Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. A Case of Sarcoidosis of the Central Nervous System and Orbita Wed, 25 Feb 2015 12:13:15 +0000 Sarcoidosis is a multisystemic disease characterized by granulomatous inflammation. Lung or lymph node involvement is common. We present a rare case of sarcoidosis that began with orbital involvement, and a month later, due to insufficient treatment, it involved the central nervous system. A 49-year-old female patient began suffering from swelling in her right eye, redness, ptosis, and limited eye movements two months ago. Gadolinium-enhanced orbital magnetic resonance imaging showed thickening of the lacrimal gland and the right medial rectus muscle. After three weeks of local antibiotic and steroid treatments, her symptoms were resolved. One month ago, the patient reported sudden weakness in her right arm and leg. After laboratory tests and imaging studies, the patient was diagnosed with probable neurosarcoidosis using the Zajicek criteria and treated with prednisone (1 mg/kg/day). Although sarcoidosis frequently presents with lung and lymph node involvement, it is rarely accompanied by orbital involvement. Patients with orbital symptoms may receive a late diagnosis and insufficient central nervous system treatment. Involvement of the central nervous system in sarcoidosis leads to high morbidity and mortality rates. Therefore, early diagnosis and treatment are very important. Metin Mercan, Aslı Akyol, Yahya Karaman, and Hayrunnisa Bolay Copyright © 2015 Metin Mercan et al. All rights reserved. Chin Necrosis as a Consequence of Prone Positioning in the Intensive Care Unit Tue, 24 Feb 2015 06:52:33 +0000 Pressure necrosis of the skin is a rarely reported avoidable complication of prone positioning that can be minimised by active collaboration between care teams. We report a case of pressure necrosis of the chin after prone ventilation in the intensive care setting. Such injuries pose a risk of infection, possible need for surgical intervention, and increased costs to the health care system. Pressure necrosis injuries should be diligently guarded against by the careful selection of support devices, frequent turning, and rigorous skin care to minimise extended external compression, particularly on the face and bony prominences. Daniel Lee John Bunker and Michael Thomson Copyright © 2015 Daniel Lee John Bunker and Michael Thomson. All rights reserved. A Unique Case of Primary Ewing’s Sarcoma of the Cervical Spine in a 53-Year-Old Male: A Case Report and Review of the Literature Mon, 23 Feb 2015 12:09:19 +0000 Extraskeletal Ewing’s sarcoma (EES) is a rare presentation, representing only 15% of all primary Ewing’s sarcoma cases. Even more uncommon is EES presenting as a primary focus in the spinal canal. These rapidly growing tumors often present with focal neurological symptoms of myelopathy or radiculopathy. There are no classic characteristic imaging findings and thus the physician must keep a high index of clinical suspicion. Diagnosis can only be definitively made by histopathological studies. In this report, we discuss a primary cervical spine EES in a 53-year-old man who presented with a two-month history of left upper extremity pain and acute onset of weakness. Imaging revealed a cervical spinal canal mass. After undergoing cervical decompression, histopathological examination confirmed a diagnosis of Ewing’s sarcoma. A literature search revealed fewer than 25 reported cases of primary cervical spine EES published in the past 15 years and only one report demonstrating this pathology in a patient older than 30 years of age . Given the low incidence of this pathology presenting in this age group and the lack of treatment guidelines, each patient’s plan should be considered on a case-by-case basis until further studies are performed to determine optimal evidence based treatment. Marshall T. Holland, Oliver E. Flouty, Liesl N. Close, Chandan G. Reddy, and Matthew A. Howard III Copyright © 2015 Marshall T. Holland et al. All rights reserved. Isolated Rheumatoid Nodules: A Diagnostic Dilemma Mon, 23 Feb 2015 09:03:11 +0000 We present a 27-year-old male with multiple nonpainful soft tissue masses over several metacarpals, bilateral elbows, the left wrist, and both knees since the age of 4. Physical exam was significant for firm, nonmobile, nodular growths over the extensor surfaces of bilateral elbows and knees and on the 2nd and 5th metacarpal phalangeal joints. Laboratory studies revealed an unremarkable rheumatoid factor, negative ANA screening and normal joint radiographs. Differential diagnosis included subcutaneous granuloma annulare (SGA), seronegative rheumatoid nodule, and calcinosis cutis. Biopsy is the only method to distinguish benign rheumatoid nodules from SGA. This case illustrates the importance of biopsy in diagnosis, an awareness of the potential complications, and the need for good follow-up. Michael Gale, Erin Gilbert, and David Blumenthal Copyright © 2015 Michael Gale et al. All rights reserved. Cytomegalovirus Colitis with Common Variable Immunodeficiency and Crohn’s Disease Mon, 23 Feb 2015 08:56:01 +0000 Here we present an eleven-year-old male patient who had been diagnosed with common variable immunodeficiency (CVID) three years ago due to recurrent sinopulmonary infections. Two years later he had been diagnosed with Crohn’s disease (CD) due to diarrhea episodes which were unresponsive to the treatment. Depending on the active gastrointestinal bleeding and perforation he underwent total colectomy. Despite immunoglobulin and antiviral therapies, general condition of patient deteriorated and he died in the postoperative seventh day. Laboratory analysis was seronegative. CMV inclusion containing cells were detected in postmortem biopsies taken from liver, lungs, and lymph nodes. Betül Ünal, Cumhur İbrahim Başsorgun, Sinem Çil Gönülcü, Aslı Uçar, Fatih Çelik, and Gülsüm Özlem Elpek Copyright © 2015 Betül Ünal et al. All rights reserved. Daisaikoto for Menstrual Pain: A Lesson from a Case with Menstrual Pain Successfully Treated with Daisaikoto Sun, 22 Feb 2015 12:14:29 +0000 Menstrual pain is one of the common symptoms among women. It is estimated that 5–14% of women are sometimes absent from school or work because of pain. Usually gynecologists prescribe analgesics and/or low-dose oral contraceptives. However, such treatment is not always effective and sometimes causes an adverse effect, such as stomach pain or low body temperature. Kampo medicine is one of the choices for the menstrual pain in Japan. Tokishakuyakusan, kamishoyosan, or keishibukuryogan is commonly used for the treatment of menstrual pain. Here we report a case of menstrual pain successfully treated with daisaikoto which is not commonly used for such a case. Twenty-five-year-old woman suffered from severe menstrual pain and stress at company. She also had constipation and abdominal distension. We prescribed daisaikoto extract 7.5 g per day. Not only menstrual pain but also constipation and abdominal distension improved within 6 months. Here we propose that daisaikoto is one of the choices for the treatment of menstrual pain with mental stress. Yuko Horiba, Tetsuhiro Yoshino, and Kenji Watanabe Copyright © 2015 Yuko Horiba et al. All rights reserved. Nightmare-Induced Atypical Midventricular Tako-Tsubo Cardiomyopathy Thu, 19 Feb 2015 11:37:36 +0000 Tako-Tsubo cardiomyopathy (TTC) is a reversible cardiomyopathy characterized by acute left ventricular segmental dysfunction, whose clinical presentation resembles that of acute myocardial infarction. The syndrome often follows a psychophysical stressful event and is characterized by echocardiographic evidence of akinesia of the left ventricular mid-apical segments. Atypical echocardiographic patterns of TTC have recently been described, often triggered by emotional stressors, rather than physical. In this report, we describe a case of atypical TTC triggered by an unusual stressor (recurrent nightmare) in a 45-year-old woman, with peculiar clinical presentation and evolution characterized by persistent loss of consciousness, neurological deterioration, absence of typical symptoms of TTC, and features suggestive of a hysterical crisis. Veronica Fibbi, Piercarlo Ballo, Marco Nannini, Lorenzo Consoli, Tania Chechi, Andrea Bribani, Francesca Fiorentino, Leandro Chiodi, and Alfredo Zuppiroli Copyright © 2015 Veronica Fibbi et al. All rights reserved. How to Be 80 Year Old and Have a VO2max of a 35 Year Old Wed, 18 Feb 2015 14:33:51 +0000 Background. To discuss the cardiovascular and pulmonary physiology and common risk factors of an 80-year-old man with a world record maximal oxygen uptake of 50 mL·kg−1·min−1. Methods. Case report. Results. His maximal oxygen uptake of 3.31 L·min−1, maximal heart rate of 175 beats·min−1, and maximal oxygen pulse of 19 mL·beats−1 are high. He is lean (66.6 kg) and muscular (49% skeletal muscle mass). His echo parameters of mitral flow (left ventricular filling, E = 82 cm·s−1 and E/A = 1.2) were normal for 40- to 60-year-old men. Systolic and diastolic function increased adequately during exercise, with no increase in left ventricular filling pressure. He has excellent pulmonary function (FVC = 4.31 L, FEV1 = 3.41, FEV1/FVC = 0.79, and DLCO = 12.0 Si1) and normal FMD and blood volumes (5.8 L). He has a high level of daily activity (10,900 steps·day−1 and 2:51 hours·day−1 of physical activity) and a lifelong history of physical activity. Conclusion. The man is in excellent cardiopulmonary fitness and is highly physically active. His cardiac and pulmonary functions are above expectations for his age, and his V is comparable to that of an inactive 25-year-old and of a normal, active 35-year-old Norwegian man. Trine Karlsen, Ingeborg Megård Leinan, Fredrik Hjulstad Bækkerud, Kari Margrethe Lundgren, Atefe Tari, Sigurd Loe Steinshamn, Asbjørn Støylen, and Øivind Rognmo Copyright © 2015 Trine Karlsen et al. All rights reserved. Acute Retinal Pigment Epitheliitis: Spectral Domain Optical Coherence Tomography, Fluorescein Angiography, and Autofluorescence Findings Thu, 12 Feb 2015 09:37:52 +0000 A 17-year-old presented with central and paracentral scotomas in his right eye for one week. There was no remarkable medical or ocular history. Blood analyses were within normal range. At presentation both eyes’ best-corrected visual acuities were 20/20. Slit-lamp examination result was normal. Fundus examination revealed yellow-white hypopigmented areas in the macula. Fluorescein angiography (FA) showed hypofluorescence surrounded by ring of hyperfluorescence. Fundus autofluorescence (FAF) was slightly increased. Spectral domain optical coherence tomography (SD-OCT) showed disruption of IS/OS junction with expansion of abnormal hyperreflectivity from retinal pigment epithelium to the outer nuclear layer (ONL). One month later fundus examination showed disappearance of the lesions. FA revealed transmission hyperfluorescence. FAF showed increased autofluorescence and pigment clumping. Hyperreflective band in SD-OCT disappeared. Loss of photoreceptor segment layers was observed in some of the macular lesions. The diagnosis of acute retinal pigment epitheliitis can be challenging after disappearance of fundus findings. FA, FAF, and SD-OCT are important tests for diagnosis after resolution of the disease. Tuğba Aydoğan, Esra Güney, Betül İlkay Sezgin Akçay, Tahir Kansu Bozkurt, Cihan Ünlü, and Ahmet Ergin Copyright © 2015 Tuğba Aydoğan et al. All rights reserved. Common Atrium: A Rare Cause of Acute Decompensated Heart Failure Wed, 11 Feb 2015 12:59:44 +0000 We report a rare case of common atrium and acute decompensated heart failure most likely precipitated by acute bacterial pericarditis leading to premature death, in a 25-year-old male footballer. The silent course of the disease for decades as well as the diagnostic and management pitfalls of this case illustrates the importance of early detection by echocardiography and urgent appropriate treatment in intensive care settings to limit the poor prognosis of the condition. K. M. Karaye, S. A. Balarabe, M. M. Yakasai, I. M. Suleiman, H. Saidu, and Aimé Bonny Copyright © 2015 K. M. Karaye et al. All rights reserved. Vomiting-Induced Gastric Emphysema and Hepatoportal Venous Gas: A Case Report and Review of the Literature Wed, 11 Feb 2015 09:58:27 +0000 Gastric pneumatosis is the presence of air within the wall of the stomach. It represents a spectrum of conditions ranging from benign disease to septic shock and death. Etiopathologically, it can be classified into emphysematous gastritis or gastric emphysema (GE). Along with hepatoportal venous gas (HPVG), it was considered as an ominous radiological sign and warranted an emergent surgical exploration; however, with widespread use of computerized tomographic (CT) scan, an increasing number of benign causes of GE and HPVG have been reported in the literature, where patients can be managed by noninvasive and conservative measures. We hereby describe a case where recurrent episodes of vomiting led to development of GE and HPVG and the patient was managed successfully by conservative measures. Malav P. Parikh, Muhammed Sherid, Venu Ganipisetti, Venu Gopalakrishnan, Maria Habib, and Monika Tripathi Copyright © 2015 Malav P. Parikh et al. All rights reserved. Clozapine-Induced Late Agranulocytosis and Severe Neutropenia Complicated with Streptococcus pneumonia, Venous Thromboembolism, and Allergic Vasculitis in Treatment-Resistant Female Psychosis Tue, 10 Feb 2015 13:10:04 +0000 Clozapine is a second-generation antipsychotic agent from the benzodiazepine group indicated for treatment-resistant schizophrenia and other psychotic conditions. Using clozapine earlier on once a case appears to be refractory limits both social and personal morbidity of chronic psychosis. However treatment with second-generation antipsychotics is often complicated by adverse effects. We present a case of a 33-year-old Caucasian woman with a 25-year history of refractory psychotic mania after switching to a 2-year clozapine therapy. She presented clozapine-induced absolute neutropenia, agranulocytosis, which were complicated by Streptococcus pneumonia and sepsis. Clozapine-induced thromboembolism of the common femoral and right proximal iliac vein, as well as allergic vasculitis, was diagnosed. She achieved full remission on granulocyte-colony stimulating factor and specific antibiotic treatment. Early detection of severe clozapine-induced absolute neutropenia and agranulocytosis enabled the effective treatment of two among its most severe complications. Additional evidence to the previously reported possible causal relation between clozapine and venous thromboembolism is offered. Finally, clozapine-induced allergic vasculitis is confirmed as a late adverse effect of clozapine therapy. Christina Voulgari, Raphael Giannas, Georgios Paterakis, Anna Kanellou, Nikolaos Anagnostopoulos, and Stamata Pagoni Copyright © 2015 Christina Voulgari et al. All rights reserved. Bilateral Psoas Muscle Abscess Associated with Emphysematous Cystitis Tue, 10 Feb 2015 06:14:34 +0000 Psoas muscle abscess associated with emphysematous urinary tract infection is very rare. There were very few reports about urinary tract infections such as renal abscess, perinephric abscess, and emphysematous pyelonephritis complicated with psoas muscle abscess; however, psoas muscle abscess associated with emphysematous cystitis has not yet been reported. Here, we report a case of bilateral posas muscle abscess following emphysematous cystitis in an 81-year-old nondiabetic man, who was treated successfully with prolonged antibiotic therapy and supportive care. Early recognition of psoas muscle abscess can prevent aggressive interventional procedure and warrant good prognosis. Jae-Ki Choi and Jae-Cheol Kwon Copyright © 2015 Jae-Ki Choi and Jae-Cheol Kwon. All rights reserved. Antiphospholipid Syndrome in a Pregnant Female Presenting with Severe Thrombocytopenia and Bleeding Thu, 05 Feb 2015 06:10:03 +0000 The antiphospholipid antibody syndrome (APS) is defined by the persistent presence of antiphospholipid antibodies in patients with recurrent venous or arterial thromboembolism or pregnancy morbidity. Antithrombotic therapy is the mainstay of treatment given the high risk of recurrent thromboembolism that characterizes this condition. Despite the prothrombotic nature of APS, thrombocytopenia is present in a proportion of patients, which can complicate management and limit the use of antithrombotic therapy. The mechanism of APS-associated thrombocytopenia is multifactorial and its relation to thrombotic risk is poorly characterized. The presence of thrombocytopenia does not appear to reduce thrombotic risk in patients with APS, who can develop thromboembolic complications necessitating antithrombotic treatment. In these cases, treatment of the thrombocytopenia may be necessary to facilitate administration of antithrombotic agents. We present such a pregnant lady with history of recurrent pregnancy losses who presented with severe thrombocytopenia and bleeding manifestations, who was subsequently diagnosed to have antiphospholipid antibody syndrome. She was initially managed with steroids and when her platelet counts improved, antithrombotic therapy was started. She delivered an uneventful and successful pregnancy outcome without any complications during follow-up. Kunal Mahajan, Virender Katyal, Suvrat Arya, and Meha Shrama Copyright © 2015 Kunal Mahajan et al. All rights reserved. Giant Congenital Melanocytic Nevi and Neurocutaneous Melanosis Wed, 04 Feb 2015 06:37:38 +0000 Introduction. The major medical concern with giant congenital melanocytic nevi CMN is high risk of developing cutaneous melanoma, leptomeningeal melanoma, and neurocutaneous melanocytosis. Case Report. A 30-year-old woman with a giant congenital melanocytic nevus covering nearly the entire right thoracodorsal region and multiple disseminated melanocytic nevi presented with neurological symptoms. Cerebral magnetic resonance imaging revealed a large expansive lesion in the left frontal region. Postsurgically pathological diagnosis revealed characteristics of melanoma. Immunohistochemical examination showed S100(+), HMB45(+), MelanA(+), and MiTF(+). She received radiotherapy with temozolomide followed by two more chemotherapy cycles with temozolomide. She followed a rapidly progressive course, reflecting widespread leptomeningeal infiltration, and she died of multiorgan failure seven months after diagnosis of cerebral melanoma. Discussion. This patient was diagnosed as having a neurocutaneous melanosis with malignant widespread leptomeningeal infiltration. Diffuse spinal involvement is unusual and is described in only another patient. Catarina Araújo, Cristina Resende, Francisco Pardal, and Celeste Brito Copyright © 2015 Catarina Araújo et al. All rights reserved. Metastatic Malignant Melanoma of the Inguinal Lymph Node with Unknown Primary Lesion Sun, 01 Feb 2015 11:15:31 +0000 Background. Malignant melanoma could present with metastasis with unknown primary (MUP) and this happens in 2-3% according to the studies. Around 90% of melanomas have cutaneous origin, but still there are melanomas that could be found in visceral organs or lymph nodes with unknown primary site. Spontaneous regression of the primary site could be an explanation. Case Report. We report a 58-year-old Caucasian male who presented with a right sided swelling in the inguinal region. Surgery was performed and biopsy showed metastatic malignant melanoma. No cutaneous lesions were identified by history or physical examination. Work up could not detect the primary lesion and patient was started on radiotherapy and immunotherapy. Conclusion. We present a case of malignant melanoma of unknown primary presenting in an unusual place which is the inguinal lymph node. Theories try to explain the pathway of development of such tumors and one of the theories mentions that it could be a spontaneous regression of the primary cutaneous lesion. Another theory is that it could be from transformation of aberrant melanocyte within the lymph node. Prognosis is postulated to be better in this case than in melanoma with a known primary. Sherif Ali Eltawansy, Ryane Panasiti, Samaa Hasanien, Dennis Lourdusamy, and David Sharon Copyright © 2015 Sherif Ali Eltawansy et al. All rights reserved. Successful and Safe Treatment of Chronic Spontaneous Urticaria with Omalizumab in a Woman during Two Consecutive Pregnancies Thu, 29 Jan 2015 10:11:49 +0000 Chronic spontaneous urticaria is an itching skin disease characterised by wheals, angioedema, or both present for more than six weeks. Omalizumab is a humanized anti-IgE monoclonal antibody recently approved for treatment of chronic urticaria. Several randomised controlled trials have investigated the safety, tolerability, and efficacy of omalizumab for chronic urticaria. The safety of omalizumab in pregnancy is not known. We describe a female patient with chronic spontaneous urticaria who was treated with omalizumab continuously through two consecutive pregnancies with convincing results and no apparent toxicity. Misbah Nasheela Ghazanfar and Simon Francis Thomsen Copyright © 2015 Misbah Nasheela Ghazanfar and Simon Francis Thomsen. All rights reserved. An Unusual Occurrence of Hepatic Granulomas and Secondary Sitosterolemia in Turner Syndrome Thu, 29 Jan 2015 10:11:35 +0000 Although abnormal liver function tests occur in 50–80% of cases with Turner syndrome, there are no previous reports of overt hepatic disease or hepatic granulomas associated with Turner’s syndrome. We report three cases of Turner syndrome associated with hepatic granulomas with a wide range of liver dysfunction. Of the three patients, first patient underwent liver transplantation; second patient remained stable on immunosuppressants; and third patient died from complications of decompensated liver cirrhosis as she declined liver transplantation due to multiple comorbidities. One patient had sitosterolemia, a rare inherited autosomal recessive disorder of cholesterol metabolism, after she ingested β-sitosterol supplement and had worsening liver function tests and lipid panel. She had remarkably abnormal lipid panel that responded to ezetimibe and by stopping the β-sitosterol supplement. JayaKrishna Chintanaboina, Pragnesh R. Shah, and Thomas R. Riley III Copyright © 2015 JayaKrishna Chintanaboina et al. All rights reserved. Sinus Venosus Atrial Septal Defect as a Cause of Palpitations and Dyspnea in an Adult: A Diagnostic Imaging Challenge Thu, 29 Jan 2015 06:29:50 +0000 Sinus venosus atrial septal defects (SV-ASD) have nonspecific clinical presentations and represent a diagnostic imaging challenge. Transthoracic echocardiography (TTE) remains the initial diagnostic imaging modality. However, detection rates have been as low as 12%. Transesophageal echocardiography (TEE) improves diagnostic accuracy though it may not detect commonly associated partial anomalous pulmonary venous return (PAPVR). Cardiac magnetic resonance (CMR) imaging provides a noninvasive, highly sensitive and specific imaging modality of SV-ASD. We describe a case of an adult male with exercise-induced, paroxysmal supraventricular tachycardia who presented with palpitations and dyspnea. Despite nondiagnostic imaging results on TTE, CMR proved to be instrumental in visualizing a hemodynamically significant SV-ASD with PAPVR that ultimately led to surgical correction. Michael S. Donovan, David Kassop, Robert A. Liotta, and Edward A. Hulten Copyright © 2015 Michael S. Donovan et al. All rights reserved. Cutaneous and Gastrointestinal Symptoms in Two Patients with Systemic Mastocytosis Successfully Treated with Omalizumab Wed, 28 Jan 2015 11:45:22 +0000 The pathogenesis of mastocytosis is not well defined and thus treatment remains challenging and remains on a palliative basis. We present two cases (a 48-year-old woman and a 57-year-old man) with indolent systemic mastocytosis in whom omalizumab (anti-IgE) reduced gastrointestinal and cutaneous symptoms significantly. This observation provides additional insight into the effects of omalizumab on systemic mastocytosis. Sofie Lieberoth and Simon Francis Thomsen Copyright © 2015 Sofie Lieberoth and Simon Francis Thomsen. All rights reserved. Fatal Retroperitoneal Bleeding Caused by Neurofibromatosis: A Case Report and Review of the Literature Mon, 26 Jan 2015 09:02:37 +0000 A young female was brought into the emergency department with pulseless electrical activity (PEA) after local resection of neurofibromateous lesions. Chest ultrasonography was normal. Abdominal ultrasonography was not performed. After successful resuscitation a total body CT-scan was performed to rule out potential bleeding sources. However, haemodynamic instability reoccurred and the scan had to be aborted at the thoracoabdominal level. No thoracic abnormalities were found. Resuscitation was reinitiated and abdominal ultrasonography was performed, showing a large amount of abdominal fluid. A progressive fall in haemoglobin was noted. Emergency laparotomy was performed, revealing a large retroperitoneal haematoma. Despite ligation and packing, bleeding continued. Postoperative angiography showed active bleeding from a branch of the left internal iliac artery, which could be successfully coiled. Unfortunately, the patient died five days later due to irreversible brain damage. Revision of an MRI scan made one year earlier showed a 10 cm large retroperitoneal neurofibromatous lesion exactly at the location of the current bleeding. This case shows that patients with neurofibromatosis might develop spontaneous life-threatening bleeding from retroperitoneal located lesions. Furthermore, it points out the necessity of focused assessment with ultrasonography of the abdomen in all patients with PEA of unknown origin. Patrick R. Moerbeek, Jesse M. van Buijtenen, Baukje van den Heuvel, and Arjan W. J. Hoksbergen Copyright © 2015 Patrick R. Moerbeek et al. All rights reserved. Giant Polypoid Tumor Expressing on the Pyloric Ring Thu, 22 Jan 2015 06:39:51 +0000 A 66-year-old Japanese man was referred to our hospital because of suspected duodenal cancer. Upper gastric endoscopy revealed a giant polypoid-type tumor that extended from the duodenum bulb to the pyloric ring. A computed tomography scan revealed a slightly enhanced lobular tumor protruding into the duodenum bulb. Positron emission tomography showed an accumulation of 18F-fluorodeoxyglucose in the area extending from the antrum of the stomach to the duodenum bulb. Since an endoscopic ultrasound test suggested that the tumor might invade the muscular tunic, indications of endoscopic mucosal resection were not favored, and the tumor was curatively removed via distal gastrectomy. The histopathologic diagnosis was papillary adenocarcinoma, and the invasion depth was the mucosal layer without vascular invasion, which was different from the preoperative diagnosis. Our case suggests the difficulties in precise diagnosis of the invasion depth of the giant polypoid cancer. Hirofumi Sonoda, Takashi Kobayashi, Yuhei Endo, Shoichi Irie, Toru Hirata, Keisuke Minamimura, Ken-ichi Mafune, and Masaya Mori Copyright © 2015 Hirofumi Sonoda et al. All rights reserved. A Case of IFAP Syndrome with Severe Atopic Dermatitis Wed, 21 Jan 2015 11:15:01 +0000 Introduction. The IFAP syndrome is a rare X-linked genetic disorder characterized by the triad of follicular ichthyosis, atrichia, and photophobia. Case Report. A three-month-old Caucasian, male patient was observed with noncicatricial universal alopecia and persistent eczema from birth. He had dystrophic nails, spiky follicular hyperkeratosis, and photophobia which became apparent at the first year of life. Short stature and psychomotor developmental delay were also noticed. Histopathological examination of skin biopsy on left thigh showed epidermis with irregular acanthosis, lamellar orthokeratotic hyperkeratosis, and hair follicles fulfilled by parakeratotic hyperkeratosis. The chromosomal study showed a karyotype 46, XY. Total IgE was 374 IU/mL. One missense mutation c.1360G>C (p.Ala454Pro) in hemizygosity was detected on the MBTPS2 gene thus confirming the diagnosis of IFAP syndrome. Conclusions. We describe a boy with a typical clinical presentation of IFAP syndrome and severe atopic manifestations. A novel missense mutation c.1360G>C (p.Ala454Pro) in MBTPS2 gene was observed. The phenotypic expression of disease is quantitatively related to a reduced function of a key cellular regulatory system affecting cholesterol and endoplasmic reticulum homeostasis. It can cause epithelial disturbance with failure in differentiation of epidermal structures and abnormal skin permeability barrier. However, no correlation phenotype/genotype could be established. Catarina Araújo, Miguel Gonçalves-Rocha, Cristina Resende, Ana Paula Vieira, and Celeste Brito Copyright © 2015 Catarina Araújo et al. All rights reserved. Acute Obstructive Suppurative Pancreatic Ductitis in an Asymptomatic Patient Tue, 20 Jan 2015 11:23:21 +0000 Acute obstructive suppurative pancreatic ductitis (AOSPD), defined as suppuration from the pancreatic duct without associated pseudocyst, abscess, or necrosis, is a rare complication of chronic pancreatitis. We present the first case of AOSPD in an asymptomatic patient with a polymicrobial infection and review the literature on this rare clinical entity. Eisha Wali, Patrick Koo, and Clifford D. Packer Copyright © 2015 Eisha Wali et al. All rights reserved. Recurrent Syncope Attributed to Left Main Coronary Artery Severe Stenosis Thu, 15 Jan 2015 11:22:01 +0000 Patients with acute coronary syndrome (ACS) rarely manifest as recurrent syncope due to malignant ventricular arrhythmia. We report a case of a 56-year-old Chinese male with complaints of paroxysmal chest burning sensation and distress for 2 weeks as well as loss of consciousness for 3 days. The electrocardiogram (ECG) revealed paroxysmal multimorphologic ventricular tachycardia during attack and normal heart rhythm during intervals. Coronary angiograph showed 90% stenosis in left main coronary artery and 80% stenosis in anterior descending artery. Two stents sized  mm and  mm were placed at left main coronary artery and anterior descending artery, respectively, during percutaneous coronary intervention (PCI). The patient was discharged and never had ventricular arrhythmia again during a 3-month follow-up since the PCI. This indicated that ventricular tachycardia was correlated with persistent severe myocardial ischemia. Coronary vasospasm was highly suspected to be the reason of the sudden attack and acute exacerbation. PCI is recommended in patients with both severe coronary artery stenosis and ventricular arrhythmia. Removing myocardial ischemia may stop or relieve ventricular arrhythmia and prevent cardiac arrest. Min Li, Xinyi Zheng, Hua Liu, and Yujie Liu Copyright © 2015 Min Li et al. All rights reserved. The Incidental Finding of a Persistent Left Superior Vena Cava: Implications for Primary Care Providers—Case and Review Tue, 06 Jan 2015 11:16:40 +0000 Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and is a persistent congenital remnant of the vena caval system from early cardiac development. Patients with congenital anomalous venous return are at increased risk of developing various cardiac arrhythmias, due to derangement of embryologic conductive tissue during the early development of the heart. Previously this discovery was commonly made during the placement of pacemakers or defibrillators for the treatment of the arrhythmias, when the operator encountered difficulty with proper lead deployment. However, in today’s world of various easily obtainable imaging modalities, PLSVC is being discovered more and more by primary care providers during routine testing or screening for other ailments. Given the known association between anomalous venous return and the propensity for cardiac arrhythmias, we review the embryology of PLSVC and the mechanisms by which it leads to conduction abnormalities. We also provide the practitioner with recommendations for certain baseline cardiac observations and suggestions for proper surveillance in hopes that better understanding will reduce unnecessary and potentially harmful testing, premature subspecialty referral, and unneeded patient anxiety. Loren Garrison Morgan, Jonathan Gardner, and Joe Calkins Copyright © 2015 Loren Garrison Morgan et al. All rights reserved. Neurocognitive Rehabilitation in Parkinson’s Disease with Motor Imagery: A Rehabilitative Experience in a Case Report Tue, 06 Jan 2015 10:01:24 +0000 A 50-year-old female with Parkinson’s disease underwent a neurocognitive rehabilitation program consisting of one-hour-lasting sessions attended twice a week for three months. The balance and the risk of falls were determined using the Tinetti Balance and Gait Evaluation Scale. The pain was determined using the Visual Analog Scale and the course of the disease was examined using the Unified Parkinson’s Disease Rating Scale (UPDRS). Endpoints were before the treatment, at the end of the treatment, and at a 12-week follow-up. The aim of this study is to evaluate the efficacy of neurocognitive rehabilitation in PD with motor imagery. Primary outcome is the improvement in balance and the falls risk reduction; secondary outcome is lower limb pain reduction. Federico Zangrando, Giulia Piccinini, Andrea Pelliccioni, Vincenzo Maria Saraceni, and Teresa Paolucci Copyright © 2015 Federico Zangrando et al. All rights reserved. Preservation of the External Jugular Vein in Bilateral Radical Neck Dissections: Technique in Two Cases and Review of the Literature Tue, 06 Jan 2015 09:01:36 +0000 Context. The possibility of cephalic venous hypertension with the resultant facial edema and elevated cerebrospinal fluid pressure continues to challenge head and neck surgeons who perform bilateral radical neck dissections during simultaneous or staged procedures. Case Report. The staged procedure in patients who require bilateral neck dissections allows collateral venous drainage to develop, mainly through the internal and external vertebral plexuses, thereby minimizing the risks of deleterious consequences. Nevertheless, this procedure has disadvantages, such as a delay in definitive therapy, the need for a second hospitalization and anesthesia, and the risk of cutting lymphatic vessels and spreading viable cancer cells. In this paper, we discuss the rationale and feasibility of preserving the external jugular vein. Considering the limited number of similar reports in the literature, two cases in which this procedure was accomplished are described. The relevant anatomy and technique are reviewed and the patients’ outcomes are discussed. Conclusion. Preservation of the EJV during bilateral neck dissections is technically feasible, fast, and safe, with clinically and radiologically demonstrated patency. Rodrigo Lima Bastos da Rocha, André Del Negro, Alfio José Tincani, Maíra Soliani Del Negro, and Antonio Santos Martins Copyright © 2015 Rodrigo Lima Bastos da Rocha et al. All rights reserved. Isolated Splenic Tuberculosis without Any Radiological Focal Lesion Tue, 06 Jan 2015 07:02:09 +0000 Incidence of tuberculosis (TB) of spleen is a rare entity and isolated splenic tuberculosis is an unusual phenomenon, especially in immunocompetent individuals. We came across a case of 63-year-old male who presented with high grade fever, loss of weight, and generalized weakness of one-month duration. When physically examined, he had pallor and moderate nontender splenomegaly without any other significant clinical findings. He had pancytopenia, elevated ESR, and positive Mantoux test. Ultrasonography and CT scan of abdomen showed splenomegaly without any other relevant findings. Markers of connective tissue disorders and bone marrow aspiration and biopsy all were noncontributory for diagnosis. Hence splenic biopsy was done and sent for histopathological examination. Presence of caseation surrounded by epitheloid granulomas and Langerhans cells was suggestive of diagnosis as tuberculosis. And gene probe for the AFB (acid fast bacilli) came to be positive. No primary focus was present in either lungs or other organs. Patient improved clinically with antitubercular treatment. Sunil Raviraj, A. Gogia, A. Kakar, and S. P. Byotra Copyright © 2015 Sunil Raviraj et al. All rights reserved. Management of Six Root Canals in Mandibular First Molar Mon, 05 Jan 2015 09:07:00 +0000 Success in root canal treatment is achieved after thorough cleaning, shaping, and obturation of the root canal system. This clinical case describes conventional root canal treatment of an unusual mandibular first molar with six root canals. The prognosis for endodontic treatment in teeth with abnormal morphology is unfavorable if the clinician fails to recognize extra root canals. Claudio Maniglia-Ferreira, Fabio de Almeida Gomes, and Bruno Carvalho Sousa Copyright © 2015 Claudio Maniglia-Ferreira et al. All rights reserved.