Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Histopathologic Finding of Both Gastric and Respiratory Epithelia in a Lingual Foregut Cyst Thu, 30 Jul 2015 11:25:34 +0000 Foregut cysts are uncommon, mucosa-lined congenital lesions that may occur anywhere along the gastrointestinal or respiratory tract and typically present within the first year of life. Although infrequent, these cysts may generate feeding or respiratory difficulties depending on the size and location of the lesion. Foregut cysts of the oral cavity are rarely seen and of those cases localized to the tongue are even more uncommon. We describe a 4-month-old girl with a foregut cyst involving the floor of mouth and anterior tongue. Subsequent histologic analysis demonstrated a cyst lined with both gastric and respiratory epithelia. This case represents an extremely rare finding of both gastric and respiratory epithelia lined within a single cystic structure in the tongue. Although a very rare finding, a foregut cyst should be on the differential diagnosis of any lesion involving the floor of mouth or tongue in an infant or child. Yangfan Luo, Nick Shillingford, and Jeffrey A. Koempel Copyright © 2015 Yangfan Luo et al. All rights reserved. First Case of Tricuspid Valve Endocarditis Caused by Gemella bergeri Thu, 30 Jul 2015 09:44:33 +0000 Gemella bergeri is a Gram-positive cocci species arranged in pairs and composes the normal flora of oral cavity, digestive and urinary tract. Several species of Gemella are known to cause endocarditis. Here, we report the first case in Thailand of G. bergeri endocarditis whose blood culture was negative using routine methods but was positive by PCR identification of bacteria in the affected valve. A 37-year-old male presented with prolonged fever, weight loss, and dyspnea on exertion. By transthoracic echocardiography, he was suspected of having infective endocarditis of the tricuspid valve. The patient underwent tricuspid valve repair and vegetectomy. Routine hospital blood cultures were negative but G. bergeri was identified by PCR/sequencing of the heart valve tissue. Orathai Pachirat, George Watt, and Burabha Pussadhamma Copyright © 2015 Orathai Pachirat et al. All rights reserved. Laparoscopic Sleeve Gastrectomy in a Morbidly Obese Patient with Myasthenia Gravis: A Review of the Management Wed, 29 Jul 2015 15:36:30 +0000 Myasthenia gravis, a disorder of neuromuscular transmission, presents a unique challenge to the perioperative anesthetic management of morbidly obese patients. This report describes the case of a 27-year-old morbidly obese woman with a past medical history significant for myasthenia gravis and fatty liver disease undergoing bariatric surgery. Anesthesia was induced with intravenous agents and maintained with an inhalational and balanced intravenous technique. The nondepolarizing neuromuscular blocker Cisatracurium was chosen so that no reversal agents were given. Neostigmine was not used to antagonize the effects of Cisatracurium. The goal of this approach was to reduce the risk of complications such as postoperative mechanical ventilation. The anesthetic and surgical techniques used resulted in an uneventful hospital course. Therefore, we can minimize perioperative risks and complications by adjusting the anesthetic plan based on the patient’s physiology and comorbidities as well as the pharmacology of the drugs. Megana Ballal and Tracey Straker Copyright © 2015 Megana Ballal and Tracey Straker. All rights reserved. Baclofen-Induced Encephalopathy in End Stage Renal Disease Wed, 29 Jul 2015 10:00:37 +0000 Baclofen is a highly used centrally acting GABA agonist that continues to be an effective therapy for spasticity and chronic hiccups. The renally dependent excretion determines the circulating concentrations and guides effective dosing to decrease adverse reactions. Caution should be considered in administering baclofen to patients with decreased renal function. We present a patient with end stage renal disease on hemodialysis with recent baclofen ingestion who presented with toxic encephalopathy that was resolved with additional dialysis sessions. Andrew Meillier, Cara Heller, and Shyam Patel Copyright © 2015 Andrew Meillier et al. All rights reserved. Papillary Thyroid Cancer and Lung Adenocarcinoma Presenting as Two Primary Malignancies in a Patient with Symptomatic Goiter Tue, 28 Jul 2015 12:45:01 +0000 In rare instances, patients may be diagnosed with two different primary malignancies. Though such synchronous malignancies have been documented in sporadic case reports, the overwhelming majority of malignancies involving multiple organs can be attributed to a primary source. Papillary thyroid carcinoma and lung adenocarcinoma are rarely diagnosed within the same year. Our case report presents a patient who was diagnosed with these two malignancies during her same hospital visit. Biopsies results proved that the two malignancies were in fact separate entities and not a consequence of metastasis from a primary source. Deepu Daniel, Leah Delumpa, and Natasha Bray Copyright © 2015 Deepu Daniel et al. All rights reserved. Walking with Neuropathic Pain: Paradoxical Shift from Burden to Support? Tue, 28 Jul 2015 11:28:49 +0000 Baclofen 5% cream can be used for the treatment of neuropathic pain. We describe an unusual case of a neuropathic pain patient with spinal cord injury. A 71-year-old woman with a partial spinal cord injury lesion at L4 complained of tingling, pins and needles, and burning in her legs. She scored her pain as 6 before adding baclofen 5% cream to her pain medication (pregabalin 450 mg, acetaminophen 3000 mg, and diclofenac 150 mg daily). One month later she experienced complete pain relief, though experienced increased difficulties in walking, leading to frequent falls. Her steadier walking without stumbling and falling was more important to her than pain reduction. Thus she decided to stop using baclofen. This unusual case report discusses two important issues that relate to pain medicine and rehabilitation in patients with painful spinal cord lesions: (1) the presence of wide areas of sensory loss “covered” by the presence of painful sensations and (2) pathological sensations that can be used and integrated in the body schema to create an improved spatiovisual orientation and thus mobility. Both these aspects have to be taken into account when treating pain and design rehabilitation programs. David J. Kopsky, Jan M. Keppel Hesselink, and Roberto Casale Copyright © 2015 David J. Kopsky et al. All rights reserved. Brodie’s Abscess in a Patient Presenting with Sickle Cell Vasoocclusive Crisis Tue, 28 Jul 2015 09:02:11 +0000 First described by Sir Nicholas Brodie in 1832, Brodie’s abscess is a localized subacute or chronic infection of the bone, typically seen in the metaphases of long bones in children and adolescents. The diagnosis can prove to be enigmatic due to absence of clinical signs and symptoms of systemic disease. We report a very interesting case of Brodie’s abscess masquerading as sickle cell vasoocclusive crisis in a 20-year-old female with sickle cell disease and review the literature. Onyekachi Henry Ogbonna, Yonette Paul, Hasan Nabhani, and Adriana Medina Copyright © 2015 Onyekachi Henry Ogbonna et al. All rights reserved. 16 Y/O Female with “Watermelon Stomach”? Tue, 21 Jul 2015 09:14:28 +0000 Background. Gastric antral vascular ectasia (GAVE) also known as “watermelon stomach” (WS) is an uncommon cause of gastrointestinal (GI) blood loss. It typically presents in middle aged females. We are presenting a case of GAVE at an unusually early age with atypical symptoms. Case. A previously healthy 16 y/o Caucasian female presented to the ER with a one-month history of upper abdominal pain. Physical examination was benign except tenderness in the epigastric region. There were no significant findings on laboratory data. Upper endoscopy showed incidental findings of linear striae in the antrum indicative of GAVE but histology was equivocal. Discussion. GAVE is a poorly understood but treatable entity and an increasingly identifiable cause of chronic iron deficiency anemia or acute or occult upper GI bleeding. The pathophysiology of GAVE remains unclear. It is an endoscopic finding characterized by longitudinal columns of tortuous red ectatic vessels (watermelon stripes), pathognomonic for WS. Treatment options include endoscopic, pharmacologic, and surgical approaches. Failure to recognize GAVE can result in delayed treatment for years. Our patient with GAVE was unusually young and was diagnosed incidentally. Due to lack of anemia on laboratory examination we elected to monitor her clinically for any future development of anemia. Amandeep Singh, Anwaar A. Khan, Robert Krall, and Zafar K. Mirza Copyright © 2015 Amandeep Singh et al. All rights reserved. First Reported Case of Methicillin-Resistant Staphylococcus aureus Vertebral Osteomyelitis with Multiple Spinal and Paraspinal Abscesses Associated with Acupuncture Wed, 15 Jul 2015 10:49:13 +0000 Acupuncture is one of the oldest medical procedures in the world and originated in China about 2,000 years ago. Acupuncture is a form of complementary medicine and has gained popularity worldwide in the last few decades. It is mainly used for the treatment of chronic pain. Acupuncture is usually considered a safe procedure but has been reported to cause serious complications including death. It has been associated with transmission of many viruses and bacteria. Two cases of Methicillin-Resistant Staphylococcus aureus have been reported recently following acupuncture therapy. We are reporting a case of a 57-year-old Korean female who developed vertebral osteomyelitis and intraspinal and paraspinal abscesses as a complication of acupuncture. Blood cultures, skin lesion culture, and body fluid culture yielded Methicillin-Resistant Staphylococcus aureus (MRSA). Good anatomical and medical knowledge, good hygiene standards, and proper acupuncture techniques should be followed to prevent the complications. Acupuncturists should consistently review the infection control guidelines to acupuncture. This case should raise awareness of such condition and hazards of presumably benign procedures such as acupuncture. Sandeep Singh Lubana, Mostafa Alfishawy, Navdeep Singh, and Debra J. Brennessel Copyright © 2015 Sandeep Singh Lubana et al. All rights reserved. Lemierre’s Syndrome: A Neglected Disease with Classical Features Wed, 15 Jul 2015 07:27:57 +0000 We report the case of a previously healthy, immunocompetent 23-year-old male who presented to the Emergency Department with general malaise, difficulty in breathing, fever, and chest pain. He reported a two-week history of progressively worsening sore throat that he presumed to be a viral infection and thus initially neglected. However, when his condition deteriorated, he was admitted to hospital acutely unwell and in respiratory distress. He quickly developed septic shock requiring intensive care admission for inotropic support. Ultrasound and CT imaging revealed internal jugular vein thrombosis with associated septic emboli reaching the lungs to form bilateral cavitations and consequently pleural effusions. Blood cultures were positive for Fusobacterium necrophorum. Based on these findings, a diagnosis of Lemierre’s syndrome was made. The patient was treated with appropriate antibiotics and anticoagulation and gradually recovered. He was discharged 20 days after admission with advice to complete a six-week course of antibiotics. Andreas V. Hadjinicolaou and Yiannis Philippou Copyright © 2015 Andreas V. Hadjinicolaou and Yiannis Philippou. All rights reserved. Transhepatic Embolization of Congenital Intrahepatic Portosystemic Venous Shunts with Associated Aneurysms Tue, 14 Jul 2015 09:12:47 +0000 Intrahepatic shunts between the portal and systemic venous systems with associated aneurysms are extremely rare. A middle aged woman presented with hepatic encephalopathy and was found to have two intrahepatic portosystemic venous shunts with associated aneurysms. Diagnosis was made by duplex ultrasound and was confirmed with contrast enhanced MRI. Treatment was performed percutaneously with an Amplatzer vascular plug. Kalyan Paudel and Eric K. Hoffer Copyright © 2015 Kalyan Paudel and Eric K. Hoffer. All rights reserved. An Unusual Case: Salmonella UTI and Orchitis in HIV Patient Tue, 14 Jul 2015 08:40:27 +0000 Salmonellosis is a major cause of gastroenteritis in the United States; however, nontyphoidal strains of Salmonella have also been known to cause urinary tract infections, usually transmitted via the fecal-urethral route. This can lead to critical illness in those patients with immune deficiencies, especially HIV, cancer patients, and those with diabetes mellitus. However, the spread of the infection from the urinary tract to involve the testicles and epididymis is very rare. Here, we present the first documented case of an immune-compromised young male with a urinary tract infection with orchitoepididymitis. Sabrina Arshed, Hongxiu Luo, John Middleton, and Abdalla Yousif Copyright © 2015 Sabrina Arshed et al. All rights reserved. Pituitary Insufficiency and Hyperprolactinemia Associated with Giant Intra- and Suprasellar Carotid Artery Aneurysm Sun, 12 Jul 2015 09:37:16 +0000 Pituitary insufficiency secondary to internal carotid artery (ICA) aneurysm is a very rare condition. Its prevalence is reported as 0.17% (Heshmati et al., 2001). We present a case of pituitary insufficiency and hyperprolactinemia secondary to suprasellar giant intracranial aneurysm. A 71-year-old man was admitted to our clinic with symptoms of hypopituitarism, hyperprolactinemia, and visual field defect. His pituitary MRI and cerebral angiography revealed a giant saccular aneurysm filling suprasellar cistern arising from the ophthalmic segment of the right ICA. Endovascular treatment was performed on the patient to decrease the mass effect of aneurysm and improve the hypophysis dysfunction. After treatment, his one-year follow-up showed the persistence of hypophysis insufficiency, decrease of prolactin (PRL) level, and normal visual field. An intracranial aneurysm can mimic the appearance and behavior of a pituitary adenoma. Intracranial aneurysms should be taken into consideration in the situation of hypopituitarism and hyperprolactinemia. It is important to distinguish them because their treatment approach is different from the others. A. Gungor, N. Gokkaya, A. Bilen, H. Bilen, E. M. Akbas, Y. Karadeniz, and S. Eren Copyright © 2015 A. Gungor et al. All rights reserved. Congenital Vallecular Cyst Causing Airway Compromise in a 2-Month-Old Girl Thu, 09 Jul 2015 13:40:24 +0000 Congenital vallecular cyst is a rare entity and may present with acute airway obstruction. This is a case of congenital vallecular cyst presenting with airway compromise requiring immediate management. The epidemiology, pathogenesis, and clinical presentation of vallecular cysts are discussed as well as the diagnosis and management. Amal Faisal AlAbdulla Copyright © 2015 Amal Faisal AlAbdulla. All rights reserved. Pericarditis Epistenocardica or Dressler Syndrome? An Autopsy Case Thu, 09 Jul 2015 08:28:40 +0000 Postinfarction pericarditis can be classified as “early,” referred to as pericarditis epistenocardica, or “delayed,” referred to as Dressler syndrome. The incidence of postinfarction pericarditis has decreased to <5% since the introduction of reperfusion therapies and limitation of infarct size. We report on a 57-year-old man who suffered sudden cardiac death as a result of acute myocardial infarction. Autopsy revealed an area of previous infarction and fibrinous pericarditis related to the previous infarction, leading to a diagnosis of Dressler syndrome. Alessandro Feola, Noè De Stefano, and Bruno Della Pietra Copyright © 2015 Alessandro Feola et al. All rights reserved. Unusual Extramedullary Plasmacytoma: A Rare but Possible Cause of Lymphadenopathy in Chronic Lymphocytic Leukemia Tue, 07 Jul 2015 12:37:50 +0000 Cervical bilateral lymphadenopathy is a frequent event during chronic lymphocytic leukemia (CLL) natural history. However, lymph node biopsy is generally not required as long as transformation into an aggressive lymphoma (Richter syndrome) is not suspected. We present here a rare case of CLL patient who developed progressive bilateral cervical lymph node and bilateral tonsillar hypertrophy. CLL front-line therapy was ineffective leading to adenectomy and diagnosis of concomitant extramedullary plasmacytoma. Radiotherapy did not result in the disappearance of lymphadenopathy. Adenectomy should be performed in CLL cases to avoid misdiagnosis. S. P. Chantepie, Q. Cabrera, J. B. Mear, V. Salaun, E. Lechapt-Zalcman, and M. Macro Copyright © 2015 S. P. Chantepie et al. All rights reserved. Unruptured Aneurysm of Sinus of Valsalva Coexisting with the Large Ventricular Septal Defect and Severe Aortic Regurgitation in a Young Man Tue, 07 Jul 2015 05:52:25 +0000 Introduction. Unruptured sinus of valsalva aneurysm (SVA) is a rare congenital anomaly, particularly, when it coexists with a ventricular septal defect (VSD) and aortic regurgitation due to the prolapse of the elongated aortic cusp into the VSD. In this report, we present the case of a 19-year-old young man with VSD challenging in spite of dyspnea and lower limb edema. Presentation of Case. Its diagnosis was made on the basis of transthoracic echocardiography results. Surgical management consisted of replacing the SVA with mechanical valve prosthesis. A Gore-Tex patch repaired the VSD. Discussion. In the follow-up periods, clinical and echocardiographic tests showed that the patient was in excellent status. Conclusion. SVA requires a surgical procedure due to its high risk of mortality in unoperated patients and a good safety of surgery. Pouya Nezafati, Mohammad Hassan Nezafati, and Hamid Hoseinikhah Copyright © 2015 Pouya Nezafati et al. All rights reserved. Intramucosal Signet Ring Cell Gastric Cancer Diagnosed 15 Months after the Initial Endoscopic Examination Mon, 06 Jul 2015 08:10:13 +0000 The size and shape of intramucosal signet ring gastric cancer in this case remained endoscopically unchanged for 15 months. Laparoscopy-assisted distal gastrectomy was performed, and immunohistochemical analysis revealed Ki-67 and p53 mutations to be negative in this case. Signet ring gastric cancer has long been thought to confer a worse prognosis than other forms of gastric cancer; however, our case did not progress to advanced gastric cancer for 15 months. Keisuke Taniuchi, Koji Ookawauchi, Kento Kumon, Tatsuaki Sumiyoshi, Jun Iwata, Mutsuo Furihata, Toshio Nakamura, and Junko Uchiumi Copyright © 2015 Keisuke Taniuchi et al. All rights reserved. Collapsing Focal Segmental Glomerulosclerosis in a Patient with Acute Malaria Sun, 05 Jul 2015 14:04:44 +0000 Introduction. Collapsing focal segmental glomerulosclerosis (FSGS) is most commonly seen in association with HIV infection. Rare data is available about the association between collapsing FSGS and malaria. Case Description. A 72-year-old African male patient presented to the hospital for generalized body aches, fatigue, fever, and night sweats for three days. He had history of recent travel to Ghana. Patient looked in acute distress and was shivering. Laboratory tests showed elevated serum creatinine (Cr) of 2.09 mg/dL (baseline was 1.5 mg/dL in 2012). Hospital course was significant for rapid elevation of Cr to 9.5 mg/dL and proteinuria of 7.9 grams. Autoimmune studies resulted negative. Blood smear resulted positive for Plasmodium falciparum and patient was treated with Artemether/Lumefantrine. Patient’s fever and pain improved, but kidney function continued to deteriorate and he became oliguric. On day seven, he was started on Hemodialysis. Tests for different causes of glomerular pathology were also negative. He underwent left kidney biopsy which resulted in findings consistent with severe collapsing glomerulopathy. Discussion. This case illustrates a biopsy proven collapsing FSGS likely secondary to malarial infection requiring renal replacement therapy. Literature review revealed only few case reports that suggested the possible association of malaria with secondary form of FSGS. Najamus Sehar, Emad Gobran, and Suzanne Elsayegh Copyright © 2015 Najamus Sehar et al. All rights reserved. Exercise-Induced Pulmonary Edema in a Triathlon Thu, 02 Jul 2015 09:55:40 +0000 Introduction. Family physicians have more opportunities to attend athletic competitions as medical staff at first-aid centers because of the increasing popularity of endurance sports. Case. A 38-year-old man who participated in a triathlon race experienced difficulty in breathing after swimming and was moved to a first-aid center. His initial oxygen saturation was 82% and a thoracic computed tomography scan showed bilateral ground glass opacity in the peripheral lungs. His diagnosis was noncardiogenic pulmonary edema associated with exercise or swimming: exercise-induced pulmonary edema (EIPE) or swimming-induced pulmonary edema (SIPE). Treatment with furosemide and corticosteroid relieved his symptoms of pulmonary edema. Discussion. Noncardiogenic pulmonary edema associated with endurance sports is not common, but knowledge about EIPE/SIPE or neurogenic pulmonary edema associated with hyponatremia, which is called Ayus-Arieff syndrome, is crucial. Knowledge and caution for possible risk factors, such as exposure to cold water or overhydration, are essential for both medical staff and endurance athletes. Conclusion. To determine the presence of pulmonary edema associated with strenuous exercise, oxygen saturation should be used as a screening tool at a first-aid center. To avoid risks for EIPE/SIPE, knowledge about these diseases is essential for medical staff and for athletes who perform extreme exercise. Hirotomo Yamanashi, Jun Koyamatsu, Masaharu Nobuyoshi, Kunihiko Murase, and Takahiro Maeda Copyright © 2015 Hirotomo Yamanashi et al. All rights reserved. Lupus-Associated Pulmonary Arterial Hypertension: Variable Course and Importance of Prompt Recognition Thu, 02 Jul 2015 09:13:42 +0000 We describe a critically ill young woman with systemic lupus erythematosus (SLE) presenting with circulatory shock, multiorgan dysfunction, and elevated right-sided heart pressures. She was found to have recurrent acute severe pulmonary arterial hypertension (PAH) in the setting of an SLE flare. Our report highlights the variable course that SLE-associated PAH can take in the same patient and the implications of this for instituting the most effective treatment approach with each episode. This report also highlights the potential for SLE-associated PAH to present with life-threatening symptoms requiring critical care level interventions. We also describe evidence-based therapies, which can result in significant improvement in symptoms, function, and long-term outcomes. Kofi A. Mensah, Rajwardhan Yadav, Terence K. Trow, Cristina M. Brunet, and Wassim H. Fares Copyright © 2015 Kofi A. Mensah et al. All rights reserved. Intravascular Hemolysis and Septicemia due to Clostridium perfringens Emphysematous Cholecystitis and Hepatic Abscesses Wed, 01 Jul 2015 09:10:17 +0000 Context. Clostridium perfringens septicemia is often associated with translocation from the gastrointestinal or gastrourinary tract and occurs in patients who have malignancy or are immunocompromised. Clostridium perfringens septicemia is usually fatal without early identification, source control, and antibiotics. Case. We present a case of a 65-year-old female with Clostridium perfringens septicemia secondary to emphysematous cholecystitis, with progression to hepatic abscesses. Conclusion. Septicemia secondary to Clostridium perfringens is generally fatal if not detected early. Source control with surgery or percutaneous drainage and early antibiotic therapy is imperative. Hyperbaric oxygen therapy may reduce mortality. Clinicians caring for patients with sepsis and intravascular hemolysis must have Clostridium perfringens septicemia on their differential diagnosis with a low threshold for starting antibiotics and pursuing source of infection. Justin Cochrane, Lacie Bland, and Mary Noble Copyright © 2015 Justin Cochrane et al. All rights reserved. Acute Renal Failure Induced by Chinese Herbal Medication in Nigeria Thu, 25 Jun 2015 09:03:37 +0000 Traditional herbal medicine is a global phenomenon especially in the resource poor economy where only the very rich can access orthodox care. These herbal products are associated with complications such as acute renal failure and liver damage with a high incidence of mortalities and morbidities. Acute renal failure from the use of herbal remedies is said to account for about 30–35% of all cases of acute renal failure in Africa. Most of the herbal medications are not usually identified, but some common preparation often used in Nigeria includes “holy water” green water leaves, bark of Mangifera indica (mango), shoot of Anacardium occidentale (cashew), Carica papaya (paw-paw) leaves, lime water, Solanum erianthum (Potato tree), and Azadirachta indica (Neem) trees. We report a rare case of a young man who developed acute renal failure two days after ingestion of Chinese herb for “body cleansing” and general wellbeing. He had 4 sessions of haemodialysis and recovered kidney function fully after 18 days of admission. Effiong Ekong Akpan and Udeme E. Ekrikpo Copyright © 2015 Effiong Ekong Akpan and Udeme E. Ekrikpo. All rights reserved. Bernese Periacetabular Osteotomy in a Hip Extra-Articular Resection Followed by Reconstruction Using an Extracorporeal Irradiated Acetabulum Autograft with Megaprosthesis, for Proximal Femur Osteosarcoma in a Pediatric Patient Thu, 25 Jun 2015 08:13:42 +0000 Osteosarcoma is the most common primary malignant tumour of bone. The oncologic surgery of a proximal femur osteosarcoma affecting the hip joint can be very challenging. We present an 8-year-old boy with a 5-month history of right hip pain. Radiographs and magnetic resonance imaging (MRI) showed a lytic lesion of the proximal femur extending 13 cm to the diaphysis. Histological evaluation was consistent with high-grade osteoblastic osteosarcoma. After completing chemotherapy we performed an extra-articular resection of the hip. Reconstruction was accomplished by reimplanting the acetabulum after irradiation and modular proximal femur megaprosthesis. Endoprosthetic reconstruction following proximal femur resection is a good treatment alternative achieving good postoperative function. Extra-articular resection of the hip using a periacetabular osteotomy technique enabled us to achieve wide margins and leave an intact posterior column to optimize acetabular reconstruction stability. Extracorporeal irradiation and reimplantation is a valuable treatment option in a situation such as this where allograft geometric fit is a priority. We conclude that an extra-articular resection of the hip, followed by reconstruction with an extracorporeally irradiated acetabulum and a proximal femur modular megaprosthesis, is a useful combined treatment option for malignant lesions involving the hip joint, especially in paediatric patients. Victor Barro, Roberto Velez, Daniel Pacha, Jordi Giralt, Isabel Roca, and Marius Aguirre Copyright © 2015 Victor Barro et al. All rights reserved. Hypercalcemia, Anemia, and Acute Kidney Injury: A Rare Presentation of Sarcoidosis Tue, 23 Jun 2015 11:53:23 +0000 We discuss a case of a 61-year-old woman who presented with substernal chest pain. She was found to have elevated calcium levels, anemia, and acute kidney injury. The hypercalcemia persisted despite therapy with fluids and bisphosphonates. She was found to have nonparathyroid hormone (PTH) mediated hypercalcemia. The chest X-ray did not reveal any pathology. Our Initial impression was likely underlying hematologic malignancy such as lymphoma or multiple myeloma. A bone marrow biopsy was performed that revealed nonnecrotizing granulomatous inflammation. Further workup revealed elevated vitamin 1,25 dihydroxy level, beta-two microglobulin level, and ACE levels. Noncontrast computed tomography (CT) scan of chest showed bilateral apical bronchiectasis, but did not show any lymphadenopathy or evidence of malignancy. Subsequently, a fiber optic bronchoscopy with transbronchial biopsy showed nonnecrotizing granulomatous inflammation consistent with sarcoidosis. After initiating glucocorticoid therapy, the patient’s hypercalcemia improved and her kidney function returned to baseline. Neeraj Sharma, Hassan Tariq, Kalpana Uday, Yevgeniy Skaradinskiy, Masooma Niazi, and Sridhar Chilimuri Copyright © 2015 Neeraj Sharma et al. All rights reserved. Myocardial Infarction in a Premenopausal Woman on Leuprolide Therapy Tue, 23 Jun 2015 06:28:04 +0000 Premenopausal women with chest pain syndrome may have nonatherosclerotic coronary arteries with abnormal coronary flow. Estrogens have cardioprotective effect improving coronary vasodilatation. This case report discusses the consequences of leuprolide use by decreasing estrogen levels which led to acute myocardial infarction. Irving E. Perez, Mark A. Menegus, and Cynthia C. Taub Copyright © 2015 Irving E. Perez et al. All rights reserved. Complete Surgical Resection of a Leiomyosarcoma Arising from the Inferior Vena Cava Thu, 18 Jun 2015 07:26:43 +0000 A 76-year-old Japanese man was referred to our hospital with chief complaint of right hypochondoralgia. Abdominal ultrasound showed a retroperitoneal tumor in the suprarenal region of the right kidney. Computed tomography revealed an enhanced lobular tumor with irregular, circumscribed, and indistinct border. Ultrasound-guided biopsy was performed. The tumor consisted of spindle-shaped cells with a giant nucleus and multinuclear cells. The diagnosis was leiomyosarcoma by immunohistochemical staining. The patient underwent surgery accessed by a right eighth intercostal thoracoabdominal incision. The tumor was completely resected, accompanied by removal of the posterosuperior segment of the right hepatic lobe, right adrenal gland, and a portion of the inferior vena cava (IVC). The histopathologic diagnosis was leiomyosarcoma arising from the IVC. We present a rare case of a successfully managed leiomyosarcoma of the IVC. This case suggests the importance of curative surgical resection of the tumor due to low efficacy of adjuvant chemotherapy for leiomyosarcoma. Hirofumi Sonoda, Keisuke Minamimura, Yuhei Endo, Shoichi Irie, Toru Hirata, Takashi Kobayashi, Ken-ichi Mafune, and Masaya Mori Copyright © 2015 Hirofumi Sonoda et al. All rights reserved. Propionibacterium acnes: A Treatable Cause of Constrictive Pericarditis Wed, 17 Jun 2015 13:19:19 +0000 In this case report we share a case of infective Pericarditis caused by Propionibacterium acnes (P. acnes) in an immune-competent, nonsurgical patient. This case and review will illustrate the importance of considering P. acnes as a cause of idiopathic pericardial effusion and effusive constrictive disease. The patient was a 61-year-old male with history of osteoarthritis of the knee. He received an intra-articular steroid injection in July 2013. Two months later, he presented with atrial fibrillation and heart failure. He was found to have pericardial and bilateral pleural effusions which grew P. acnes. This organism was initially considered to be contaminant; however, as P. acnes was isolated from both pleural and pericardial fluids, he was started on oral amoxicillin. He was noted to have recurrence of effusions within 2 weeks with evidence of constrictive physiology by echocardiography. Treatment was subsequently changed to intravenous Penicillin G with marked symptomatic improvement, resolution of pericardial/pleural effusions, and no echocardiographic evidence of constrictive pericarditis at 10 weeks follow-up. Pursuit and treatment of P. acnes could lead to prevention of constrictive pericarditis. We believe that further studies are needed to assess prevalence of P. acnes and response to intravenous Penicillin G in patients presenting with effusive constrictive disease. Daniel Cruz, Haitham Ahmed, Yousuf Gandapur, and M. Roselle Abraham Copyright © 2015 Daniel Cruz et al. All rights reserved. Neuroleptic Malignant Syndrome: A Case Aimed at Raising Clinical Awareness Thu, 11 Jun 2015 14:31:36 +0000 A 60-year-old man with a history of bipolar disorder on risperidone, bupropion, and escitalopram was admitted for community acquired streptococcal pneumonia. Four days later, he developed persistent hyperthermia, dysautonomia, rigidity, hyporeflexia, and marked elevation of serum creatine phosphokinase. He was diagnosed with neuroleptic malignant syndrome (NMS) and improved with dantrolene, bromocriptine, and supportive therapy. This case emphasizes the importance of considering a broad differential diagnosis for fever in the ICU, carefully reviewing the medication list for all patients, and considering NMS in patients with fever and rigidity. Jad Al Danaf, John Madara, and Caitlin Dietsche Copyright © 2015 Jad Al Danaf et al. All rights reserved. Autoresuscitation: A Case and Discussion of the Lazarus Phenomenon Mon, 08 Jun 2015 09:24:25 +0000 Lazarus phenomenon or autoresuscitation is a very rare condition defined as delayed unassisted return of spontaneous circulation after cessation of cardiopulmonary resuscitation. Based on a case with a 67-year-old male who came back to life after discontinuation of cardiopulmonary resuscitation, we discuss the background and possible countermeasures related to the Lazarus phenomenon. Kjartan Eskjaer Hannig, Rasmus Wulff Hauritz, and Erik Lerkevang Grove Copyright © 2015 Kjartan Eskjaer Hannig et al. All rights reserved.