Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Hereditary Hemorrhagic Telangiectasia with Hepatic Vascular Malformations Thu, 21 May 2015 12:05:14 +0000 Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant hereditary disease. Early diagnosis is important to avoid complications from vascular lesions, but diagnosis is difficult in asymptomatic patients. A 69-year-old Japanese male patient was referred to our hospital for evaluation of hepatic vascular malformations. He had mild anemia with iron deficiency, and dynamic contrast-enhanced computed tomography revealed significant arteriovenous and arterioportal shunts throughout the liver. Telangiectasia from the pharynx to the duodenum was confirmed by gastrointestinal endoscopy. The patient history revealed episodes of epistaxis as well as a family history of epistaxis. He was diagnosed with HHT, although no other family member had been diagnosed with definite HHT. A diagnosis of HHT must be considered in patients with hepatic vascular malformations. Yujiro Nishioka, Nobuhisa Akamatsu, Yasuhiko Sugawara, Junichi Kaneko, Junichi Arita, Yoshihiro Sakamoto, Kiyoshi Hasegawa, and Norihiro Kokudo Copyright © 2015 Yujiro Nishioka et al. All rights reserved. Primary Breast Burkitt’s Lymphoma in an HIV-Infected Woman Thu, 21 May 2015 11:47:25 +0000 A 30-year-old HIV positive woman presented with a multifocal mass tumour associated with axillary and lateral-cervical lymphadenopathy in the right breast. Laboratory examination of the biopsy confirmed a case of mammary Burkitt’s lymphoma with a nodular infiltration of the breast. Antiretroviral treatment and chemotherapy were effective to control the tumour. Although Burkitt’s lymphoma rarely involves the breasts, it should be considered during routine breast examination of African woman. Bangaly Traoré, Marie-Eve Fondrevelle, Mamoudou Condé, Catherine Chassagne-Clément, Tidiane Kourouma, Ahmed Monzomba Keita, Moussa Koulibaly, and Bakary Sidiki Sylla Copyright © 2015 Bangaly Traoré et al. All rights reserved. Deep Venous Thrombosis with Pulmonary Embolism Related to IVIg Treatment: A Case Report and Literature Review Tue, 19 May 2015 13:09:03 +0000 IVIg therapy has potentially been related to arterial and venous therapy. We performed an Ovid review focusing on IVIg and thrombotic events. While a few case reports were reviewed case series and case control studies were particularly reviewed in relation to thrombotic events. Outcomes demonstrate a correlation between underlying cardiovascular risk factors with predominately arterial events which typically occurred within 4–24 hours of infusion. While venous events occurred less commonly they were associated with traditional risk factors and occurred later, typically, 1–7 days following infusion of IVIg. Potential causation of thrombotic events was discussed. Michael T. Flannery and Deborah Humphrey Copyright © 2015 Michael T. Flannery and Deborah Humphrey. All rights reserved. Treatment of Refractory Postural Tachycardia Syndrome with Subcutaneous Octreotide Delivered Using an Insulin Pump Tue, 19 May 2015 11:02:19 +0000 Postural Tachycardia Syndrome (PoTS) represents a disorder of the autonomic nervous system that results in symptoms of orthostatic intolerance. Despite having a severe impact on the patient’s quality of life, the current treatment options for PoTS are based on limited evidence. Subsequently, this results in clinicians having to utilise a variety of treatment regimens in the hope of successfully providing symptomatic relief. However, the options available for PoTS are not without significant side effects that can worsen an already debilitating condition. Our cases provide a further novel treatment option for clinicians to consider in PoTS refractory to established treatments. Muhammad Khan, Jing Ouyang, Karen Perkins, John Somauroo, and Franklin Joseph Copyright © 2015 Muhammad Khan et al. All rights reserved. A Case Report of Acute Esotropia in a Young Woman following Heroin Withdrawal Sun, 17 May 2015 12:08:29 +0000 Introduction. Esotropia is a form of strabismus that can give the affected individual a “cross-eyed” appearance. Acute onset of esotropia is an uncommon form; in the vast majority of cases, no underlying neurological etiology is found. Case Presentation. A 22-year-old female with a long history of opiate abuse presented with acute onset of diplopia. She noted her eyes were crossing and started seeing double. She stopped using heroin 11 days prior to presentation. There was large inward deviation of her left eye. Convergence was difficult and accompanied by horizontal nystagmus. Diplopia resolved by covering each eye. Further investigations including imaging studies were normal. Discussion. Acute onset esotropia is rare and must be investigated right away to exclude central nervous system pathologies, where no opiates use is reported. Diplopia in the form of acute esotropia may manifest in up to 30% of individuals undergoing heroin withdrawal. Evaluating acute esotropia requires detailed information of medical history with an emphasis on drug use. Conclusion. Acute onset esotropia with double vision can be caused by abrupt withdrawal of opiates. This case should serve to raise awareness among health care professionals, to avoid costly and unnecessary diagnostic evaluations and interventions. Bethel Shiferaw, Ebisa Bekele, Sara Syed, Lu Fan, Nirav Patel, Samia Qazi, and Nicolas Biro Copyright © 2015 Bethel Shiferaw et al. All rights reserved. Merkel Cell Carcinoma of the Axilla and Adrenal Gland: A Case Report with Imaging and Pathologic Findings Sun, 17 May 2015 11:41:00 +0000 Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine carcinoma of the skin. MCC is characterized by a high incidence of locoregional recurrence, and distant metastasis, and often requires short-term follow-up after treatment. In this present paper, we describe a rare case of MCC, which presented as a palpable axillary mass and an incidental adrenal mass, and report on the ultrasonography, computed tomography, and 18F-fluorodeoxyglucose-positron emission tomography findings. The patient underwent surgery and adjuvant radiation therapy. Seven months after the initial diagnosis, distant metastasis was detected during a follow-up examination. Soo Heui Baek, Hyun Kyung Jung, WooGyeong Kim, Suk Jung Kim, Hye Jin Baek, Seung Ho Kim, Yedaun Lee, and Young Mi Park Copyright © 2015 Soo Heui Baek et al. All rights reserved. An Incarcerated Colon Inguinal Hernia That Perforated into the Scrotum and Exhibited an Air-Fluid Level Wed, 13 May 2015 09:11:06 +0000 There are few reports of a transverse colon inguinal hernia; furthermore, an inguinal hernia perforating the scrotum is rare. Here we report the case of a 79-year-old man who died after developing an incarcerated colon inguinal hernia that perforated the scrotum and exhibited an air-fluid level. The patient was referred to our hospital in November 2011 with a complaint of inability to move. Physical examination revealed an abnormally enlarged left scrotum and cold extremities. He reported a history of gastric cancer that was surgically treated more than 30 years ago. His white blood cell count and C-reactive protein level were elevated. Abdominal and inguinal computed tomography revealed that his transverse colon was incarcerated in the left inguinal canal. Free air and air-fluid level were observed around the transverse colon, suggestive of a perforation. The patient and his family refused any surgical intervention; therefore, he was treated with sultamicillin tosilate hydrate and cefotiam hydrochloride. However, he succumbed to panperitonitis 19 days after admission. The findings from this case indicate that the transverse colon can perforate into an inguinal hernia sac. Seisuke Ota, Toshio Noguchi, Tomoya Takao, Takumi Sakamoto, Yuichiro Kanie, Ken-ichi Omae, Shunji Fujie, Yoshiaki Kanaya, Akinori Kasahara, and Tadashi Matsumra Copyright © 2015 Seisuke Ota et al. All rights reserved. Intoxication due to Papaver rhoeas (Corn Poppy): Five Case Reports Wed, 13 May 2015 06:56:57 +0000 Introduction. In this paper, we aimed to present five Papaver rhoeas intoxication cases, which is very rare in the literature. Case 1. A 35-year-old female patient was admitted to our emergency room with the complaints of nausea, restlessness, and dyspnea developing 3 hours after eating Papaver rhoeas. On physical examination, her general condition was moderate; she was conscious and the vital findings were normal. The pupils were myotic. She was transferred to the toxicology intensive care unit as she experienced a generalized tonic clonic seizure lasting for three minutes. Case 2. A 41-year-old female patient was brought to our emergency room by 112 ambulance as she had contractions in her arms and legs, unconsciousness, and foam coming from her mouth two hours after Papaver rhoeas ingestion. On physical examination, she was confused, the pupils were myotic, and she was tachycardic. Arterial blood gases analysis revealed lactic acidosis. Case 3. A 38-year-old female patient was admitted to our emergency room with complaints of nausea and vomiting two hours after ingestion of Papaver rhoeas. Her physical examination and tests were normal. Case 4. A 34-year-old male patient was admitted to our emergency room with complaints of numbness and loss of power in his arms and legs one hour after Papaver rhoeas ingestion. He was hospitalized at the toxicology intensive care unit for follow-up and treatment. Dyspnea and bradycardia developed on the follow-up. The oxygen saturation without oxygen support was 90%. ECG revealed sinus bradycardia. The cardiac enzymes did not increase. Case 5. A 42-year-old female patient was brought to our emergency room by 112 ambulance with contractions in her arms and legs and unconsciousness two hours after Papaver rhoeas ingestion. On her physical examination, she was confused and the pupils were myotic. Arterial blood gases analysis revealed lactic acidosis. Conclusion. All patients were followed up for a few days and then discharged from the hospital with recovery. Unconscious consumption of Papaver rhoeas leads to a clinical condition resembling morphine intoxication, CNS depression, and epileptic seizures. Yahya Kemal Günaydın, Zerrin Defne Dündar, Bora Çekmen, Nazire Belgin Akıllı, Ramazan Köylü, and Başar Cander Copyright © 2015 Yahya Kemal Günaydın et al. All rights reserved. Rare Case of Aspergillus ochraceus Osteomyelitis of Calcaneus Bone in a Patient with Diabetic Foot Ulcers Tue, 12 May 2015 11:18:31 +0000 Diabetes is the most common metabolic disease in humans. One of the major complications of the disease is foot ulcer that is prone to infection. The most common causes of infection which have been reported in these patients are bacteria and fungi such as Candida, Aspergillus, and Rhizopus species. We report one such rare case with calcaneal osteomyelitis caused by Aspergillus ochraceus in a patient with diabetic foot osteomyelitis. The case was a 68-year-old male with a history of type II diabetes for 2 years. The patient had two ulcers on the right heel bones for the past 6 months with no significant improvement. One of the most important predisposing factors to infectious diseases, especially opportunistic fungal infection, is diabetes mellitus. Aspergillus species can involve bony tissue through vascular system, direct infection, and trauma. Proper and early diagnosis and treatment of diabetic foot infection can reduce or prevent complications, such as osteomyelitis and amputation. The annual examination of feet for skin and nail lesion, sensation, anatomical changes, and vascular circulation can be useful for prevention and control of infection. Farhang Babamahmoodi, Tahereh Shokohi, Fatemeh Ahangarkani, Mojtaba Nabili, Elham Afzalian Ashkezari, and Sosan Alinezhad Copyright © 2015 Farhang Babamahmoodi et al. All rights reserved. A Rare Reason for Pelvic Pain in Pregnancy: Infectious Sacroiliitis Tue, 12 May 2015 09:23:26 +0000 Introduction. Although the incidence of pregnancy-associated sacroiliitis is low, it is associated with significant morbidity and mortality. Timely diagnosis of the disease is confusing due to its nonspecific clinical features. Case. A 28-year-old woman at 34 weeks of gestation with severe pain in her right buttock radiating down the backside of the right thigh was admitted to our hospital. White blood cell (WBC) count and C-reactive protein (CRP) were elevated. The pelvic magnetic resonance imaging (MRI) scan revealed right sacroiliitis. Conclusion. Infectious sacroiliitis should be considered as a differential diagnosis even in low-risk women who present with debilitating pelvic pain in pregnancy and medical treatment should not be delayed. Yasemin Cekmez, Ahmet Göçmen, Oğuz Arslan, Fatih Şanlıkan, and Simge Bağcı Türkmen Copyright © 2015 Yasemin Cekmez et al. All rights reserved. Recurrent Syncope Associated with Lung Cancer Tue, 12 May 2015 07:13:33 +0000 Syncope is an important problem in clinical practice with many possible causes that might be misdiagnosed. We present an unusual case of syncope, which has a normal chest X-ray. Exercise EKG and coronary angioplasty results confirmed the existence of serious coronary heart disease. The patient was treated with coronary stent transplantation. However, scope occurred again and the elevated tumor makers cytokeratin-19-fragment and neuron-specific enolase revealed the bronchogenic carcinoma, which was confirmed by enhanced CT examination. The treatment of carcinoma by chemotherapy was indeed sufficient for prompt elimination of the syncope symptoms. Dingguo Zhang, Liansheng Wang, and Zhijian Yang Copyright © 2015 Dingguo Zhang et al. All rights reserved. Autologous Fat Grafting in the Treatment of Painful Postsurgical Scar of the Oral Mucosa Tue, 12 May 2015 06:36:47 +0000 Background. Persistent pain as a consequence of surgical treatment has been reported for several common surgical procedures and represents a clinical problem of great magnitude. Material and Methods. We describe the case of a 47-year-old female who presented a retractile scar that adhered to deep planes at the upper right of the vestibule due to surgical removal of maxillary exostosis, which determined important pain symptoms extending till the right shoulder during both chewing and rest. We subsequently treated her with autologous fat grafting according to Coleman’s technique. Results. Clinical assessments were performed at 5 and 14 days, 1, 3, and 6 months, and 1 year after surgical procedure. We observed a progressive release of scar retraction together with an important improvement of pain symptoms. Conclusion. The case described widens the possible application of autologous fat grafting on a new anatomical site as buccal vestibule and in one specific clinical setting confirming its promising biological effects. Andrea Lisa, Valeria Summo, Valeria Bandi, Luca Maione, Matteo Murolo, Francesco Klinger, and Marco Klinger Copyright © 2015 Andrea Lisa et al. All rights reserved. Macrophage Activation Syndrome as Onset of Systemic Lupus Erythematosus: A Case Report and a Review of the Literature Thu, 07 May 2015 14:14:33 +0000 Macrophage activation syndrome (MAS) is a potentially fatal condition. It belongs to the hemophagocytic lymphohistiocytosis group of diseases. In adults, MAS is rarely associated with systemic lupus erythematosus, but it also arises as complication of several systemic autoimmune disorders, like ankylosing spondylitis, rheumatoid arthritis, and adult-onset Still’s disease. Several treatment options for MAS have been reported in the literature, including a therapeutic regimen of etoposide, dexamethasone, and cyclosporine. Here we report a case of 42-year-old woman in whom MAS occurred as onset of systemic lupus erythematosus. Guido Granata, Dario Didona, Giuseppina Stifano, Aldo Feola, and Massimo Granata Copyright © 2015 Guido Granata et al. All rights reserved. Spontaneous Bacterial Peritonitis and Henoch-Schönlein Purpura in a Patient with Liver Cirrhosis Thu, 07 May 2015 13:32:17 +0000 Henoch-Schönlein purpura (HSP) is a small vessel systemic vasculitis, predominantly affecting children, characterized by a tetrad of manifestations, specifically palpable purpura, arthralgia, abdominal pain, and renal disease. HSP in the adult population is rare, and no case has been described of HSP in liver cirrhosis with spontaneous bacterial peritonitis (SBP). We present the case of a 58-year-old male with liver cirrhosis, who was subsequently diagnosed with SBP and later HSP. In this patient, the diagnosis of HSP was demonstrated clinically by his palpable purpura, diarrhea, hematuria, and abdominal pain and confirmed pathologically by his renal and skin biopsies demonstrating leukocytoclastic vasculitis and IgA complexes. We believe that this is an example of altered IgA processing in cirrhosis leading to the development of IgA immune complexes and ultimately HSP. The patient additionally had SBP, which may have increased his risk for developing HSP given antigen processing by mucosa-associated lymphoid tissues leading to immune complex deposition, which may not have been effectively cleared in the context of his liver disease. The patient unfortunately died of gastrointestinal hemorrhage, which is unclear to be due to his underlying cirrhosis or a gastrointestinal manifestation of HSP itself. Neil Gupta, Joyce Kim, and Basile Njei Copyright © 2015 Neil Gupta et al. All rights reserved. Disseminated Gastric MALT Lymphoma with Monoclonal Gammopathy, t(11;18)(q21;q21), and Subsequent Development of T-Large Granular Lymphocytic Leukemia: A Case Report and Review of the Literature Wed, 06 May 2015 10:25:39 +0000 Background. Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) is a well-characterized entity that may share clinical and morphological findings with other low-grade non-Hodgkin’s lymphomas. Dissemination of MALT-type lymphoma to bone marrow and peripheral blood simultaneously with the presence of T-large granular cell leukemia (T-LGL) has rarely been reported. Case Presentation. This is the case of a 42-year-old male who presented with a gastric MALT-type lymphoma, disseminated to the bone marrow and the peripheral blood with high serum IgM levels and t(11;18)(q21;q21). The morphological, immunophenotypical and, immunohistochemical studies of the successive bone marrow and peripheral blood samples had revealed the coexistence of two distinct lymphoma cell populations: a B-cell, marginal zone type population expressing CD19, CD20, CD22, CD79b, IgM, and kappa light chain, and a T-large granular cell population, developed after treatment with rituximab expressing CD3, CD8, CD5, CD7, and CD45. Conclusion. Based on the analysis of this unusual case we performed an extensive review of the literature to elucidate the relationship between T-LGL and B-cell lymphomas and to emphasize the importance of paraprotein analysis at diagnosis of gastric MALT lymphoma. Riad Akoum, Wassim Serhal, and Hussein Farhat Copyright © 2015 Riad Akoum et al. All rights reserved. A Rare Cutaneous Adnexal Tumor: Malignant Proliferating Trichilemmal Tumor Mon, 04 May 2015 14:09:44 +0000 Proliferating trichilemmal tumors (PTTs) are neoplasms derived from the outer root sheath of the hair follicle. These tumors, which commonly affect the scalp of elderly women, rarely demonstrate malignant transformation. Although invasion of the tumors into neighboring tissues and being accompanied with anaplasia and necrosis are accepted as findings of malignancy, histological features may not always be sufficient to identify these tumors. The clinical behavior of the tumor may be incompatible with its histological characteristics. Squamous-cell carcinoma should certainly be considered in differential diagnosis because of its similarity in morphological appearance with PTT. Immunostaining for CD34, P53, and Ki-67 is a useful adjuvant diagnostic method that can be used in differential diagnosis aside from morphological findings. In this study, we aimed to present the case of a 52-year-old female patient with clinicopathological features. We reported a low-grade malignant proliferating trichilemmal tumor in this patient and detected no relapse or metastasis in a 24-month period of follow-up. Omer Alici, Musa Kemal Keles, and Alper Kurt Copyright © 2015 Omer Alici et al. All rights reserved. A Case of Diverticular Perforation in a Young Patient with Rheumatoid Arthritis on Methotrexate Wed, 29 Apr 2015 08:05:57 +0000 Background. Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate (MTX), are associated with gastrointestinal toxicity. MTX inhibits dihydrofolate reductase, but it is unclear if polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene predict toxicity. Case. We describe a 33-year-old male with polyarticular rheumatoid arthritis who developed sigmoid diverticular perforation while receiving methotrexate, folic acid, prednisone, and naproxen. He tested heterozygous for the C677T allele MTHFR gene. Discussion. Rheumatoid arthritis and its treatments are associated with increased risk of gastrointestinal disease. In one study, perforation was highest among individuals with concomitant exposure to NSAIDs, nonbiologic DMARDs, and glucocorticoids. Multiple mutations of the MTHFR gene have been identified, but their association with MTX toxicity is unclear. This case adds to a growing body of literature that could help inform the treatment of others in the future. Ian Chang, Carla Guggenheim, and Heather Laird-Fick Copyright © 2015 Ian Chang et al. All rights reserved. Rhabdomyosarcoma of the Upper Lip in an Adult Patient Tue, 21 Apr 2015 12:31:33 +0000 Rhabdomyosarcoma (RMS) is a high-grade, malignant mesenchymal neoplasm. These tumors represent the most common soft tissue sarcomas of children and adolescents. RMS is uncommon on the lip and it is rarely seen in adults. Here, we report a rare case of primary RMS, embryonal type, occurring on the upper lip in a 27-year-old female. Bengu Cobanoglu, Mustafa Simsek, and Serkan Senol Copyright © 2015 Bengu Cobanoglu et al. All rights reserved. Long-Lasting Cranial Nerve III Palsy as a Presenting Feature of Chronic Inflammatory Demyelinating Polyneuropathy Thu, 16 Apr 2015 13:04:22 +0000 We describe a patient with chronic inflammatory demyelinating polyneuropathy (CIDP) in which an adduction deficit and ptosis in the left eye presented several years before the polyneuropathy. A 52-year-old man presented with a 14-year history of unremitting diplopia, adduction deficit, and ptosis in the left eye. At the age of 45 a mild bilateral foot drop and impaired sensation in the four limbs appeared, with these symptoms showing a progressive course. The diagnostic workup included EMG/ENG which demonstrated reduced conduction velocity with bilateral and symmetrical sensory and motor involvement. Cerebrospinal fluid studies revealed a cytoalbuminologic dissociation. A prolonged treatment with corticosteroids allowed a significant improvement of the limb weakness. Diplopia and ptosis remained unchanged. This unusual form of CIDP presented as a long-lasting isolated cranial nerve palsy. A diagnostic workup for CIDP should therefore be performed in those patients in which an isolated and unremitting cranial nerve palsy cannot be explained by common causes. Rossella Spataro and Vincenzo La Bella Copyright © 2015 Rossella Spataro and Vincenzo La Bella. All rights reserved. Prevention of Cerebral Embolism Progression by Emergency Surgery of the Left Atrial Myxoma Tue, 14 Apr 2015 14:09:08 +0000 A 21-year-old woman developed left hemiparesis during work and was hospitalized. Her National Institutes of Health Stroke Scale score was 4. Hyperintense areas in the left basal ganglia, corona radiata, and cortex of the temporal lobe were found by brain diffusion-weighted magnetic resonance imaging, indicating acute cerebral infarction. Echocardiography showed a giant mass of diameter 7 × 4 cm in the left atrium. Therefore, she was diagnosed with cerebral embolism due to a left atrial myxoma. Currently, thrombolytic therapy may continue to be effective because the embolic source may be composed of tumor tissue itself. In case of atrial myxoma, we considered that the use of tPA as emergency treatment in all patients with infarction by atrial myxoma may be questioned. Thus, cardiac tumor extraction was performed the next day after hospitalization without thrombolytic therapy. The excised myxoma measured 7 × 6 × 4 cm. The patient recovered and her neurological symptoms also improved. Furthermore, her National Institutes of Health Stroke Scale score improved to 0. Thirteen days after admission, the patient was discharged from our hospital. Cardiac myxoma is often associated with a high risk of embolic episodes, which emphasizes the need for prompt surgical excision as soon as the diagnosis is confirmed. Syuichi Tetsuka and Kunihiko Ikeguchi Copyright © 2015 Syuichi Tetsuka and Kunihiko Ikeguchi. All rights reserved. Topical and Intranasal Analgesic Therapy in a Woman with Refractory Postherpetic Neuralgia Thu, 09 Apr 2015 12:34:38 +0000 A patient-specific, stepped approach to topical and intranasal analgesic pharmacotherapy was effective in reducing refractory postherpetic neuralgia (PHN) not responding to the current standard of care for PHN. The use of topical analgesic therapy allowed for higher concentrations of medication locally while reducing the likelihood of systemic side effects common to the drugs used. No adverse effects were noted for either topical or intranasal drug therapy. The patient-specific, stepped approach resulted in clinically significant decreases in pain on visual analog scale (VAS), with the use of intranasal ketamine 10% solution and topical gabapentin 6%, ketoprofen 10%, lidocaine 5%, and ketamine 10% cream. Kenneth C. Hohmeier and Lyndsey M. Almon Copyright © 2015 Kenneth C. Hohmeier and Lyndsey M. Almon. All rights reserved. The Challenging Diagnosis of Pancreatic Masses: Not All Tumors Are Cancers Sun, 05 Apr 2015 14:17:47 +0000 In the elderly patients, where biopsy-induced complications could outweigh the benefit, the identification of pancreatic masses is generally referred to as a synonymous of pancreatic cancer and patients are dismissed with no further options than palliative and supportive care. Notwithstanding, not all pancreatic tumors are cancers and therefore alternative diagnoses need to be investigated, especially when patients are unfit for invasive diagnostic procedures. Here, we report a case of an aged patient that was admitted to an internal medicine division for a previously diagnosed pancreatic cancer. The reassessment of the diagnosis has allowed identifying the pancreatic mass as a manifestation of focal pancreatitis in the context of an IgG4-related disease. Accordingly, patient was treated with steroids with rapid clinical improvement. This clinical case suggests that autoimmune diseases should always be considered in the differential diagnosis of pancreatic masses of the elderly. Alessandro Morotti, Dario Gned, Leonardo Di Martino, Gaetano Cristaldi, Anna Alì, Paolo Nicoli, Andrea Veltri, and Angelo Guerrasio Copyright © 2015 Alessandro Morotti et al. All rights reserved. Vertigo as a Predominant Manifestation of Neurosarcoidosis Thu, 02 Apr 2015 09:30:12 +0000 Sarcoidosis is a granulomatous disease of unknown etiology that affects multiple organ systems. Neurological manifestations of sarcoidosis are less common and can include cranial neuropathies and intracranial lesions. We report the case of a 21-year-old man who presented with vertigo and uveitis. Extensive workup including brain imaging revealed enhancing focal lesions. A lacrimal gland biopsy confirmed the diagnosis of sarcoidosis. The patient was initially treated with prednisone, which did not adequately control his symptoms, and then was switched to methotrexate with moderate symptomatic improvement. Our patient had an atypical presentation with vertigo as the predominant manifestation of sarcoidosis. Patients with neurosarcoidosis typically present with systemic involvement of sarcoidosis followed by neurologic involvement. Vertigo is rarely reported as an initial manifestation. This case highlights the importance of consideration of neurosarcoidosis as an entity even in patients that may not have a typical presentation or systemic involvement of disease. Tasnim F. Imran, Sobia Nizami, Igor Eyzner, Neena Mirani, Tanzib Hossain, Robert Fede, and Eugenio Capitle Copyright © 2015 Tasnim F. Imran et al. All rights reserved. Rash with DERMABOND PRINEO Skin Closure System Use in Bilateral Reduction Mammoplasty: A Case Series Wed, 01 Apr 2015 10:37:55 +0000 Background. Bilateral reduction mammoplasty is a common plastic surgery procedure that can be complicated by unfavorable scar formation along incision sites. Surgical adhesives can be utilized as an alternative or as an adjunct to conventional suture closures to help achieve good wound tension and provide an adequate barrier with excellent cosmesis. The recently introduced DERMABOND PRINEO Skin Closure System Skin Closure System combines the skin adhesive 2-octyl cyanoacrylate with a self-adhering polyester-based mesh. Proposed benefits of wound closure with DERMABOND PRINEO Skin Closure System, used with or without sutures, include its watertight seal, easy removal, microbial barrier, even distribution of tension, and reduction in wound closure time. Although allergic reactions to 2-octyl cyanoacrylate have been reported, few allergic reactions to DERMABOND PRINEO Skin Closure System have been noted in the literature. This case series describes three patients who experienced an allergic reaction to DERMABOND PRINEO Skin Closure System after undergoing elective bilateral reduction mammoplasties at our institution to further explore this topic. Methods. Retrospective chart review of bilateral reduction mammoplasty patients who received DERMABOND PRINEO Skin Closure System dressing at our institution was performed. Results. Three patients were identified as having a rash in reaction to DERMABOND PRINEO Skin Closure System after bilateral reduction mammoplasty. All three patients required systemic steroid treatment to resolve the rash. One patient was identified as having a prior adhesive reaction. Conclusions. DERMABOND PRINEO Skin Closure System has demonstrated its efficacy in optimizing scar healing and appearance. However, as we demonstrate these three allergic reactions to DERMABOND PRINEO Skin Closure System, caution must be utilized in its usage, namely, in patients with a prior adhesive allergy and in sites where moisture or friction may be apparent. R. W. Knackstedt, J. A. Dixon, P. J. O’Neill, and F. A. Herrera Copyright © 2015 R. W. Knackstedt et al. All rights reserved. Severe Transient Hyperglycemia in a Prediabetic Patient during Mild Acute Pancreatitis Mon, 30 Mar 2015 12:01:23 +0000 A 30-year-old obese male patient had been diagnosed with diabetes mellitus due to acute hyperglycemia and ketonuria. He also presented with severe hypertriglyceridemia and high levels of serum lipase. He was initially misdiagnosed with type 1 diabetes and treated with insulin for one month. At two months from first presentation, pancreatic antibodies were negative, and the C-peptide level was normal. A1c level was 5.9% without insulin treatment. The association between diabetes mellitus and acute pancreatitis is well established. We reported a case of severe transient hyperglycemia during mild acute pancreatitis in a metabolically ill patient. Aura Diana Reghina, Silvia Craciun, and Simona Fica Copyright © 2015 Aura Diana Reghina et al. All rights reserved. Myotonic Dystrophy-1 Complicated by Factor-V (Leiden) Mutation Mon, 30 Mar 2015 08:15:40 +0000 Objectives. Presence of a factor-V Leiden mutation in a patient with myotonic dystrophy type 1 (DM1) has been reported only once. Here we report the second DM1 patient carrying a factor-V mutation who died from long-term complications of this mutation. Case Report. A 66-year-old DM1 patient with multi-organ-disorder syndrome developed a first deep venous thrombosis (DVT) and consecutive pulmonary embolism (PE) at age 50 y. Acetyl-salicylic acid was given. One year later he experienced a second DVT; that is why phenprocoumon was started. Despite anticoagulation, he experienced a third DVT bilaterally and a second PE bilaterally at 61 y; that is why a vena cava filter was additionally deployed. Despite therapeutic anticoagulation, he experienced a vena cava filter thrombosis at age 62 y. Genetic workup revealed a heterozygous factor-V mutation in addition to a CTG-repeat expansion of 500. As a consequence of PE he developed chronic obstructive pulmonary disease and experienced recurrent pulmonary infections, which were lastly responsible for decease at age 66 y despite intensive care measures. Conclusion. The heterozygous Leiden mutation may severely affect DM1 patients to such a degree that they die from its complications. If DM1 patients present with unusual manifestations, search for causes other than a CTG-repeat expansion is indicated. Josef Finsterer and Claudia Stöllberger Copyright © 2015 Josef Finsterer and Claudia Stöllberger. 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.