Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Course of Encephalopathy in a Cirrhotic Dialysis Patient Treated Sequentially with Peritoneal and Hemodialysis Wed, 25 Mar 2015 09:41:34 +0000 End-stage kidney disease and advanced cirrhosis are sometimes seen concomitantly. There is no consensus on dialysis modality in terms of determining the optimal way of treating these patients. It has been suggested that peritoneal dialysis is a better choice for these patients, but efficacy of hemodialysis in stable cirrhotic patients has not been evaluated sufficiently. We report a case with advanced cirrhosis and end-stage kidney disease who was faced with hepatic encephalopathy episodes up on starting renal replacement therapy. The case is also interesting in that it reveals effects of hemodialysis and peritoneal dialysis on hepatic encephalopathy episodes and quality of life of the patient. Suleyman Koz, Idris Sahin, Zafer Terzi, and Sema Tulay Koz Copyright © 2015 Suleyman Koz et al. All rights reserved. Ectopic Pancreas in the Stomach Successfully Resected by Endoscopic Submucosal Dissection Tue, 24 Mar 2015 13:23:41 +0000 A 32-year-old Japanese man presented with a gastric submucosal tumor. Esophagogastroduodenoscopy showed a sessile submucosal tumor measuring approximately 10 mm in diameter on the greater curvature of the gastric antrum. Endoscopic ultrasonography examination revealed a solid tumor with a diameter of 11.8 mm, which was located in the deep mucosal and submucosal layers. The internal echogenicity was homogenous and hypoechoic. Biopsy examinations were performed twice but were not diagnostic since only the intact mucosal layer was obtained. The patient was subsequently diagnosed with ectopic pancreas in the stomach by endoscopic submucosal dissection (ESD). This case underscores the usefulness of the ESD technique for the pathological diagnosis of gastric submucosal tumors. Masaya Iwamuro, Takao Tsuzuki, Shogen Ohya, Hiroyuki Okada, Takehiro Tanaka, Keisuke Hori, Masahide Kita, Seiji Kawano, Yoshiro Kawahara, and Kazuhide Yamamoto Copyright © 2015 Masaya Iwamuro et al. All rights reserved. Isolated Central Nervous System Relapse in Chronic Myeloid Leukemia Mon, 23 Mar 2015 11:27:33 +0000 Chronic myeloid leukemia is a myeloproliferative disorder that has three distinguished phases: chronic, accelerated, and blastic. In extremely rare cases, the blast phase can affect the central nervous system without concomitant bone marrow involvement. We report the case of a patient with chronic myeloid leukemia who, despite having achieved complete cytogenetic remission in the bone marrow for several years, experienced a blast crisis of the central nervous system following an episode of infectious meningoencephalitis. Juliana Gomez and Victor Duenas Copyright © 2015 Juliana Gomez and Victor Duenas. All rights reserved. Balloon Dilatation of a Case of Tuberculous Tracheobronchial Stenoses during the Course of Antituberculous Treatment Thu, 19 Mar 2015 13:20:58 +0000 We report a case of posttuberculosis (TB) tracheobronchial stenoses presented with progressive exertional dyspnea during the course of anti-TB treatment. An 83-year-old Japanese man was admitted for progressive dyspnea; chest X-ray and CT showed stenosis of distal trachea and left main bronchus. Pulmonary function test revealed reduction of FEV1. Balloon dilatation without stent insertion was the choice for this patient for multiple reasons with marked improvement of symptoms. Shimaa Nour Moursi Ahmed, Potjanee Korrungruang, Hideo Saka, Gyo Asai, Yuko Ise, Chiyoe Kitagawa, and Masahide Oki Copyright © 2015 Shimaa Nour Moursi Ahmed et al. All rights reserved. A Case of Scopulariopsis brevicaulis Endocarditis with Mycotic Aneurysm in an Immunocompetent Host Tue, 17 Mar 2015 10:46:30 +0000 Scopulariopsis is a genus of mold that is usually associated with onychomycosis and rarely causes complicated infection in immunocompetent persons. We describe a case of an immunocompetent 65-year-old male with a history of mitral valve repair with prosthetic ring placement who developed acute left posterior knee pain. Imaging showed a left popliteal artery aneurysm and thrombus, and further evaluation with transesophageal echocardiogram demonstrated two large, mobile mitral valve vegetations. He underwent debridement and replacement of the mitral valve, followed by debridement of the left popliteal artery with peroneal artery bypass. The intraoperative cultures grew Scopulariopsis brevicaulis. Due to the resistant nature of the organism, he was initially treated with combination antifungals including liposomal amphotericin B, caspofungin, and voriconazole and was continued on chronic suppression with posaconazole with no evidence of recurrence. Scopulariopsis is a rare cause of fungal endocarditis. Treatment of Scopulariopsis endocarditis is challenging and is not well understood due to its rarity. Kelly Cawcutt, Larry M. Baddour, and Mary Burgess Copyright © 2015 Kelly Cawcutt et al. All rights reserved. Minimal Invasive Management of Anastomosis Leakage after Colon Resection Mon, 16 Mar 2015 13:13:13 +0000 The gold standard of surgical treatment of colorectal anastomotic leak is abdominal drainage of collected fluid and stoma formation. Conventional laparotomy has been the preferred approach for treatment. However, both laparoscopic surgical techniquesand endoscopic stenting have gained popularity over the past years as minimal invasive approaches, especially in the management and treatment of perforations of the gastrointestinal system. We present here a successful treatment with a minimal invasive management of anastomosis leak in the early postoperative period after colon resection in a 62-year-old female patient who had undergone urgent laparoscopic intra-abdominal lavage and drainage followed by endoscopic stenting. Esin Kabul Gürbulak, İsmail Ethem Akgün, Ayhan Öz, Sinan Ömeroğlu, Muharrem Battal, Fevzi Celayir, and Mehmet Mihmanlı Copyright © 2015 Esin Kabul Gürbulak et al. All rights reserved. A Case of the Serotonin Syndrome Secondary to Phenelzine Monotherapy at Therapeutic Dosing Mon, 16 Mar 2015 06:54:50 +0000 A 27-year-old Caucasian female with a history of depression was admitted to our local hospital with vague events that occurred a day before. This included an episode of dysarthria, and unsteadiness, followed by feeling generally unwell. Two weeks prior to presentation she was commenced on phenelzine. During clinical assessment she suddenly deteriorated with a dramatic fall in her conscious level. Moreover, she became hyperthermic, tachycardic, and diaphoretic, and developed increased tone in all muscles and ocular clonus. Rectal diazepam was administered but failed to control the symptoms. Consequently, she was transferred to the intensive care unit for intubation and muscle relaxants were commenced. She responded well and recovered next day without complications. Her symptoms and signs were consistent with the serotonin syndrome with phenelzine being the likely cause. To the best of our knowledge, this is the first reported case to associate the condition with phenelzine alone at therapeutic dose. A. Malik and N. Junglee Copyright © 2015 A. Malik and N. Junglee. All rights reserved. Probable Hydrochlorothiazide-Induced Myopericarditis: First Case Reported Sun, 15 Mar 2015 12:55:40 +0000 Hydrochlorothiazide has never been reported as a reason for myopericarditis. An African American female, with past history of hypertension, coronary artery disease, and sulfa allergy, presented with indolent onset and retrosternal chest pain which was positional, pleuritic, and unresponsive to sublingual nitroglycerin. Her medications included hydrochlorothiazide (HCTZ) which was started three months ago for uncontrolled hypertension. Significant laboratory parameters included erythrocyte sedimentation rate (ESR) of 47 mm/hr and peak troponin of 0.26 ng/mL. Transthoracic echocardiogram (TTE) revealed preserved ejection fraction with no segmental wall motion abnormalities; however, it showed moderate pericardial effusion without tamponade physiology. We hypothesize that this myopericarditis could be due to HCTZ allergic reaction after all other common etiologies have been ruled out. There is a scarcity of the literature regarding HCTZ as an etiology for pericardial disease, with only one case reported as presumed hydrochlorothiazide-induced pericardial effusion. Management involves discontinuation of HCTZ and starting anti-inflammatory therapy. Toufik Mahfood Haddad, Muhammad Sarfraz Nawaz, Ahmed S. Abuzaid, Smrithy Upadhyay, Pallavi Bellamkonda, and Aryan N. Mooss Copyright © 2015 Toufik Mahfood Haddad et al. All rights reserved. Primary Meningococcal Polyarthritis in an Adult Woman Sun, 08 Mar 2015 11:36:28 +0000 Primary joint infection caused by the Gram-negative bacteria Neisseria meningitidis is rare. Normally, joint involvement comes secondary to meningitis or severe sepsis caused by this agent. When primary arthritis is seen, monoarthritis is the most common presentation. A meningococcal polyarthritis is described in less than 10 case reports according to current literature. This case report aims to briefly review this rare clinical event in an adult woman with no previous history of rheumatological disease. Early diagnosis of polyarthritis caused by meningococcal bacteria usually present a good prognosis when properly treated. José Celso Giordan Cavalcanti Sarinho, Marília Soares e Silva Arcadipane, Graziela Tavares Miola Menezes, Danilo Fernando Costa Duarte, Waldenise Cossermelli, and Ivan Aprahamian Copyright © 2015 José Celso Giordan Cavalcanti Sarinho et al. All rights reserved. Lacrimal Gland Fistula following Severe Head Trauma Thu, 05 Mar 2015 11:46:30 +0000 We aim to present a unique case with discharging lacrimal gland fistula secondary to severe head trauma by an animal. A 9-year-old girl presented with serous fluid discharge from a cutaneous fistula in the left orbital region. The patient had history of surgery for traumatic frontal bone fracture and skin laceration in the superior orbital rim three weeks earlier. She underwent a complete ophthalmological examination and there was no anterior segment or fundus pathology. The orifice of the fistula was detected in mediolateral part of the left superior orbital rim and fluid secretion was increasing with irritation of the left eye. Neurosurgical complications were excluded and radiological assessment was nonremarkable. The patient’s legal representatives were informed and lacrimal gland fistulectomy was planned. However, the fistula was self-closed one week after initial ophthalmological examination, and the patient had no symptoms. In conclusion, traumatic injuries of superior orbital region should be carefully evaluated and wounds should be well closed to prevent consecutive lacrimal gland fistula. Cemil Demir, Ibrahim Toprak, Sukru Gungen, and Alp Arslan Copyright © 2015 Cemil Demir et al. All rights reserved. Diabetic Ketoacidosis as First Presentation of Latent Autoimmune Diabetes in Adult Thu, 05 Mar 2015 06:50:17 +0000 A 54-year-old white female with hypothyroidism presented with abdominal pain, nausea, vomiting, and diarrhea. She was found to have diabetic ketoacidosis (DKA) and admitted to our hospital for treatment. Laboratory workup revealed positive antiglutamic acid decarboxylase antibodies and subsequently she was diagnosed with latent onset autoimmune diabetes in adult (LADA). She was successfully treated with insulin with clinical and laboratory improvement. Diagnosis of LADA has been based on three criteria as given by The Immunology of Diabetes Society: (1) adult age of onset (>30 years of age); (2) presence of at least one circulating autoantibody (GADA/ICA/IAA/IA-2); and (3) initial insulin independence for the first six months. The importance of this case is the unlikely presentation of LADA. We believe that more research is needed to determine the exact proportion of LADA patients who first present with DKA, since similar cases have only been seen in case reports. Adult patients who are obese and have high blood sugar may deserve screening for LADA, especially in the presence of other autoimmune diseases. Those patients once diagnosed with LADA need extensive diabetic education including potentially serious events such as diabetic ketoacidosis. Omar Nadhem, Essam Nakhla, and Roger D. Smalligan Copyright © 2015 Omar Nadhem et al. All rights reserved. PEComa in a Young Patient with Known Li-Fraumeni Syndrome Wed, 04 Mar 2015 09:48:04 +0000 Perivascular epithelioid cells neoplasms (PEComas) constitute a family of rare tumours which have been reported virtually in all anatomic sites. The histological clarification of the malignant potential of these tumours is still problematic despite the proposed risk stratification systems. Li-Fraumeni syndrome (LFS) is caused by a germline mutation in the TP53 tumour suppressor gene. It is a rare but well-characterized cancer predisposition syndrome leading to the development of a variety of different tumour types. To the best of our knowledge, an association between this syndrome and PEComas has not been previously documented. A 24-year-old lady with known LFS presented with two uncertain-in-nature lesions, one within the right part of the liver and one within the upper pole of the right kidney. The patient underwent an uncomplicated open simultaneous right partial nephrectomy and resection of segment 7 of the liver. The morphological and immunohistochemical features of both lesions were of epithelioid angiomyolipoma (PEComa). Although the obvious scenario was that the liver lesion was a metastasis from the renal lesion, the assessment of their malignant potential according to the existing risk stratification systems was rather in favour of two synchronous primary PEComas, pointing out that the histological assessment of malignant potential of PEComas is still problematic. Kyriakos Neofytou, Simone Famularo, and Aamir Z. Khan Copyright © 2015 Kyriakos Neofytou et al. All rights reserved. Granulomatosis with Polyangiitis Presenting as a Parotid Gland Abscess Sun, 01 Mar 2015 12:49:42 +0000 Granulomatosis with polyangiitis (GPA) is a small-vessel vasculitis consisting of necrotizing granulomatous lesions in airways and focal necrotizing glomerulonephritis. However, it may affect other sites such as the skin, central nervous system, eyes, heart, gastrointestinal tract, and liver. We describe a rare case of GPA in which the initial manifestation was the involvement of the parotid gland mimicking a pyogenic abscess. Blenda Dias, Daniela Soares, Patrick Sampaio, and Mittermayer Santiago Copyright © 2015 Blenda Dias et al. All rights reserved. Intertoe Squamous Cell Carcinoma Developed in a Patient with Rheumatoid Arthritis under Etanercept Therapy Sun, 01 Mar 2015 09:25:48 +0000 The use of tumor necrosis factor-α (TNF-α) inhibitors in the treatment of various inflammatory conditions has altered the field of medical therapeutics. Squamous cell carcinoma is the second most common cancer of the skin, usually affecting sun-exposed areas of the body. We present here the case of a 75-year-old woman with rheumatoid arthritis, who developed an intertoe squamous cell carcinoma (SCC) of the right foot. According to her history, she received etanercept and methotrexate for 5 years for rheumatoid arthritis. The rare localization of this cancer could suggest a possible linkage of the malignancy to the chronic intake of anti-TNF-α treatment. This is the first reported case of an interdigital SCC developed under the use of an anti-TNF-α agent. Efstathios Rallis, Vasiliki-Kalliopi Bournia, Constantinos Verros, and Alexios Iliopoulos Copyright © 2015 Efstathios Rallis et al. All rights reserved. A Case of Sarcoidosis of the Central Nervous System and Orbita Wed, 25 Feb 2015 12:13:15 +0000 Sarcoidosis is a multisystemic disease characterized by granulomatous inflammation. Lung or lymph node involvement is common. We present a rare case of sarcoidosis that began with orbital involvement, and a month later, due to insufficient treatment, it involved the central nervous system. A 49-year-old female patient began suffering from swelling in her right eye, redness, ptosis, and limited eye movements two months ago. Gadolinium-enhanced orbital magnetic resonance imaging showed thickening of the lacrimal gland and the right medial rectus muscle. After three weeks of local antibiotic and steroid treatments, her symptoms were resolved. One month ago, the patient reported sudden weakness in her right arm and leg. After laboratory tests and imaging studies, the patient was diagnosed with probable neurosarcoidosis using the Zajicek criteria and treated with prednisone (1 mg/kg/day). Although sarcoidosis frequently presents with lung and lymph node involvement, it is rarely accompanied by orbital involvement. Patients with orbital symptoms may receive a late diagnosis and insufficient central nervous system treatment. Involvement of the central nervous system in sarcoidosis leads to high morbidity and mortality rates. Therefore, early diagnosis and treatment are very important. Metin Mercan, Aslı Akyol, Yahya Karaman, and Hayrunnisa Bolay Copyright © 2015 Metin Mercan et al. All rights reserved. Chin Necrosis as a Consequence of Prone Positioning in the Intensive Care Unit Tue, 24 Feb 2015 06:52:33 +0000 Pressure necrosis of the skin is a rarely reported avoidable complication of prone positioning that can be minimised by active collaboration between care teams. We report a case of pressure necrosis of the chin after prone ventilation in the intensive care setting. Such injuries pose a risk of infection, possible need for surgical intervention, and increased costs to the health care system. Pressure necrosis injuries should be diligently guarded against by the careful selection of support devices, frequent turning, and rigorous skin care to minimise extended external compression, particularly on the face and bony prominences. Daniel Lee John Bunker and Michael Thomson Copyright © 2015 Daniel Lee John Bunker and Michael Thomson. All rights reserved. A Unique Case of Primary Ewing’s Sarcoma of the Cervical Spine in a 53-Year-Old Male: A Case Report and Review of the Literature Mon, 23 Feb 2015 12:09:19 +0000 Extraskeletal Ewing’s sarcoma (EES) is a rare presentation, representing only 15% of all primary Ewing’s sarcoma cases. Even more uncommon is EES presenting as a primary focus in the spinal canal. These rapidly growing tumors often present with focal neurological symptoms of myelopathy or radiculopathy. There are no classic characteristic imaging findings and thus the physician must keep a high index of clinical suspicion. Diagnosis can only be definitively made by histopathological studies. In this report, we discuss a primary cervical spine EES in a 53-year-old man who presented with a two-month history of left upper extremity pain and acute onset of weakness. Imaging revealed a cervical spinal canal mass. After undergoing cervical decompression, histopathological examination confirmed a diagnosis of Ewing’s sarcoma. A literature search revealed fewer than 25 reported cases of primary cervical spine EES published in the past 15 years and only one report demonstrating this pathology in a patient older than 30 years of age . Given the low incidence of this pathology presenting in this age group and the lack of treatment guidelines, each patient’s plan should be considered on a case-by-case basis until further studies are performed to determine optimal evidence based treatment. Marshall T. Holland, Oliver E. Flouty, Liesl N. Close, Chandan G. Reddy, and Matthew A. Howard III Copyright © 2015 Marshall T. Holland et al. All rights reserved. Isolated Rheumatoid Nodules: A Diagnostic Dilemma Mon, 23 Feb 2015 09:03:11 +0000 We present a 27-year-old male with multiple nonpainful soft tissue masses over several metacarpals, bilateral elbows, the left wrist, and both knees since the age of 4. Physical exam was significant for firm, nonmobile, nodular growths over the extensor surfaces of bilateral elbows and knees and on the 2nd and 5th metacarpal phalangeal joints. Laboratory studies revealed an unremarkable rheumatoid factor, negative ANA screening and normal joint radiographs. Differential diagnosis included subcutaneous granuloma annulare (SGA), seronegative rheumatoid nodule, and calcinosis cutis. Biopsy is the only method to distinguish benign rheumatoid nodules from SGA. This case illustrates the importance of biopsy in diagnosis, an awareness of the potential complications, and the need for good follow-up. Michael Gale, Erin Gilbert, and David Blumenthal Copyright © 2015 Michael Gale et al. All rights reserved. Cytomegalovirus Colitis with Common Variable Immunodeficiency and Crohn’s Disease Mon, 23 Feb 2015 08:56:01 +0000 Here we present an eleven-year-old male patient who had been diagnosed with common variable immunodeficiency (CVID) three years ago due to recurrent sinopulmonary infections. Two years later he had been diagnosed with Crohn’s disease (CD) due to diarrhea episodes which were unresponsive to the treatment. Depending on the active gastrointestinal bleeding and perforation he underwent total colectomy. Despite immunoglobulin and antiviral therapies, general condition of patient deteriorated and he died in the postoperative seventh day. Laboratory analysis was seronegative. CMV inclusion containing cells were detected in postmortem biopsies taken from liver, lungs, and lymph nodes. Betül Ünal, Cumhur İbrahim Başsorgun, Sinem Çil Gönülcü, Aslı Uçar, Fatih Çelik, and Gülsüm Özlem Elpek Copyright © 2015 Betül Ünal et al. All rights reserved. Daisaikoto for Menstrual Pain: A Lesson from a Case with Menstrual Pain Successfully Treated with Daisaikoto Sun, 22 Feb 2015 12:14:29 +0000 Menstrual pain is one of the common symptoms among women. It is estimated that 5–14% of women are sometimes absent from school or work because of pain. Usually gynecologists prescribe analgesics and/or low-dose oral contraceptives. However, such treatment is not always effective and sometimes causes an adverse effect, such as stomach pain or low body temperature. Kampo medicine is one of the choices for the menstrual pain in Japan. Tokishakuyakusan, kamishoyosan, or keishibukuryogan is commonly used for the treatment of menstrual pain. Here we report a case of menstrual pain successfully treated with daisaikoto which is not commonly used for such a case. Twenty-five-year-old woman suffered from severe menstrual pain and stress at company. She also had constipation and abdominal distension. We prescribed daisaikoto extract 7.5 g per day. Not only menstrual pain but also constipation and abdominal distension improved within 6 months. Here we propose that daisaikoto is one of the choices for the treatment of menstrual pain with mental stress. Yuko Horiba, Tetsuhiro Yoshino, and Kenji Watanabe Copyright © 2015 Yuko Horiba et al. All rights reserved. Nightmare-Induced Atypical Midventricular Tako-Tsubo Cardiomyopathy Thu, 19 Feb 2015 11:37:36 +0000 Tako-Tsubo cardiomyopathy (TTC) is a reversible cardiomyopathy characterized by acute left ventricular segmental dysfunction, whose clinical presentation resembles that of acute myocardial infarction. The syndrome often follows a psychophysical stressful event and is characterized by echocardiographic evidence of akinesia of the left ventricular mid-apical segments. Atypical echocardiographic patterns of TTC have recently been described, often triggered by emotional stressors, rather than physical. In this report, we describe a case of atypical TTC triggered by an unusual stressor (recurrent nightmare) in a 45-year-old woman, with peculiar clinical presentation and evolution characterized by persistent loss of consciousness, neurological deterioration, absence of typical symptoms of TTC, and features suggestive of a hysterical crisis. Veronica Fibbi, Piercarlo Ballo, Marco Nannini, Lorenzo Consoli, Tania Chechi, Andrea Bribani, Francesca Fiorentino, Leandro Chiodi, and Alfredo Zuppiroli Copyright © 2015 Veronica Fibbi et al. All rights reserved. How to Be 80 Year Old and Have a VO2max of a 35 Year Old Wed, 18 Feb 2015 14:33:51 +0000 Background. To discuss the cardiovascular and pulmonary physiology and common risk factors of an 80-year-old man with a world record maximal oxygen uptake of 50 mL·kg−1·min−1. Methods. Case report. Results. His maximal oxygen uptake of 3.31 L·min−1, maximal heart rate of 175 beats·min−1, and maximal oxygen pulse of 19 mL·beats−1 are high. He is lean (66.6 kg) and muscular (49% skeletal muscle mass). His echo parameters of mitral flow (left ventricular filling, E = 82 cm·s−1 and E/A = 1.2) were normal for 40- to 60-year-old men. Systolic and diastolic function increased adequately during exercise, with no increase in left ventricular filling pressure. He has excellent pulmonary function (FVC = 4.31 L, FEV1 = 3.41, FEV1/FVC = 0.79, and DLCO = 12.0 Si1) and normal FMD and blood volumes (5.8 L). He has a high level of daily activity (10,900 steps·day−1 and 2:51 hours·day−1 of physical activity) and a lifelong history of physical activity. Conclusion. The man is in excellent cardiopulmonary fitness and is highly physically active. His cardiac and pulmonary functions are above expectations for his age, and his V is comparable to that of an inactive 25-year-old and of a normal, active 35-year-old Norwegian man. Trine Karlsen, Ingeborg Megård Leinan, Fredrik Hjulstad Bækkerud, Kari Margrethe Lundgren, Atefe Tari, Sigurd Loe Steinshamn, Asbjørn Støylen, and Øivind Rognmo Copyright © 2015 Trine Karlsen et al. All rights reserved. Acute Retinal Pigment Epitheliitis: Spectral Domain Optical Coherence Tomography, Fluorescein Angiography, and Autofluorescence Findings Thu, 12 Feb 2015 09:37:52 +0000 A 17-year-old presented with central and paracentral scotomas in his right eye for one week. There was no remarkable medical or ocular history. Blood analyses were within normal range. At presentation both eyes’ best-corrected visual acuities were 20/20. Slit-lamp examination result was normal. Fundus examination revealed yellow-white hypopigmented areas in the macula. Fluorescein angiography (FA) showed hypofluorescence surrounded by ring of hyperfluorescence. Fundus autofluorescence (FAF) was slightly increased. Spectral domain optical coherence tomography (SD-OCT) showed disruption of IS/OS junction with expansion of abnormal hyperreflectivity from retinal pigment epithelium to the outer nuclear layer (ONL). One month later fundus examination showed disappearance of the lesions. FA revealed transmission hyperfluorescence. FAF showed increased autofluorescence and pigment clumping. Hyperreflective band in SD-OCT disappeared. Loss of photoreceptor segment layers was observed in some of the macular lesions. The diagnosis of acute retinal pigment epitheliitis can be challenging after disappearance of fundus findings. FA, FAF, and SD-OCT are important tests for diagnosis after resolution of the disease. Tuğba Aydoğan, Esra Güney, Betül İlkay Sezgin Akçay, Tahir Kansu Bozkurt, Cihan Ünlü, and Ahmet Ergin Copyright © 2015 Tuğba Aydoğan et al. All rights reserved. Common Atrium: A Rare Cause of Acute Decompensated Heart Failure Wed, 11 Feb 2015 12:59:44 +0000 We report a rare case of common atrium and acute decompensated heart failure most likely precipitated by acute bacterial pericarditis leading to premature death, in a 25-year-old male footballer. The silent course of the disease for decades as well as the diagnostic and management pitfalls of this case illustrates the importance of early detection by echocardiography and urgent appropriate treatment in intensive care settings to limit the poor prognosis of the condition. K. M. Karaye, S. A. Balarabe, M. M. Yakasai, I. M. Suleiman, H. Saidu, and Aimé Bonny Copyright © 2015 K. M. Karaye et al. All rights reserved. Vomiting-Induced Gastric Emphysema and Hepatoportal Venous Gas: A Case Report and Review of the Literature Wed, 11 Feb 2015 09:58:27 +0000 Gastric pneumatosis is the presence of air within the wall of the stomach. It represents a spectrum of conditions ranging from benign disease to septic shock and death. Etiopathologically, it can be classified into emphysematous gastritis or gastric emphysema (GE). Along with hepatoportal venous gas (HPVG), it was considered as an ominous radiological sign and warranted an emergent surgical exploration; however, with widespread use of computerized tomographic (CT) scan, an increasing number of benign causes of GE and HPVG have been reported in the literature, where patients can be managed by noninvasive and conservative measures. We hereby describe a case where recurrent episodes of vomiting led to development of GE and HPVG and the patient was managed successfully by conservative measures. Malav P. Parikh, Muhammed Sherid, Venu Ganipisetti, Venu Gopalakrishnan, Maria Habib, and Monika Tripathi Copyright © 2015 Malav P. Parikh et al. All rights reserved. Clozapine-Induced Late Agranulocytosis and Severe Neutropenia Complicated with Streptococcus pneumonia, Venous Thromboembolism, and Allergic Vasculitis in Treatment-Resistant Female Psychosis Tue, 10 Feb 2015 13:10:04 +0000 Clozapine is a second-generation antipsychotic agent from the benzodiazepine group indicated for treatment-resistant schizophrenia and other psychotic conditions. Using clozapine earlier on once a case appears to be refractory limits both social and personal morbidity of chronic psychosis. However treatment with second-generation antipsychotics is often complicated by adverse effects. We present a case of a 33-year-old Caucasian woman with a 25-year history of refractory psychotic mania after switching to a 2-year clozapine therapy. She presented clozapine-induced absolute neutropenia, agranulocytosis, which were complicated by Streptococcus pneumonia and sepsis. Clozapine-induced thromboembolism of the common femoral and right proximal iliac vein, as well as allergic vasculitis, was diagnosed. She achieved full remission on granulocyte-colony stimulating factor and specific antibiotic treatment. Early detection of severe clozapine-induced absolute neutropenia and agranulocytosis enabled the effective treatment of two among its most severe complications. Additional evidence to the previously reported possible causal relation between clozapine and venous thromboembolism is offered. Finally, clozapine-induced allergic vasculitis is confirmed as a late adverse effect of clozapine therapy. Christina Voulgari, Raphael Giannas, Georgios Paterakis, Anna Kanellou, Nikolaos Anagnostopoulos, and Stamata Pagoni Copyright © 2015 Christina Voulgari et al. All rights reserved. Bilateral Psoas Muscle Abscess Associated with Emphysematous Cystitis Tue, 10 Feb 2015 06:14:34 +0000 Psoas muscle abscess associated with emphysematous urinary tract infection is very rare. There were very few reports about urinary tract infections such as renal abscess, perinephric abscess, and emphysematous pyelonephritis complicated with psoas muscle abscess; however, psoas muscle abscess associated with emphysematous cystitis has not yet been reported. Here, we report a case of bilateral posas muscle abscess following emphysematous cystitis in an 81-year-old nondiabetic man, who was treated successfully with prolonged antibiotic therapy and supportive care. Early recognition of psoas muscle abscess can prevent aggressive interventional procedure and warrant good prognosis. Jae-Ki Choi and Jae-Cheol Kwon Copyright © 2015 Jae-Ki Choi and Jae-Cheol Kwon. All rights reserved. Antiphospholipid Syndrome in a Pregnant Female Presenting with Severe Thrombocytopenia and Bleeding Thu, 05 Feb 2015 06:10:03 +0000 The antiphospholipid antibody syndrome (APS) is defined by the persistent presence of antiphospholipid antibodies in patients with recurrent venous or arterial thromboembolism or pregnancy morbidity. Antithrombotic therapy is the mainstay of treatment given the high risk of recurrent thromboembolism that characterizes this condition. Despite the prothrombotic nature of APS, thrombocytopenia is present in a proportion of patients, which can complicate management and limit the use of antithrombotic therapy. The mechanism of APS-associated thrombocytopenia is multifactorial and its relation to thrombotic risk is poorly characterized. The presence of thrombocytopenia does not appear to reduce thrombotic risk in patients with APS, who can develop thromboembolic complications necessitating antithrombotic treatment. In these cases, treatment of the thrombocytopenia may be necessary to facilitate administration of antithrombotic agents. We present such a pregnant lady with history of recurrent pregnancy losses who presented with severe thrombocytopenia and bleeding manifestations, who was subsequently diagnosed to have antiphospholipid antibody syndrome. She was initially managed with steroids and when her platelet counts improved, antithrombotic therapy was started. She delivered an uneventful and successful pregnancy outcome without any complications during follow-up. Kunal Mahajan, Virender Katyal, Suvrat Arya, and Meha Shrama Copyright © 2015 Kunal Mahajan et al. All rights reserved. Giant Congenital Melanocytic Nevi and Neurocutaneous Melanosis Wed, 04 Feb 2015 06:37:38 +0000 Introduction. The major medical concern with giant congenital melanocytic nevi CMN is high risk of developing cutaneous melanoma, leptomeningeal melanoma, and neurocutaneous melanocytosis. Case Report. A 30-year-old woman with a giant congenital melanocytic nevus covering nearly the entire right thoracodorsal region and multiple disseminated melanocytic nevi presented with neurological symptoms. Cerebral magnetic resonance imaging revealed a large expansive lesion in the left frontal region. Postsurgically pathological diagnosis revealed characteristics of melanoma. Immunohistochemical examination showed S100(+), HMB45(+), MelanA(+), and MiTF(+). She received radiotherapy with temozolomide followed by two more chemotherapy cycles with temozolomide. She followed a rapidly progressive course, reflecting widespread leptomeningeal infiltration, and she died of multiorgan failure seven months after diagnosis of cerebral melanoma. Discussion. This patient was diagnosed as having a neurocutaneous melanosis with malignant widespread leptomeningeal infiltration. Diffuse spinal involvement is unusual and is described in only another patient. Catarina Araújo, Cristina Resende, Francisco Pardal, and Celeste Brito Copyright © 2015 Catarina Araújo et al. All rights reserved. Metastatic Malignant Melanoma of the Inguinal Lymph Node with Unknown Primary Lesion Sun, 01 Feb 2015 11:15:31 +0000 Background. Malignant melanoma could present with metastasis with unknown primary (MUP) and this happens in 2-3% according to the studies. Around 90% of melanomas have cutaneous origin, but still there are melanomas that could be found in visceral organs or lymph nodes with unknown primary site. Spontaneous regression of the primary site could be an explanation. Case Report. We report a 58-year-old Caucasian male who presented with a right sided swelling in the inguinal region. Surgery was performed and biopsy showed metastatic malignant melanoma. No cutaneous lesions were identified by history or physical examination. Work up could not detect the primary lesion and patient was started on radiotherapy and immunotherapy. Conclusion. We present a case of malignant melanoma of unknown primary presenting in an unusual place which is the inguinal lymph node. Theories try to explain the pathway of development of such tumors and one of the theories mentions that it could be a spontaneous regression of the primary cutaneous lesion. Another theory is that it could be from transformation of aberrant melanocyte within the lymph node. Prognosis is postulated to be better in this case than in melanoma with a known primary. Sherif Ali Eltawansy, Ryane Panasiti, Samaa Hasanien, Dennis Lourdusamy, and David Sharon Copyright © 2015 Sherif Ali Eltawansy et al. All rights reserved.