Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Spontaneous Superficial Femoral Artery Pseudoaneurysm in Behcet's Disease Wed, 16 Apr 2014 12:02:54 +0000 Behcet’s disease is an autoimmune multisystemic disorder on vasculitis base. Cardiovascular involvement is the most important predictor of morbidity and mortality. The treatment should be planned carefully for pathologies requiring interventions. In our report, we present a 45-year-old patient with spontaneous superficial femoral artery pseudoaneurysm, our treatment strategy, and circumstances we faced. Murat Ugurlucan, Selin Sendil, Omer Ali Sayin, Mehmet Barburoglu, Emre Gok, Gulsum Turkyilmaz, Murat Basaran, Ufuk Alpagut, and Enver Dayioglu Copyright © 2014 Murat Ugurlucan et al. All rights reserved. Pancreatic Tuberculosis or Autoimmune Pancreatitis Tue, 15 Apr 2014 14:02:42 +0000 Introduction. Isolated pancreatic and peripancreatic tuberculosis is a challenging diagnosis due to its rarity and variable presentation. Pancreatic tuberculosis can mimic pancreatic carcinoma. Similarly, autoimmune pancreatitis can appear as a focal lesion resembling pancreatic malignancy. Endoscopic ultrasound-guided fine needle aspiration provides an effective tool for differentiating between benign and malignant pancreatic lesions. The immune processes involved in immunoglobulin G4 related systemic diseases and tuberculosis appear to have some similarities. Case Report. We report a case of a 59-year-old Southeast Asian male who presented with fever, weight loss, and obstructive jaundice. CT scan revealed pancreatic mass and enlarged peripancreatic lymph nodes. Endoscopic ultrasound-guided fine needle aspiration confirmed the presence of mycobacterium tuberculosis. Patient also had high immunoglobulin G4 levels suggestive of autoimmune pancreatitis. He was started on antituberculosis medications and steroids. Clinically, he responded to treatment. Follow-up imaging showed findings suggestive of chronic pancreatitis. Discussion. Pancreatic tuberculosis and autoimmune pancreatitis can mimic pancreatic malignancy. Accurate diagnosis is imperative as unnecessary surgical intervention can be avoided. Endoscopic ultrasound-guided fine needle aspiration seems to be the diagnostic test of choice for pancreatic masses. Long-term follow-up is warranted in cases of chronic pancreatitis. Ayesha Salahuddin and Muhammad Wasif Saif Copyright © 2014 Ayesha Salahuddin and Muhammad Wasif Saif. All rights reserved. Multiple Gastrointestinal Complications of Crack Cocaine Abuse Tue, 15 Apr 2014 12:28:37 +0000 Cocaine and its alkaloid free base “crack-cocaine” have long since been substances of abuse. Drug abuse of cocaine via oral, inhalation, intravenous, and intranasal intake has famously been associated with a number of medical complications. Intestinal ischemia and perforation remain the most common manifestations of cocaine associated gastrointestinal disease and have historically been associated with oral intake of cocaine. Here we find a rare case of two relatively uncommon gastrointestinal complications of hemorrhage and pancreatitis presenting within a single admission in a chronic crack cocaine abuser. Neal Carlin, Nhat Nguyen, and Joseph R. DePasquale Copyright © 2014 Neal Carlin et al. All rights reserved. A Giant Dissecting Aneurysm of Ascending Aorta Following Aortic Valve Replacement Tue, 15 Apr 2014 07:21:26 +0000 Ascending aortic dissection and aneurysm are rare but life-threatening complications after aortic valve replacement. Preoperative evaluation of risk factors such as aortic diameter, structural features of aortic wall, and associated diseases may decrease complication rate. We herein present analysis of risk factors of proximal aortic events following aortic valve replacement based on patient with giant dissecting aneurysm who underwent modified Bentall procedure. Faruk Hökenek, Mete Gürsoy, Füsun Gülcan, Egemen Duygu, and Murat Şener Copyright © 2014 Faruk Hökenek et al. All rights reserved. Rapid Progression of Pulmonary Blastomycosis in an Untreated Patient of Chronic Lymphocytic Leukemia Sun, 13 Apr 2014 15:56:23 +0000 Chronic lymphocytic leukemia (CLL) is associated with a state of immunosuppression characterized by hypogammaglobulinemia as well as B and T lymphocyte dysfunction. Though opportunistic infections are common in CLL patients, particularly after treatment, reports of infections by endemic dimorphic fungi are very few. Here we report a case of pulmonary blastomycosis in a CLL patient who initially presented with an indolent pulmonary mass lesion. The pulmonary lesions progressed rapidly over a two-week period. The diagnosis was established by transbronchial lung biopsy. He was treated with Amphotericin B lipid complex followed by oral itraconazole and recovered uneventfully. This case illustrates the importance of a timely diagnosis and treatment. The presentation of blastomycosis in immunocompromised patients, diagnosis, and treatment are discussed. Pralay K. Sarkar, Paras Malhotra, and P. S. Sriram Copyright © 2014 Pralay K. Sarkar et al. All rights reserved. Penetrating Fish-Hook Ocular Injury: Management of an Unusual Intraocular Foreign Body Sun, 13 Apr 2014 13:27:00 +0000 Importance. Ocular penetrating fish-hook injuries represent an unusual and very dangerous ocular trauma. We report the management of an unusual case of a simple-single barbed fish-hook accident globe injury successfully treated with surgery. Observations. We described a case report of a caucasian 32-year-old man presented with a scleral perforation of the left eye caused by a fish-hook injury while fishing. The fish-hook penetrated the sclera, passed the trabecular meshwork, and exited into the anterior chamber. He underwent surgery under local anesthesia to remove the intraocular foreign body and to repair the wound. The hook was removed backing through the entrance wound, enlarge the primary scleral laceration. Final visual outcome, one month after trauma, was 0.0 LogMar. Conclusions and Relevance. Our unusual case shows a modified extraction technique of fish-hook from the eye. Although the fish-hook injury represents generally a serious occurrence, in some cases, a prompt and appropriate method of extraction can lead to a good final outcome. Ludovico Iannetti and Paolo Tortorella Copyright © 2014 Ludovico Iannetti and Paolo Tortorella. All rights reserved. Budd-Chiari Syndrome Caused by TIPS Malposition: A Case Report Sun, 13 Apr 2014 08:06:23 +0000 Budd-Chiari syndrome refers to hepatic pathology secondary to diminished venous outflow, most commonly associated with venothrombotic disease. Clinically, patients with Budd-Chiari present with hepatomegaly, ascites, abdominal distension, and pain. On imaging, Budd-Chiari syndrome is hallmarked by occluded IVC and or hepatic veins, caudate lobe enlargement, heterogeneous liver enhancement, intrahepatic collaterals, and hypervascular nodules. Etiopathological factors for Budd-Chiari syndrome include several systemic thrombotic and nonthrombotic conditions that can cause venous outflow obstruction at hepatic veins and/or IVC. While the transjugular intrahepatic portosystemic shunt (TIPS) is used as a treatment option for Budd-Chiari syndrome, Budd-Chiari syndrome is not a well-known complication of TIPS procedure. We report a case of Budd-Chiari syndrome that occurred in a transplanted cirrhotic liver from malpositioned proximal portion of the TIPS in IVC causing occlusion of the ostia of hepatic veins which was subsequently diagnosed on contrast-enhanced CT. A. S. Katkar, Anderson H. Kuo, S. Calle, K. Gangadhar, and K. Chintapalli Copyright © 2014 A. S. Katkar et al. All rights reserved. Rhabdomyolysis and Acute Renal Impairment in a Patient with Hypothyroidism: A Case Report Sun, 13 Apr 2014 00:00:00 +0000 We report the case of a 33-year-old male with hypothyroidism who developed acute renal impairment with rhabdomyolysis after strenuous physical activity (snow shoveling). His thyroid function test confirmed marked hypothyroidism. Severe elevation of serum CK consistent with rhabdomyolysis was noted and an elevated creatinine indicated acute renal impairment. Patient’s condition improved significantly after starting him on thyroid hormone replacement therapy and aggressive hydration. Acute renal impairment with rhabdomyolysis in patients with hypothyroidism is quite rare and we expect that this case report adds to the existing literature on this subject. We also emphasize that thyroid status should be evaluated in patients with unexplained acute renal impairment and presenting with the symptoms of muscle involvement. Arshi Naz and Mayada Issa Copyright © 2014 Arshi Naz and Mayada Issa. All rights reserved. A Case Series of Emphysematous Pyelonephritis Wed, 09 Apr 2014 12:02:29 +0000 Introduction. Emphysematous pyelonephritis (EPN) is an uncommon infection characterized by gas in the renal parenchyma and surrounding tissues. It is rapidly progressive, requiring appropriate therapy to salvage the infected kidney. Case Description. The case series presents 5 patients with a clinical and radiologic diagnosis of EPN. Each patient had a unique predisposing factor for developing EPN. Early goal directed therapy with intravenous fluids and antibiotics was given. This was followed by less invasive urologic interventions in an attempt to avoid nephrectomy and thereby salvage the infected kidney. All five patients were discharged in clinically stable conditions. Discussion and Conclusion. This case series provides added practice based support to available literature for managing EPN. Early goal directed medical therapy for sepsis coupled with interventional urologic procedures is a valuable alternative to circumvent an upfront emergent nephrectomy, except in cases where a fulminant infection may be present at the time of admission or develop later on in the course of the patients illness despite conservative line of therapy. It also highlights the importance of considering a diagnosis of EPN in patients with urinary infections, who have certain common predisposing factors listed in our case series. Camelia Arsene, Abhijit Saste, Shankar Arul, Janee Mestrovich, Revark Kammo, Mohammed Elbashir, and Gregory Berger Copyright © 2014 Camelia Arsene et al. All rights reserved. Plasmodium falciparum Malaria Complicated by Symmetrical Peripheral Gangrene, Bowel Ischemia, Repeated Candidemia, and Bacteraemia Wed, 09 Apr 2014 07:16:27 +0000 A 63-year-old Caucasian woman developed severe Plasmodium falciparum malaria when travelling back from Cameroun. No antimalarial chemoprophylaxis had been observed. The patient was immediately admitted to the intensive care unit after evidence of multiple organ failure (coma, shock, acute respiratory distress syndrome, acute renal failure, etc.). However, initial parasitemia was less than 1%. The patient was managed by intravenous quinine and norepinephrine infusion due to refractory shock. The patient developed as an early complication ischemic lesions of both arms and feet. In addition to laboratory changes consistent with disseminated intravascular coagulation, there was also evidence for a low activity of the von Willebrand factor (VWF) cleaving protease ADAMTS13. Later complications included repeated candidemia and bacteraemia despite appropriate therapy; the origin appeared to be diffuse ischemic injury of the gastrointestinal tract. The patient ultimately recovered, but quadriamputation was necessary to treat symmetrical peripheral gangrene (SPG). In severe Plasmodium falciparum malaria, ischemic changes may be due to microvascular obstruction, but, in patients with low parasitemia, other endothelial factors may also be involved as observed in other groups of thrombotic microangiopathies. Emeline Masse and Philippe Hantson Copyright © 2014 Emeline Masse and Philippe Hantson. All rights reserved. Hypothyroidism Induced Severe Rhabdomyolysis in a Hemodialysis Patient Mon, 07 Apr 2014 14:04:59 +0000 Hypothyroidism occurs relatively common and is a significant cause of morbidity and mortality during the course of chronic kidney disease. Rhabdomyolysis is a potentially life-threatening condition characterised by necrosis of muscular tissue and rarely associates with hypothyroidism. Here we describe a case of rhabdomyolysis due to severe hypothyroidism in a 56-year-old female hemodialysis patient. Erhan Tatar, Tolgay Isikyakar, Kezban Pinar Yeniay, Hasan Huseyin Uzuner, and Ebru Sevinc Ok Copyright © 2014 Erhan Tatar et al. All rights reserved. Dorsalis Pedis Free Flap: The Salvage Option following Failure of the Radial Forearm Flap in Total Lower Lip Reconstruction Wed, 02 Apr 2014 12:44:20 +0000 Reconstruction after resection of large tumors of the lower lip requires the use of free flaps in order to restore the shape and the function of the lip, with the free radial forearm flap being the most popular. In this study we describe our experience in using the dorsalis pedis free flap as a salvage option in reconstruction of total lower lip defect in a patient with an extended lower lip carcinoma after failure of the radial forearm free flap, that was initially used. The flap was integrated excellently and on the followup the patient was free of disease and fully satisfied with the aesthetic and functional result. Theodoros Stathas, Georgios Tsinias, Dimitra Tsiliboti, Aris Tsiros, Nicholas Mastronikolis, and Panos Goumas Copyright © 2014 Theodoros Stathas et al. All rights reserved. Successful Outcome of a Corticodependent Henoch-Schönlein Purpura Adult with Rituximab Tue, 01 Apr 2014 11:44:36 +0000 Henoch-Schönlein purpura (HSP) is a systemic vasculitis involving small vessels with deposition of immunoglobulin A (IgA) complexes, usually affecting children. Compared with children, HSP in adults is more severe and frequently associated with cancer. We report the case of a 49-year-old woman with medical history of kidney transplantation for segmental glomerular hyalinosis. Eight years after the transplantation, while taking combined immunosuppressive therapy with tacrolimus and azathioprine indicated for the prevention against transplant rejection, she developed a Henoch-Schönlein purpura. Vasculitis involves skin and sciatic peroneal nerve and she received systemic corticosteroid treatment. Because of four relapses and corticosteroid dependence, the patient was treated with rituximab (two intravenous infusions of 1000 mg given two weeks apart). Successful outcome was observed along two years of follow-up. This new case of successful use of rituximab in HSP promotes more investigations of this treatment in clinical trials. Taylor Pindi Sala, Jean-Marie Michot, Renaud Snanoudj, Marion Dollat, Emmanuel Estève, Bernadette Marie, Yacine Taoufik, Jean-François Delfraissy, Thierry Lazure, and Olivier Lambotte Copyright © 2014 Taylor Pindi Sala et al. All rights reserved. Late Onset Combined Immunodeficiency Presenting with Recurrent Pneumocystis jiroveci Pneumonia Mon, 31 Mar 2014 16:12:35 +0000 Late onset combined immunodeficiency (LOCID) is a recently described variant of common variable immunodeficiency (CVID), involving adult patients presenting with opportunistic infections and/or low CD4+ lymphocyte counts. A 36-year-old male with unremarkable past medical history presented with fever, respiratory failure, and lymphocytopenia. He was found to have Pneumocystis jiroveci pneumonia (PJP), subsequently complicated by recurrent hospital-acquired Pseudomonas aeruginosa pneumonia and immune reconstitution phenomena, attributed to restoration of immunoglobulin levels. Clinicians should be aware of LOCID, which could be confused with HIV infection/AIDS or idiopathic CD4 lymphocytopenia. In the English bibliography there is only one case report, where PJP was the initial presentation of CVID (that case would probably be classified as LOCID). Phenomena of immune reconstitution are described in various settings, including primary immunodeficiency, manifesting as temporary clinical and radiologic deterioration and leading to misperceptions of therapeutic failure and/or presence of alternative/additional diagnoses. Ilias Papakonstantinou, Ioannis G. Baraboutis, and Lazaros Karnesis Copyright © 2014 Ilias Papakonstantinou et al. All rights reserved. A Case of Secondary Leukemia Subsequent to Myelodysplastic Syndromes Successfully Treated with Azacitidine Mon, 31 Mar 2014 11:47:15 +0000 Elderly patients with secondary acute myeloid leukemia (AML) following myelodysplastic syndrome (MDS) are often medically unfit for or resistant to chemotherapy, and their prognosis is dismal. In the present paper, we reported a case of secondary leukemia following MDS in an 80-year-old male patient who was deemed unfit for chemotherapy owing to his old age and poor physical condition. Despite a high tumor burden, treatment with AZA exerted a remarkable response, leading to an immediate cytoreduction in our case. Our results suggest that AZA can be an attractive therapeutic option for elderly MDS or AML patients, offering adequate efficacy and high tolerability. Takahiro Kumode, Ayano Fukui, Go Eguchi, Terufumi Yamaguchi, and Yasuhiro Maeda Copyright © 2014 Takahiro Kumode et al. All rights reserved. Oral Allergy Syndrome in a Child Provoked by Royal Jelly Mon, 31 Mar 2014 11:41:43 +0000 Royal jelly has been demonstrated to have several physiological activities. However, in the literature, different reactions induced by royal jelly are reported. We describe a case of seven-year-old child that was referred to our observation for two episodes of oral allergy syndrome (OAS) that appeared ten minutes after ingestion of royal jelly. Skin prick test with standard panel of inhalant and food allergens, a prick-to-prick test using the royal jelly’s extract responsible for patient’s reactions, and royal jelly patch test with extemporaneous preparation were performed. The specific IgE by ImmunoCAP System method versus Hymenoptera venom, inhalant allergens, food allergens, and lipid transfer proteins was dosed. According to the positive reactions to royal jelly both by prick-by-prick test and by a first reading patch test, royal jelly immediate hypersensitivity was diagnosed. According to the positive response for almond in both in vivo and in vitro tests we can think of the royal jelly contamination with almond pollen as possible cause of patient’s reaction. Moreover, from the results of specific IgE titers versus Compositae pollens, we have argued the possibility that this case of royal jelly allergy could be explained also by the mechanism of cross-reaction with Compositae pollens. Fantini Paola, Delle Donne Pantalea, Calogiuri Gianfranco, Ferrannini Antonio, Vacca Angelo, Nettis Eustachio, and Di Leo Elisabetta Copyright © 2014 Fantini Paola et al. All rights reserved. Atrioventricular Dissociation following Blunt Chest Trauma Thu, 27 Mar 2014 09:40:51 +0000 Blunt chest trauma (BCT) is a common clinical presentation seen in emergency departments. Few cases of cardiac conduction abnormalities due to BCT have been reported in the medical literature. This dysrhythmias may present as permanent conduction defects requiring permanent pacemaker or may have temporary conduction abnormalities requiring temporary pacemaker or supportive care. We present the case of a young woman who suffered from BCT after being kicked by a horse with the development of a significant substernal hematoma. She developed temporary atrioventricular block, which was completely resolved with the decrease in the size of the substernal hematoma suffered. Salim Surani, Karen Allen, Cynthia Ocegueda-Pacheco, and Joseph Varon Copyright © 2014 Salim Surani et al. All rights reserved. Identification of an APC Variant in a Patient with Clinical Attenuated Familial Adenomatous Polyposis Thu, 27 Mar 2014 00:00:00 +0000 Introduction. The objective of this case report is to discuss an unclassified germline variant of the adenomatous polyposis coli (APC) gene identified in an older patient with attenuated familial adenomatous polyposis syndrome (AFAP). Methods. We present a case report of a 66-year-old man diagnosed with AFAP. Colonoscopy found multiple polyps and invasive adenocarcinoma arising in the transverse colon. Samples were tested for mutations in the APC gene. Results. DNA sequencing of germline DNA identified a cytosine (C) to thymine (T) transition at nucleotide 1240, heterozygous. The C to T transition at codon 414 is predicted to convert an arginine residue to a cysteine that is possibly pathogenic. Analysis of the patient’s colon tumor DNA indicated that the tumor had lost the mutant variant allele and retained only the normal allele, suggesting that the variant may not be significant. Conclusions. The p.R414C variant has been described previously as a germline mutation of probable pathogenicity. This substitution should be considered an unclassified variant and possibly not pathogenic. These findings support the need for further genetic testing of tissue, as well as for developing a mechanism for testing all variants, as this could significantly impact the lives of patients and their family members. Andrew T. Schlussel, Susan S. Donlon, Faye A. Eggerding, and Ronald A. Gagliano Copyright © 2014 Andrew T. Schlussel et al. All rights reserved. Bimaxillary Keratocystic Odontogenic Tumour: A Case of Diagnostic and Therapeutic Difficulty Wed, 26 Mar 2014 13:53:33 +0000 Keratocystic odontogenic tumour (KCOT) is a benign cystic intraosseous tumour of odontogenic origin that is usually solitary except when syndromic. It rarely occurs in the maxilla; therefore a rapidly progressive, nonsyndromic bimaxillary KCOT with locoregional extension poses significant diagnostic and management challenges. To the best of the authors’ knowledge, documentation of a nonsyndromic bimaxillary KCOT is nonexistent in the English literature. We therefore present the case of an extensive bimaxillary KCOT in a 38-year-old Nigerian male. Victoria Nwebuni Okoje-Adesomoju, Akinyele Olumuyiwa Adisa, Olalere Omoyosola Gbolahan, and Mofoluwaso Abimbola Olajide Copyright © 2014 Victoria Nwebuni Okoje-Adesomoju et al. All rights reserved. Postoperative Delayed Duodenum Perforation following Elective Laparoscopic Cholecystectomy Tue, 25 Mar 2014 08:02:27 +0000 Background. Duodenum injury is extremely rare complication of laparoscopic cholecystectomy with potentially fatal consequences. Methods. Over the past 13-year period, 3000 laparoscopic cholecystectomies were performed in our institution. Duodenum injury only occurred in one patient recently who had undergone gastrectomy owing to duodenal diverticulum. The diagnosis and management of this rare complication of laparoscopic cholecystectomy are described, and the literature is reviewed. Results. We present this case of duodenum injury on the fourth postoperative day after selective laparoscopic cholecystectomy was treated successfully by percutaneous needle aspiration and catheter drainage. The hospital stay was 26 days. No abscess recurred during the follow-up period. Conclusion. Duodenum injuries are extremely rare complications of laparoscopic cholecystectomy with potentially fatal consequences if not promptly recognized and treated. Sonographically guided percutaneous needle aspiration and catheter drainage can be used to treat the intraperitoneal abscess. Billroth II subtotal gastrectomy and gastrojejunostomy were beneficial for the treatment. Kong Jing and Wu Shuo-Dong Copyright © 2014 Kong Jing and Wu Shuo-Dong. All rights reserved. Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Imaging of a Patient with Squamous Cell Carcinoma of Prostate Mon, 24 Mar 2014 11:57:44 +0000 Primary squamous cell carcinoma is an uncommon tumor of the prostate gland. We report a 77-year-old male patient with urinary frequency and constipation. Fine needle biopsy from prostate was suspicious of squamous cell carcinoma of the prostate. Whole body positron emission tomography/computed tomography scan revealed high fluorodeoxyglucose uptake in prostate gland. Transurethral resection confirmed the diagnosis. In contrast to prostatic adenocarcinoma, high fluorodeoxyglucose accumulation was observed in the primary tumor of the prostate gland. Gonca Kara Gedik, Guler Yavas, Murat Akand, Esin Celik, and Oktay Sari Copyright © 2014 Gonca Kara Gedik et al. All rights reserved. Hydatid Disease Located in the Cerebellomedullary Cistern Mon, 24 Mar 2014 09:56:50 +0000 Hydatid disease is an endemic zoonotic disease in many areas of the world. Liver, followed by lung, is the most commonly affected organ and involvement of other organs is rare. When brain is involved, lesions are typically supratentorial, and infratentorial localisation is even rarer. We present a 45-year-old woman with hydatid disease located in premedullary location compressing the brain stem, an exceedingly rare location for cerebral echinococcosis. Relevant literature regarding typical properties of cerebral disease was reviewed. Özgür Kızılca, Murat Altaş, Utku Şenol, and Murat Alp Öztek Copyright © 2014 Özgür Kızılca et al. All rights reserved. A Confusing Coincidence: Neonatal Hypoglycemic Seizures and Hyperekplexia Mon, 24 Mar 2014 09:11:03 +0000 Hyperekplexia is a rare, nonepileptic, genetic, or sporadic neurologic disorder characterized by startle responses to acoustic, optic, or tactile stimuli. Genetic defects in glycine receptors as well as encephalitis, tumors, inflammation, and disgenesis are among the etiologic causes of the disease. The main problem in hyperekplexia is the incomplete development of inhibitory mechanisms or exaggerated stimulation of excitatory mediators. Hyperekplexia is often confused with epileptic seizures. Here we present a case with hypoglycemic convulsions coexisting with hyperekplexia, causing diagnostic difficulty. Nihat Demir, Murat Doğan, Sanem Yılmaz, Erdal Peker, Keziban Bulan, and Oğuz Tuncer Copyright © 2014 Nihat Demir et al. All rights reserved. Recurrent Retrorectal Teratoma Sun, 23 Mar 2014 14:11:05 +0000 Retrorectal tumors are a rare group of neoplasms that occur most commonly in the neonatal and infant population. They vary in presentation, but teratomas are the most common and often present as a protruding mass from the sacrococcygeal region. Immediate surgical resection is indicated when found and coccygectomy is performed to prevent recurrence. When teratomas recur, the patients most often have vague symptoms and the tumors usually have malignant transformation. Here, we present the case of a young woman who underwent surgical resection of a sacrococcygeal teratoma at 3 days of age where the coccyx was not removed. She presented at 31 years of age with lower extremity paresthesias and radiography revealed a cystic mass extending from the sacrum. After resection, pathology revealed a recurrent teratoma with nests of adenocarcinoma. P. Geoff Vana, Sherri Yong, Dana Hayden, Theodore Saclarides, Michelle Slogoff, William Boblick, and Joshua Eberhardt Copyright © 2014 P. Geoff Vana et al. All rights reserved. “Dancing Eye Syndrome” Secondary to Opsoclonus-Myoclonus Syndrome in Small-Cell Lung Cancer Sun, 23 Mar 2014 13:39:10 +0000 Among paraneoplastic neurologic disorders (PND), opsoclonus-myoclonus syndrome, so-called “dancing eye syndrome,” is a rare disorder combining multivectorial eye movements, involuntary multifocal myoclonus, and cerebellar ataxia. Although several paraneoplastic antibodies against postsynaptic or cell-surface antigens have been reported, usually most patients are serum antibody negative. We report a 65-year-old patient with opsoclonus-myoclonus syndrome revealing a small-cell lung carcinoma. If serologic antineuronal anti-body screening was negative, autoantibodies against glutamic acid decarboxylase (anti-GAD) were positive. Despite the specific anticancer treatment and high dose corticosteroids, the patient developed a severe and progressive encephalopathy and died 10 days later. S. Laroumagne, Xavier Elharrar, B. Coiffard, J. Plojoux, H. Dutau, D. Breen, and P. Astoul Copyright © 2014 S. Laroumagne et al. All rights reserved. Acute Ascending Muscle Weakness Secondary to Medication-Induced Hyperkalemia Sun, 23 Mar 2014 09:10:56 +0000 Secondary hyperkalemic paralysis is an uncommon but potentially life-threatening consequence of drug-induced disease. We report a case of a 53-year-old female with history of chronic kidney disease presenting to the emergency department with a one-day history of upper and lower extremity weakness and paresthesias. Serum potassium concentration on admission was greater than 8 mEq/L, and serum creatinine was elevated above baseline. Electrocardiogram showed first-degree atrioventricular block with peaked T waves. The patient reported compliance with daily lisinopril 10 mg, spironolactone 25 mg, and 40 mEq twice daily of potassium chloride. Symptoms and electrocardiogram returned to baseline within 24 hours of presentation and serum potassium returned to 4.2 mEq/L at approximately 36 hours without the need for dialysis. This case emphasizes the importance of including such a condition in the differential diagnosis of patients with ascending paralysis and the importance of close monitoring of patients placed on potassium-elevating agents. Lauren A. Kimmons and Justin B. Usery Copyright © 2014 Lauren A. Kimmons and Justin B. Usery. All rights reserved. Levamisole-Contaminated Cocaine: An Emergent Cause of Vasculitis and Skin Necrosis Thu, 20 Mar 2014 08:42:13 +0000 The prevalence of cocaine adulterated with levamisole-induced vasculitis is increasing and physicians should be aware of this unique entity. There have been many reports of cutaneous vasculitis syndrome caused by cocaine which is contaminated with levamisole. Levamisole was used as an antihelminth drug and later was rescinded from use in humans due to adverse effects. Through this paper, we will report a 39-year-old crack cocaine user who presented with purpuric rash and skin necrosis of his ear lobes. Levamisole-induced vasculitis syndrome was suspected. A urine toxicology screen was positive for cocaine, opiates, and marijuana. Blood work revealed positive titres of ANA and p-ANCA, as well as anti-cardiolipin antibody. Biopsy taken from the left ear showed focal acute inflammation, chronic inflammation with thrombus formation, and extravasated blood cells. Treatment was primarily supportive with wound care. Osama Souied, Hassan Baydoun, Zahraa Ghandour, and Neville Mobarakai Copyright © 2014 Osama Souied et al. All rights reserved. Bilateral Renal Tumour as Indicator for Birt-Hogg-Dubé Syndrome Thu, 20 Mar 2014 07:08:11 +0000 Birt-Hogg-Dubé (BHD) syndrome is a cancer disorder caused by a pathogenic FLCN mutation characterized by fibrofolliculomas, lung cysts, pneumothorax, benign renal cyst, and renal cell carcinoma (RCC). In this case we describe a patient with bilateral renal tumour and a positive familial history for pneumothorax and renal cancer. Based on this clinical presentation, the patient was suspected for BHD syndrome, which was confirmed after molecular testing. We discuss the importance of recognizing this autosomal dominant cancer disorder when a patient is presented at the urologist with a positive family history of chromophobe renal cell cancer or a positive familial history for renal cell cancer and pneumothorax. P. C. Johannesma, R. J. A. van Moorselaar, S. Horenblas, L. E. van der Kolk, E. Thunnissen, J. H. T. M. van Waesberghe, F. H. Menko, and P. E. Postmus Copyright © 2014 P. C. Johannesma et al. All rights reserved. Matching Biological Mesh and Negative Pressure Wound Therapy in Reconstructing an Open Abdomen Defect Wed, 19 Mar 2014 11:49:29 +0000 Reconstruction of open abdominal defects is a clinical problem which general and plastic surgeons have to address in cooperation. We report the case of a 66-year-old man who presented an abdominal dehiscence after multiple laparotomies for a sigmoid-rectal adenocarcinoma that infiltrated into the abdominal wall, subsequently complicated by peritonitis and enteric fistula. A cutaneous dehiscence and an incontinent abdominal wall resulted after the last surgery. The abdominal wall was reconstructed using a biological porcine cross-linked mesh Permacol (Covidien Inc., Norwalk, CT). Negative Pressure Wound Therapy (NPWT), instead, was used on the mesh in order to reduce wound dimensions, promote granulation tissue formation, and obtain secondary closure of cutaneous dehiscence which was finally achieved with a split-thickness skin graft. Biological mesh behaved like a scaffold for the granulation tissue that was stimulated by the negative pressure. The biological mesh was rapidly integrated in the abdominal wall restoring abdominal wall continence, while the small dehiscence, still present in the central area, was subsequently covered with a split-thickness skin graft. The combination of these different procedures led us to solve this complicated case obtaining complete wound closure after less than 2 months. Fabio Caviggioli, Francesco Maria Klinger, Andrea Lisa, Luca Maione, Davide Forcellini, Valeriano Vinci, Luca Codolini, and Marco Klinger Copyright © 2014 Fabio Caviggioli et al. All rights reserved. Secondary Acute Myeloid Leukemia in a One-Year-Old Girl Diagnosed with JAK2-V617F Mutation Positive Myeloproliferative Neoplasm Tue, 18 Mar 2014 06:47:23 +0000 Myeloproliferative neoplasms (MPNs) are a group of clonal disorders characterized by hyperproliferation of hematologic cell lines and have been associated with tyrosine kinase JAK2-V617F mutations. Secondary acute myeloid leukemia (sAML) is a known complication of JAK2-V617F+ MPNs and bears a poor prognosis. Although the evolution of a JAK2-V617F+ MPN to a mixed-lineage leukemia has been reported in the pediatric population, no evolutions into sAML have been described. We present a case of a one-year-old girl diagnosed with JAK2-V617F+ MPN with evolution into sAML. Despite initial morphologic remission, she eventually relapsed and succumbed to her disease. Gary M. Woods, Rajinder P. S. Bajwa, Samir B. Kahwash, and Terri Guinipero Copyright © 2014 Gary M. Woods et al. All rights reserved.