Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. A Case of Hemophagocytic Syndrome due to Tuberculosis: Uncommon Manifestation of a Common Disease Mon, 27 Oct 2014 09:30:53 +0000 Hemophagocytic syndrome, also known as hemophagocytic lymphohistiocytosis (HLH), is the manifestation of immune dysregulation. It is associated with ineffective but exaggerated immune response and infiltration of active lymphocytes and histiocytes in various organs. This devastating clinical condition has myriad of clinical and biochemical manifestations such as fever, splenomegaly, pancytopenia, hypertrygliceridemia, and hyperferritinemia. It can be either primary or secondary. Primary HLH usually presents in childhood. Secondary HLH occurs due to infection mostly viruses but other aetiologies are also important as early detection and treatment may improve survival. Hemophagocytosis due to tuberculosis is uncommon. Only handful of cases have been reported mostly in immunocompromised patients. We report a case of hemophagocytic syndrome associated with disseminated tuberculosis in an immunocompetent women highlighting early diagnosis and treatment is a demanding need in this devastating disease. Arijit Singha, Adreesh Mukherjee, Riddhi Dasgupta, and Tapas Das Copyright © 2014 Arijit Singha et al. All rights reserved. Conjunctival Metastasis as an Initial Sign of Small Cell Lung Cancer Thu, 23 Oct 2014 13:48:53 +0000 Introduction. To report a case of a conjunctival metastasis as the initial manifestation of small cell lung cancer. Methods. Observational case report. Results. A 50-year-old man without known systemic disease developed a conjunctival mass in his right eye. He underwent incisional biopsy of the tumor and systemic evaluation. Histopathologically, the conjunctival mass was a metastatic small cell carcinoma. Further evaluation revealed a primary small cell lung carcinoma with metastasis to liver and bones. The primary and metastatic tumors were treated with chemotherapy. Conclusion. Conjunctival metastasis may be the initial manifestation of lung cancer. It should be considered in the differential diagnosis of a deep conjunctival mass. Afsun Sahin, Nilgun Yildirim, Deniz Goren Sahin, Hikmet Basmak, and Mustafa Acikalin Copyright © 2014 Afsun Sahin et al. All rights reserved. Blastocystis and Schistosomiasis Coinfection in a Patient with Chronic Kidney Disease Sun, 19 Oct 2014 09:47:32 +0000 Chronic kidney disease (CKD) and end-stage renal disease (ESRD) represent a spectrum of impaired immunity with effects on cellular immunity, soluble immune factors, and inflammation. As a result, infections due to impaired immune system responses are responsible for significant morbidity in patients with kidney disease. Because of immune dysfunction in CKD, these patients have reduced probability to clear infections and are susceptible to pathogenic effects of common organisms. We present a case of a patient with CKD coinfected with Schistosoma mansoni and Blastocystis spp. This appears to be the first reported association of Schistosoma mansoni and Blastocystis spp. in a patient with CKD. Colin R. Young and Fred E. Yeo Copyright © 2014 Colin R. Young and Fred E. Yeo. All rights reserved. Coexisting Mantle Cell Lymphoma and Prostate Adenocarcinoma Thu, 16 Oct 2014 11:42:31 +0000 Prostatic mantle cell lymphoma (MCL) is a very rare entity with only 5 reported cases in the literature. We report a case of coexisting MCL and prostate adenocarcinoma (PCa) in an elderly male and review the morphologic features of classic and rare prostatic MCL subtypes. Careful morphologic evaluation and immunohistochemical findings of positive CD5, CD20, and cyclin D1 and negative CD23 and CD3 can guide us to the diagnosis of MCL. Given the fact that transurethral resection of prostate is done quite routinely, this paper draws attention to the manner in which long standing bladder outlet obstruction and postbiopsy prostate specimens with dense lymphoid infiltration can masquerade as lymphoma. It highlights the importance of exercising care while reviewing prostate specimens with evidence of chronic prostatitis so as not to miss this rare neoplasm. Ashish B. Rajput, Bruce Burns, Ronald Gerridzen, and Richard van der Jagt Copyright © 2014 Ashish B. Rajput et al. All rights reserved. Femoral Nerve Palsy due to Anticoagulant Induced Retroperitoneal Hematoma Thu, 16 Oct 2014 08:31:24 +0000 A forty-one-year-old man who, sought evaluation for a sudden hip flexion contracture and groin pain with a history of mechanical mitral valve replacement, had been misdiagnosed and treated as having lumbar discopathy for two days. This patient finally was diagnosed with compressive femoral neuropathy due to warfarin-induced retroperitoneal hematoma and successfully managed nonoperatively. This case is reported in order to draw attention to this rare presentation. Orcun Gurbuz, Abdulkadir Ercan, Gencehan Kumtepe, İlker Hasan Karal, Yusuf Velioglu, and Serdar Ener Copyright © 2014 Orcun Gurbuz et al. All rights reserved. Takotsubo’s Cardiomyopathy in a Patient with Kartagener’s Syndrome Wed, 15 Oct 2014 07:55:10 +0000 A 46-year-old African-American male with past medical history significant for Kartagener’s syndrome, essential hypertension, and HIV presented with acute chest pain. ECG and troponins indicated an acute myocardial infarction. Ventriculography confirmed dyskinesia of the left ventricle, with an EF of 25%. However the coronary catheterization showed nonobstructed coronaries. Ventricular contraction and EF were restored in 4 weeks. To our knowledge, this is the first incidence of Takotsubo’s reported in a young patient with Kartagener’s syndrome. Chronic lung disease may contribute to the development of Takotsubo’s cardiomyopathy, which is a documented yet not fully understood phenomenon. Luis W. Dominguez, Robert P. Doggette, Fernando Gonzalez-Ibarra, Imam H. Shaik, and Amer K. Syed Copyright © 2014 Luis W. Dominguez et al. All rights reserved. Adult Ocular Toxocariasis Mimicking Ciliary Body Malignancy Thu, 09 Oct 2014 10:11:26 +0000 Purpose. To discuss an unusual presentation of ocular toxocariasis. Methods. Case report. Results. A 40-year-old woman presented with decreased vision in the left eye with a long history of recurrent red eye from uveitis. Eosinophilia and positive ELISA titers for Toxocara canis favored the diagnosis of ocular toxocariasis. Over 3 months, an anterior scleral mass had a rapid growth raising the possibility of medulloepithelioma, which rarely can mimic uveitic syndromes. Surgical plan changed from local excision to enucleation. Histopathology demonstrated a large homogeneous mass of chronic inflammatory cells with inflammation of the overlying thinned out sclera, medial rectus insertion, and limbal cornea. The triad of peripheral granuloma, eosinophilia, and positive blood serology established the diagnosis of ocular toxocariasis. Conclusions. Ocular toxocariasis can mimic ocular malignancy such as medulloepithelioma in adults and rarely presents as an anterior scleral mass. Ahmad M. Mansour, Bachir Abiad, Fouad I. Boulos, Ramzi Alameddine, Fadi C. Maalouf, Alaa Bu Ghannam, and Rola N. Hamam Copyright © 2014 Ahmad M. Mansour et al. All rights reserved. Serological Findings in a Child with Paroxysmal Cold Haemoglobinuria Thu, 09 Oct 2014 09:24:26 +0000 PCH is a rare autoimmune hemolytic anemia (AIHA) but is one of the most common causes of AIAH in children. For the diagnosis, it is important to perform the appropriate methods of serological investigation and show the typical biphasic reaction. This is a case report of a child who presented with features of haemolysis and was diagnosed with PCH of this way. Eduardo J. Salido, Valentín Cabañas, Mercedes Berenguer, María I. Macizo, Faustino García-Candel, Raúl Pérez-López, and Jose M. Moraleda Copyright © 2014 Eduardo J. Salido et al. All rights reserved. The Development of Horner Syndrome following a Stabbing Tue, 07 Oct 2014 08:09:27 +0000 The features of Horner Syndrome are miosis, ptosis, enophthalmos, and anhidrosis on the same side as the etiologic pathology. Its causes include tumours, aneurysms, neck and chest surgery, and neck and chest trauma. This paper presents a case of Horner Syndrome due to a haemopneumothorax following penetrating chest trauma. Muhammet Sayan and Ali Çelik Copyright © 2014 Muhammet Sayan and Ali Çelik. All rights reserved. Sunitinib Induced Thrombotic Thrombocytopenic Purpura in addition to Severe Hypothyroidism: A Case Report and Review of the Literature Tue, 07 Oct 2014 00:00:00 +0000 Introduction. Sunitinib malate is an oral multitargeting tyrosine kinase inhibitor approved for the first line treatment of metastatic renal cell carcinoma. Sunitinib administration is associated with several adverse events including fatigue, diarrhea, skin toxicity, hypothyroidism, and cytopenia. Herein, we present a case of thrombotic thrombocytopenic purpura and clinical hypothyroidism presenting within 4 weeks of starting sunitinib therapy. Case Presentation. A 72-year-old woman with metastatic renal cell carcinoma presented with generalized fatigue 28 days after starting sunitinib 50 mg daily. She was found to have severe hypothyroidism, in addition to significant thrombocytopenia and anemia. The latter were explained by a clinical and laboratory diagnosis of thrombotic thrombocytopenic purpura. Sunitinib was stopped and she recovered completely after plasmapheresis. Conclusion. To our knowledge, this is the fourth case report of thrombotic thrombocytopenic purpura secondary to sunitinib. Oncologists should be aware of this rare but potentially fatal adverse event. We highly suggest to routinely test for platelet count and thyroid stimulating hormone level as early as two weeks after initiating sunitinib. Imane El Dika, Deborah Mukherji, Sally Temraz, Rita Assi, and Ali Shamseddine Copyright © 2014 Imane El Dika et al. All rights reserved. Arthroscopic Ankle Arthrodesis for Treating Osteoarthritis in a Patient with Kashin-Beck Disease Thu, 02 Oct 2014 09:44:13 +0000 Kashin-Beck disease (KBD) is an endemic degenerative osteoarthritis. Death of cartilage and growth plate is the pathologic feature; therefore, KBD involves skeletal deformity and often results in osteoarthritis. Deficiency of selenium, high humic acid levels in water, and fungi on storage gains are considered the cause of KBD. The most frequently involved joints are ankles, knees, wrists, and elbows and symptoms are pain and limited motions of those joints. The main treatments for KBD are rehabilitation and osteotomy to correct the deformities because preventive treatment has not been established. In this report, we present a case of ankle osteoarthritis due to KBD and first describe arthroscopic ankle arthrodesis for treating osteoarthritis of KBD. Kenjiro Iwasa, Noriyuki Kanzaki, Takaaki Fujishiro, Shinya Hayashi, Shingo Hashimoto, Ryosuke Kuroda, and Masahiro Kurosaka Copyright © 2014 Kenjiro Iwasa et al. All rights reserved. Hepatic Lesions with Secondary Syphilis in an HIV-Infected Patient Thu, 02 Oct 2014 09:12:23 +0000 Syphilis among HIV-infected patients continues to be a public health concern, especially in men who have sex with men. The clinical manifestations of syphilis are protean; syphilitic hepatitis is an unusual complication that can occur at any stage of the disease. We report a case of an HIV-infected male who presented with systemic symptoms and liver lesions highly suggestive of lymphoma and was proven to have syphilitic hepatitis by liver biopsy. Our case reinforces the importance of recognizing syphilis as a possible cause of unexplained abnormal liver enzymes and/or hepatic lesions in HIV-infected patients. Paola R. Solari, Christopher Jones, and Mark R. Wallace Copyright © 2014 Paola R. Solari et al. All rights reserved. Her2+ and b-HCG Producing Undifferentiated Gastric Adenocarcinoma Wed, 01 Oct 2014 10:13:20 +0000 A 25-year-old Hispanic female with a history of anemia, schizoaffective disorder, and psychosis was admitted for anemia associated with fatigue, weakness, shortness of breath, night sweats, weight loss, and abdominal and lower back pain for the past two months. On routine management, she was found to have a positive serum b-HCG of 80.4 (0–5 mIU/mL) but the patient denied any sexual activity in her life. During her admission, U/S of the pelvis was noncontributory. CT angiogram of the chest was significant for prominent mediastinal and hilar lymph nodes, diffusely thickened stomach suggesting gastric malignancy with multiple hypoenhancing lesions in the liver and diffuse lytic lesions in the spine and sacrum suspicious for metastatic disease. The MRI of the abdomen confirmed the CT angiogram findings. After these findings, EGD was performed which showed lesions in the antrum, body of the stomach, fundus, and cardia on the lesser curvature of the stomach body correlating with carcinoma. The biopsy was positive for Her2, b-HCG producing poorly differentiated gastric adenocarcinoma. Patient underwent one successful round of chemotherapy with Taxotene, Cisplatin, and 5-FU for Stage IV gastric adenocarcinoma. Sahar Eivaz-Mohammadi, Fernando Gonzalez-Ibarra, Waheed Abdul, Omer Tarar, Khurram Malik, and Amer K. Syed Copyright © 2014 Sahar Eivaz-Mohammadi et al. All rights reserved. Rectal Dieulafoy Lesions: A Rare Etiology of Chronic Lower Gastrointestinal Bleeding Wed, 01 Oct 2014 08:48:38 +0000 Dieulafoy lesion is rarely seen, yet it can be life-threatening. This lesion makes up to 1-2% of gastrointestinal bleedings and must definitely be considered in gastrointestinal bleedings whose source cannot be identified. In this case study, the 75-year-old woman was suffering from active, fresh, and massive rectal bleeding. Colonoscopy was applied in order to find out the source of bleeding. In the typical endoscopic appearance of the lesion a single round mucosal defect in the rectum and arterial bleeding were observed. To procure hemostasis, epinephrine was injected into the lesion and the bleeding vein was sutured. Ugur Dogan, Ismail Gomceli, Umit Koc, Mani Habibi, and Nurullah Bulbuller Copyright © 2014 Ugur Dogan et al. All rights reserved. Anterior Approach in a Huge Lipomatous Tumor of the Thigh Wed, 01 Oct 2014 00:00:00 +0000 Confronted with a huge lipomatous anterior thigh tumor, the surgical approach had to be assessed. Those described in the literature did not seem appropriate for our case so some modifications were made. We present the case of a 77-year-old woman who presented with a huge anterior thigh compartment tumor with one-year evolution. Magnetic resonance imaging informed the presence of a lipomatous tumor with a possible vascular contact. Based on Thomson’s anterior approach, but modifying the skin incision, the medial distal femur was reached until the neurovascular bundle and, proximally, the lesser trochanter. The tumor was totally resected due to a good visualization using this approach. Jordi Faig-Martí Copyright © 2014 Jordi Faig-Martí. All rights reserved. Desmoid-Type Fibromatosis of the Mesentery: Report of a Sporadic Case with Emphasis on Differential Diagnostic Problems Tue, 30 Sep 2014 07:56:15 +0000 Desmoid-type fibromatosis is a rare mesenchymal neoplasm with local aggressiveness. The incidence of desmoid-type fibromatosis is 2–5/million/year with intra-abdominal fibromatosis, such as that which is reported in this clinical case, occurring only in 12–18% of cases. After having analyzed the pathogenetic hypotheses of desmoid-type fibromatosis, the authors point out that the diagnosis of this disease, especially in the intra-abdominal form, is often late, specifically when highly demolitive interventions are needed or when the limits of radical surgery have been exceeded. In the clinical case reported, the tumor was infiltrating both ileus and sigma. The authors consider the differential diagnosis of desmoid-type fibromatosis, especially with GISTs, with regard to both the radiological preoperative diagnostic and histological studies on the surgical specimen. Radical surgical excision is not always, for this disease, a sign of healing; in fact, even when the resection margins are negative, the incidence of recurrence is between 13 and 68%. The average time of recurrence is between 15 and 24 months; in this case report, the patient, who has not been subjected to complementary therapies, is tumor-free for over 30 months since surgery; his prognosis may be satisfactory if we consider the negativity of resection margins, which in any case remains the most important prognostic factor. Giovanni Li Destri, Maria Jessica Ferraro, Martina Calabrini, Monica Pennisi, and Gaetano Magro Copyright © 2014 Giovanni Li Destri et al. All rights reserved. Systemic Granulomatous Diseases Associated with Multiple Palpable Masses That May Involve the Breast: Case Presentation and an Approach to the Differential Diagnosis Tue, 30 Sep 2014 00:00:00 +0000 Palpable mass is a common complaint presented to the breast surgeon. It is very uncommon for patients to report breast mass associated with palpable masses in other superficial structures. When these masses are related to systemic granulomatous diseases, the diagnosis and initiation of specific therapy can be challenging. The purpose of this paper is to report a case initially assessed by the breast surgeon and ultimately diagnosed as granulomatous variant of T-cell lymphoma, and discuss the main systemic granulomatous diseases associated with palpable masses involving the breast. Rodrigo Menezes Jales, Patrick Nunes Pereira, Rafael Fantelli Stelini, and Luciano Moro Copyright © 2014 Rodrigo Menezes Jales et al. All rights reserved. MEN1 Syndrome and Hibernoma: An Uncommonly Recognised Association? Mon, 22 Sep 2014 00:00:00 +0000 MEN1 syndrome is known to classically result in parathyroid, pituitary, and pancreatic islet cell tumours. However, the potential association of MEN1 syndrome with hibernoma, a benign tumour with differentiation towards brown fat, is far less well known, despite their genetic profile both being linked to deletion of the MEN1 gene. Herein, we describe a case with its key radiological and pathological findings. Venus Hedayati, Khin Thway, J. Meirion Thomas, and Eleanor Moskovic Copyright © 2014 Venus Hedayati et al. All rights reserved. Minimally Invasive Resection of an Extradural Far Lateral Lumbar Schwannoma with Zygapophyseal Joint Sparing: Surgical Nuances and Literature Review Thu, 18 Sep 2014 10:51:37 +0000 Introduction. Spinal schwannomas are benign nerve sheath tumors. Completely extradural schwannomas of the lumbar spine are extremely rare lesions, accounting for only 0,7–4,2% of all spinal NSTs. Standard open approaches have been used to treat these tumors, requiring extensive muscle dissection, laminectomy, radical foraminotomy, and facetectomy. In this paper the authors present the case of a minimally invasive resection of a completely extradural schwannoma. Operative technique literature review is presented. Material & Methods. A 50-year-old woman presented with progressive complains of chronic right leg pain and paresthesia. The magnetic resonance imaging revealed a giant well-encapsulated dumbbell-shaped extradural lesion at the L3-L4 level. The patient underwent a minimally invasive gross total resection of the tumor using a tubular expandable retractor system. Results. The patient had complete resolution of radiculopathy in the immediate postoperative period and she was discharged home, neurologically intact, on the second postoperative day. Postoperative MRI demonstrated no evidence of residual tumor. At latest follow-up (18 months) the patient remains asymptomatic. Conclusion. Although challenging, this minimally invasive procedure is safe and effective, being an appropriate alternative, with many potential advantages, to the open approach. Vítor M. Gonçalves, Bruno Santiago, Vítor C. Ferreira, and Manuel Cunha e Sá Copyright © 2014 Vítor M. Gonçalves et al. All rights reserved. Hyperacute Rejection of a Living Unrelated Kidney Graft Wed, 17 Sep 2014 00:00:00 +0000 We present a case report of a 59-year-old man, who received a blood group identical living unrelated kidney graft. This was his second kidney transplantation. Pretransplant T-cell crossmatch resulted negative. B-cell crossmatch, which is not considered a strict contraindication for transplantation, resulted positive. During surgery no abnormalities occurred. Four hours after the transplantation diuresis suddenly decreased. In an immediately performed relaparotomy the transplanted kidney showed signs of hyperacute rejection and had to be removed. Pathological examination was consistent with hyperacute rejection. Depositions of IgM or IgG antibodies were not present in pathologic evaluation of the rejected kidney, suggesting that no irregular endothelial specific antibodies had been involved in the rejection. We recommend examining more closely recipients of second allografts, considering not only a positive T-cell crossmatch but also a positive B-cell crossmatch as exclusion criteria for transplantation. Dietlind Tittelbach-Helmrich, Dirk Bausch, Oliver Drognitz, Heike Goebel, Christian Schulz-Huotari, Albrecht Kramer-Zucker, Ulrich Theodor Hopt, and Przemyslaw Pisarski Copyright © 2014 Dietlind Tittelbach-Helmrich et al. All rights reserved. Trial of Zolpidem, Eszopiclone, and Other GABA Agonists in a Patient with Progressive Supranuclear Palsy Tue, 16 Sep 2014 05:36:23 +0000 Progressive supranuclear palsy (PSP) is a progressive, debilitating neurodegenerative disease of the Parkinson-plus family of syndromes. Unfortunately, there are no pharmacologic treatments for this condition, as most sufferers of the classic variant respond poorly to Parkinson medications such as levodopa. Zolpidem, a gamma aminobutyric acid (GABA) agonist specific to the -1 receptor subtype, has been reported to show improvements in symptoms of PSP patients, including motor dysfunction, dysarthria, and ocular disturbances. We observed a 73-year-old woman with a six-year history of PSP, who, upon administration of a single 12.5 mg dose of sustained-release zolpidem, exhibited marked enhancements in speech, facial expressions, and fine motor skills for five hours. These results were reproduced upon subsequent clinic visits. In an effort to find a sustainable medication that maximized these beneficial effects while minimizing side effects and addressing some of her comorbid neuropsychological conditions, a trial of five other GABA receptor agonists was performed with the patient’s consent, while she and her caregivers were blinded to the specific medications. She and her caretakers subsequently reported improvements, especially visual, while on eszopiclone, and, to a lesser degree, temazepam and flurazepam. Andrew Young Chang and Erica Weirich Copyright © 2014 Andrew Young Chang and Erica Weirich. All rights reserved. Grave’s Disease with Severe Hepatic Dysfunction: A Diagnostic and Therapeutic Challenge Mon, 15 Sep 2014 07:50:05 +0000 Hepatic dysfunction in a patient with thyrotoxicosis may result from hyperthyroidism per se, as a side effect of antithyroid drugs, and causes unrelated to hyperthyroidism which sometimes causes diagnostic and therapeutic difficulties. A young female patient was admitted to our hospital with symptoms of thyrotoxicosis, diffuse goiter and ophthalmopathy along with cholestatic pattern of jaundice, and proximal muscle weakness. She was treated with propylthiouracil with gradual recovery. She was continuing her antithyroid medication with regular follow-up. The patient was readmitted a few months later with worsening thyrotoxicosis, proximal muscle weakness, fever, and a hepatocellular pattern of jaundice with sepsis. Propylthiouracil was stopped and lithium along with steroid coverage was given to control her thyrotoxicosis which was later changed to methimazole. Broad spectrum antibiotic therapy was also started but without any response. During her hospital stay, the patient also developed a flaccid paraplegia resembling Guillain-Barre syndrome. IV steroid was started for the neuropathy but meanwhile the patient succumbed to her illness. So in centers where facility for radioiodine therapy is not readily available, some definite well-tested protocols should be formulated to address such common but complicated clinical situations. Ashok Krishna Bhuyan, Dipti Sarma, Uma Kaimal Saikia, and Bipul Kumar Choudhury Copyright © 2014 Ashok Krishna Bhuyan et al. All rights reserved. Spontaneous Massive Splenic Infarction in the Setting of Renal Transplant and Septic Shock: A Case Report and Review of the Literature Mon, 15 Sep 2014 06:01:35 +0000 Massive splenic infarction (MSI) is a rare phenomenon that results from compromised blood flow to more than half of the spleen. Causes of MSI include hematological disorders, coagulopathies, infection, and embolization, and, rarely, MSI is spontaneous. The mainstay of treatment is splenectomy. We report the case of a 50-year-old man with a history of renal transplant who presented with diffuse abdominal pain and rapidly developed septic shock. A computed tomographic study (CT scan) of the abdomen demonstrated MSI. The surgical team was consulted for splenectomy but conservative management was maintained and immune function preserved. The patient’s clinical condition was resolved over a three-week period. This report demonstrates successful nonoperative management of a spontaneous MSI most likely secondary to hypoperfusion and a hypercoagulable state from both septic shock and renal transplant. Christine L. Bokman, Maroun Sfeir, Veer Chahwala, and Enrique Ginzburg Copyright © 2014 Christine L. Bokman et al. All rights reserved. Breast Cancer Presenting as Paraneoplastic Erythroderma: An Extremely Rare Case Thu, 11 Sep 2014 08:45:16 +0000 The skin may exhibit the first clinical evidence of a systemic disease and may provide the first clues to a diagnosis in malignancies. Erythroderma is defined as generalized redness and scaling and it is a clinical manifestation of a variety of underlying diseases including, rarely, solid tumors. Breast cancer is associated with a variety of skin paraneoplastic manifestations like acanthosis nigricans, erythromelalgia, thrombotic thrombocytopenic purpura, acrokeratosis paraneoplastica, dermatomyositis, systemic sclerosis, and scleroderma. However, in the literature, the correlation of erythroderma with breast cancer is quite infrequent. Here, we describe a case of a 76-year-old woman who presented with a paraneoplastic manifestation of erythroderma due to breast cancer. Ioannis Protopsaltis, Aspasia Drossou, Ioannis Katsantonis, Nikolaos Roussos, Kassiani Manoludaki, Miltiadis Arvanitis, Athanasia Papazafiropoulou, and Stavros Antonopoulos Copyright © 2014 Ioannis Protopsaltis et al. All rights reserved. Intracranial Meningioma Diagnosed during Pregnancy Caused Maternal Death Wed, 10 Sep 2014 13:12:49 +0000 Brain tumors are rarely diagnosed during pregnancy. Accelerated growth of intracranial meningiomas during pregnancy sometimes requires urgent surgical intervention. We describe a 41-year-old pregnant woman with severe neurological decompensation requiring immediate neurosurgery. Cesarean section resulted in maternal death. Meningioma diagnosed during a viable pregnancy should be managed according to the severity of maternal neurological symptoms and gestational age of pregnancy. Early intervention for intracranial tumors during pregnancy may save maternal and fetal lives. Zehra Kurdoglu, Orkun Cetin, Ismail Gulsen, Deniz Dirik, and M. Deniz Bulut Copyright © 2014 Zehra Kurdoglu et al. All rights reserved. A Pancreatic Head Tumor Arising as a Duodenal GIST: A Case Report and Review of the Literature Wed, 10 Sep 2014 11:37:46 +0000 Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal tract that originate from the intestinal cells of Cajal (ICC) (Fletcher et al., 2002). Only a few cases have been described with extragastrointestinal stromal tumors (Kim et al., 2012; Soufi et al., 2013; Meng et al., 2011). They are often diagnosed as a pancreatic head tumor as they are very difficult to relate to the duodenum with CT, MRI, or ultrasound. We present a case of a sixty-four-year-old woman who presented with abdominal pain and cardialgia for a follow-up examination after breast cancer surgery. On laparotomy there was a 3 × 5 cm hypervascular mass arising from the pancreatic head with macroscopically no attachment to the duodenum. The patient underwent pancreatoduodenectomy (PD) modified after Traverso-Longmire, histopathology proved a duodenal GIST. This case proves that duodenal GISTs can grow invasively into the pancreas and appear as solid pancreas head tumor; therefore, these tumors should be included into differential diagnosis. Fabian Bormann, Wolfgang Wild, Hüseyin Aksoy, Pius Dörr, Sanja Schmeck, and Matthias Schwarzbach Copyright © 2014 Fabian Bormann et al. All rights reserved. Pleural Effusion: A Rare Side Effect of Nilotinib—A Case Report Tue, 09 Sep 2014 08:24:13 +0000 Pleural effusion, as a side effect of tyrosine kinases, may be seen as most commonly associated with dasatinib and very rarely seen with nilotinib. In this report we present a chronic phase of CML case that was treated with nilotinib due to imatinib (Gleevec) allergy and had pleural effusion with nilotinib at 5th year of treatment. If pleural effusion develops in patients taking nilotinib and if this effusion is exudative and lymphocyte predominant, after ruling out pulmonary and cardiac etiologies, it must be associated with nilotinib; according to stage of effusion drug should be discontinued and/or steroid should be started and/or surgery should be performed. Hava Üsküdar Teke, Olga Meltem Akay, Deniz Gören Şahin, Mustafa Karagülle, Eren Gündüz, and Neslihan Andıç Copyright © 2014 Hava Üsküdar Teke et al. All rights reserved. Fulminant Wilson’s Disease Managed with Plasmapheresis as a Bridge to Liver Transplant Tue, 09 Sep 2014 07:01:01 +0000 New-onset jaundice can be a manifestation of multiple pathologic processes including hemolysis, parenchymal liver disease, and cholestasis; the differential diagnosis is broad and requires a systematic approach. We report a case of a patient who presented with jaundice after starting minocycline for the treatment of acne vulgaris and rapidly developed fulminant liver failure found to be due to Wilson’s disease. She also manifested severe Coomb’s negative hemolytic anemia and renal failure secondary to hepatorenal syndrome. As a bridge to liver transplant, she was successfully treated with plasmapheresis to decrease serum copper in addition to hemodialysis for acidosis and hyperkalemia. She was able to receive a liver and made a full recovery. The case highlights the use of plasmapheresis as an adjunctive treatment modality in cases of fulminant liver failure due to Wilson’s disease. Talal Hilal and R. Scott Morehead Copyright © 2014 Talal Hilal and R. Scott Morehead. All rights reserved. Diagnosis and Monitoring of Choroidal Osteoma through Multimodal Imaging Mon, 08 Sep 2014 07:39:13 +0000 A 16-year-old Caucasian female with a 6-month history of decreased visual acuity and metamorphopsia in the left eye is reported. The fundus of the left eye revealed a well defined lesion in the macula region. Diagnosis of choroidal osteoma was established using spectral domain optical coherence tomography (OCT), fundus fluorescein angiography (FFA), indocyanine green angiography (ICG), and B-scan ultrasonography. Subretinal fluid (SRF) and retinal pigment epithelium (RPE) detachment were noted in the absence of obvious classic choroidal neovascularisation (CNV). The patient was followed up for over 13 months without any treatment in the interim and the lesion was noted to have enlarged but visual acuity and SRF had remained stable. We report an interesting case where subretinal fluid was noted in the absence of evident choroidal neovascularisation and provide an example of the imaging modalities application in the era of “optical biopsy.” Theodoros Empeslidis, Usman Imrani, Vasileios Konidaris, Fizza Mushtaq, Pandelis Fotiou, Periyasami Kumar, Somnath Banerjee, and Konstantinos T. Tsaousis Copyright © 2014 Theodoros Empeslidis et al. All rights reserved. Successful Reversal of Acute Kidney Failure by Ultrasound-Accelerated Thrombolysis of an Occluded Renal Artery Mon, 08 Sep 2014 00:00:00 +0000 Purpose. To describe the treatment of renal artery thrombosis with ultrasound-accelerated thrombolysis and discuss the management of prolonged renal ischemia. Case. A 76-year-old patient with a single functional kidney, mild chronic renal impairment, and a recent history of endovascular repair of a thoracoabdominal aneurysm with an aortic branch graft presented with acute flank pain, anuria, and renal failure. The side branch from the aortic stent graft to his single, right, functional kidney appeared to be completely thrombosed. Symptoms had started after cessation of oral anticoagulants because of a planned mastectomy for breast cancer. After identification of the occlusion, ultrasound-accelerated thrombolysis was started 19 hours after the onset of anuria. Angiography, 4 hours after beginning of therapy, already showed partial dissolution of the thrombus and angiographic control after 18 hours showed complete patency of the renal artery side branch. Despite a long period of ischemia, renal function was completely recovered. Conclusion. In patients with acute renal ischemia due to thrombosis of the renal artery, complete recovery of function can be achieved with ultrasound-accelerated thrombolysis, even after prolonged periods of ischemia. Renske Konings, Rutger J. Lely, Shaikh A. Nurmohamed, and Arjan W. J. Hoksbergen Copyright © 2014 Renske Konings et al. All rights reserved.