of Systemic Lupus Erythematosus Presenting with an Acute Abdomen: Successful Treatment with Steroid Sun, 14 Dec 2014 06:48:41 +0000 Abdominal pain continues to pose diagnostic challenges for emergency clinicians. A 56-year-old Japanese woman was referred to our hospital due to severe abdominal pain which presented as occasional epigastric pain five months before and intermittent abdominal pain. She had a past history of ileus twice, for both of which laparotomy was performed without an alimentary tract resection. The wall thickening with marked three-wall structure from terminal ileum to sigmoid colon was seen and bladder wall was irregularly thick and enhanced irregularly. Among the differential diagnosis of the acute abdomen, autoimmune diseases were suspected, especially lupus erythematosus and Henoch-Schönlein purpura. On the second day of admission, abdominal pain worsened. The results of examinations of antinuclear antibody, anti-double-stranded DNA antibody, ANCA, and the complements were not obtained at that time; however, we started 1-g steroid pulse treatment for three days with success. With the results obtained later, the patient was given a diagnosis of probable systemic lupus erythematosus (SLE). The present case shows that SLE can present with acute abdomen and should be included in the wide range of the differential diagnosis of acute abdomen. Haruka Fukatsu, Seisuke Ota, Koichi Sugiyama, Akinori Kasahara, and Tadashi Matsumura Copyright © 2014 Haruka Fukatsu et al. All rights reserved. Toxic Anterior Segment Syndrome following Phacoemulsification Secondary to Overdose of Intracameral Gentamicin Wed, 10 Dec 2014 08:30:59 +0000 Objective. To report a case of toxic anterior segment syndrome (TASS) that was caused by inadvertent anterior chamber and cornea stromal injection with high dose gentamicin following cataract surgery. Methods. Case report. Results. We report a 72-year-old female patient who developed TASS that was caused by high dose gentamicin (20 mg/0.5 mL), which was inadvertently used during the formation of the anterior chamber and hydration of the corneal incision. Unlike previous cases, hyphema and hemorrhagic fibrinous reaction were seen in the anterior chamber. Despite treatment, bullous keratopathy developed and penetrating keratoplasty was performed. The excised corneal button was sent for histopathological examination. Conclusions. Subconjunctival gentamicin is highly toxic to the corneal endothelium and anterior chamber structures. Including it on the surgical table carries a potentially serious risk for contamination of the anterior chamber. Yaran Koban, Selim Genc, Gorkem Bilgin, Halil Huseyin Cagatay, Metin Ekinci, Melin Gecer, and Zeliha Yazar Copyright © 2014 Yaran Koban et al. All rights reserved. Kikuchi-Fujimoto Disease: A Rare Cause of Fever in the Returning Traveller Wed, 10 Dec 2014 06:47:09 +0000 Background. Kikuchi-Fujimoto disease (KFD) is typically a self-limited, benign illness which presents with fever and lymphadenopathy. It is rare in Caucasians, normally occurring in those of Asian descent. The aetiology is poorly understood, but it appears to be an autoimmune disorder with a possible infectious trigger. The clinical features are such that it is often mistaken for infectious diseases or malignancy. Case Report. Here we describe a case of a 36-year-old Asian man who presented following a recent trip to Delhi, India. He described fever, neck swelling, and arthralgia. Given his travel history an infectious cause for his presentation was presumed but multiple investigations were negative. Persistence of his symptoms led to lymph node biopsy to investigate for malignancy; surprisingly this revealed a necrotizing lymphadenitis in keeping with KFD. The patient made a full recovery with supportive treatment only. Conclusion. This case presented an opportunity to reflect on two common presenting complaints—fever in the returning traveller and unexplained lymphadenopathy. Both presentations have a wide range of aetiologies to consider. Although KFD is rare, it is an important diagnosis to make as it can prevent further expensive and invasive investigations, as well as potentially harmful treatments and psychological stress to the patient. Matthew R. Wilson, Gordon Milne, and Evangelos Vryonis Copyright © 2014 Matthew R. Wilson et al. All rights reserved.