Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. AREDS Formula, Warfarin, and Bleeding: A Case Report from the Michigan Anticoagulation Quality Improvement Initiative Thu, 28 Aug 2014 00:00:00 +0000 Importance. The anticoagulant warfarin has been shown to interact with other medications, vitamin K containing foods, and over-the-counter products. These interactions may inhibit or potentiate the effect of warfarin, resulting in serious clotting or bleeding events. Observations. We report the case of an 84-year-old woman with atrial fibrillation, prescribed warfarin in May 2010 for stroke prevention. Her international normalized ratio (INR) was stable until April 2013, when she was prescribed AREDS (Age Related Eye Disease Study) formula pills, an eye vitamin compound, to slow the progression of age-related macular degeneration. This change was not reported to the Anticoagulation Service. Eighteen days later, she presented to the ED with groin and back pain and an INR of 10.4. An abdominal CT revealed a retroperitoneal hemorrhage with extension in multiple muscles. Both warfarin and AREDS were discontinued and the patient was discharged to subacute rehabilitation. This case was reviewed by the Anticoagulation Service and actions were taken to prevent similar adverse events. Conclusions. This report provides an example of the potential danger of supplement use, in this case, AREDS formula, in patients prescribed warfarin, and the importance of communicating medication changes to the providers responsible for warfarin management. Eric Puroll, Steven T. Heidt, Brian Haymart, James B. Froehlich, and Eva Kline-Rogers Copyright © 2014 Eric Puroll et al. All rights reserved. Stump Cholecystitis: Laparoscopic Completion Cholecystectomy with Basic Laparoscopic Equipment in a Resource Poor Setting Thu, 21 Aug 2014 13:17:53 +0000 Introduction. Stump cholecystitis is a recognised condition in which a large gallbladder remnant becomes inflamed after subtotal cholecystectomy. When this occurs, a completion cholecystectomy is indicated. Traditionally, these patients were subjected to open surgery because the laparoscopic approach was anticipated to be technically difficult. We present a case of completion cholecystectomy using basic laparoscopic equipment in a resource poor setting to demonstrate that the laparoscopic approach is feasible. Case Description. A 57-year-old woman presented with right upper quadrant pain and vomiting. She had an elective open cholecystectomy seven years before but reported remarkably similar symptoms. Abdominal ultrasound suggested calculous acute cholecystitis. MRCP confirmed the presence of a large gallbladder remnant with stones. Gastroduodenoscopy excluded other differentials. She had an uneventful laparoscopic completion cholecystectomy performed. Discussion. Although traditional dogma suggested that a completion cholecystectomy should be performed through the open approach, several small studies have demonstrated that laparoscopic completion cholecystectomy is feasible and safe. This report adds to the existing data in support of the laparoscopic approach. Shamir O. Cawich, Carlos Wilson, Lindberg K. Simpson, and Akil J. Baker Copyright © 2014 Shamir O. Cawich et al. All rights reserved. Pulmonary Pleomorphic Carcinoma Detected as a Result of Pneumothorax and the Subsequent Occurrence of Multiple Cystic Metastases Wed, 20 Aug 2014 07:40:41 +0000 A 39-year-old man was admitted for spontaneous pneumothorax. He underwent pulmonary resection to correct the lesion causing the air leakage, and a pathological diagnosis of pulmonary pleomorphic carcinoma was made because we thought that the pneumothorax developed due to the direct rupture of necrotic neoplastic tissue into the pleural cavity. After the operation, the patient received chemotherapy, during which multiple cystic metastases gradually developed in the lung that caused repeated occurrences of pneumothorax. Clinicians must be careful to recognize that pneumothorax can also be a complication of primary and various metastatic pulmonary malignancies. Hideaki Yamakawa, Masahiro Yoshida, Masami Yabe, Yuri Baba, Emiri Baba, Hiroaki Katagi, Takeo Ishikawa, Masamichi Takagi, Takeo Nakada, Tadashi Akiba, and Kazuyoshi Kuwano Copyright © 2014 Hideaki Yamakawa et al. All rights reserved. Chronic Hepatitis C Therapy in Liver Cirrhosis Complicated by Telaprevir-Induced DRESS Wed, 20 Aug 2014 06:39:37 +0000 Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare yet severe adverse drug-induced reaction with up to 10% mortality rate. Recent clinical trials reported an association between DRESS and telaprevir (TVR), an NS3/4A protease inhibitor of chronic hepatitis C (CHC) virus genotype 1. Its diagnosis is challenging given the variable pattern of cutaneous eruption and the myriad internal organ involvement. We present two patients who are middle-aged, obese, and white with CHC cirrhosis. They both developed a progressive diffuse, painful pruritic maculopapular rash at weeks 8 and 10 of CHC therapy with TVR, Peg-Interferon alfa-2a, and Ribavirin. They had no exposures to other medications that can cause this syndrome. Physical exam and labs and skin biopsy supported a “Definite” clinical diagnosis of DRESS, per RegiSCAR criteria. Thus Telaprevir-based triple therapy was discontinued and both patients experienced rapid resolution of the systemic symptoms with gradual improvement of eosinophilia and the skin eruption. These two cases illustrate the paramount importance of having a high index of suspicion for TVR-induced DRESS, critical for early diagnosis. Immediate discontinuation of TVR is essential in prevention of a potentially life-threatening complication. Risk factors for development of DRESS in patients receiving TVR remain to be elucidated. Omar Y. S. Mousa, Rossa Khalaf, Rhonda L. Shannon, Chukwuma I. Egwim, Scott A. Zela, and Victor Ankoma-Sey Copyright © 2014 Omar Y. S. Mousa et al. All rights reserved. Venipuncture-Induced Complex Regional Pain Syndrome: A Case Report and Review of the Literature Tue, 19 Aug 2014 10:35:13 +0000 Venipuncture, the most frequently performed invasive medical procedure, is usually benign. Generally it produces only transitory mild discomfort. Venipuncture-induced neuropathic pain is hard to recognize at an early stage. Medical literature reviews show that there is not adequate medical knowledge about this important subject. The inciting incident in complex regional pain syndrome (CRPS) can often seem far too trivial to result in a condition with such severe pathophysiologic effects. The practicing physician has little information available to enable early recognition of the condition, initiation of multidisciplinary treatment modalities, and proper referral to pain specialists. We encountered a unique case of venipuncture-induced complex regional pain syndrome (CRPS). The patient is a 52-year-old school teacher with no significant past medical history, who presented initially to the Center of Pain Medicine with left upper extremity pain. The pain started while phlebotomy was performed in the patient’s left antecubital area for routine blood check. The patient’s pain did not improve with multiple medications, physical therapy, or several nerve blocks. The patient demonstrated all the signs and symptoms of chronic neuropathic pain of CRPS in the upper extremity with minimal response to the continuous pain management. We decided to proceed with cervical spinal cord nerve stimulation along with continuing other modalities. The patient responded to this combination. During the follow-up, we noticed that the patient’s pain course was complicated by extension of the CRPS to her lower extremity. We will describe the course of treatment for the patient in this paper. In this paper we will discuss the electrical neuromodulation as an important modality in addition to the multidisciplinary pain management for a patient with venipuncture-induced chronic neuropathic pain. Foad Elahi and Chandan G. Reddy Copyright © 2014 Foad Elahi and Chandan G. Reddy. All rights reserved. Ogilvie’s Syndrome following Cardioversion for Atrial Fibrillation Tue, 19 Aug 2014 09:08:50 +0000 Acute colonic pseudoobstruction, also known as Ogilvie’s syndrome, is characterized by distension of the colon in the absence of a mechanical obstruction as evident by abdominal radiography. This syndrome is usually treated conservatively; however, medical or surgical therapies can be employed in refractory cases. Ogilvie’s syndrome has been reported following cardiac events, such as myocardial infarction, heart failure, and cardiac bypass surgeries. We report the first case of Ogilvie’s syndrome following synchronized electric cardioversion for atrial fibrillation. Moh’d Al-Halawani, Juanito Savaille, Mohammad Thawabi, Yazan Abdeen, Richard A. Miller, and Andre A. Fedida Copyright © 2014 Moh’d Al-Halawani et al. All rights reserved. Pseudomembranous Colitis: Not Always Caused by Clostridium difficile Mon, 18 Aug 2014 10:50:11 +0000 Although classically pseudomembranous colitis is caused by Clostridium difficile, it can result from several etiologies. Certain medications, chemical injury, collagenous colitis, inflammatory bowel disease, ischemia, and other infectious pathogens can reportedly cause mucosal injury and subsequent pseudomembrane formation. We present the case of a middle-aged woman with vascular disease who was incorrectly diagnosed with refractory C. difficile infection due to the presence of pseudomembranes. Further imaging, endoscopy, and careful histopathology review revealed chronic ischemia as the cause of her pseudomembranous colitis and diarrhea. This case highlights the need for gastroenterologists to consider non-C. difficile etiologies when diagnosing pseudomembranous colitis. Derek M. Tang, Nathalie H. Urrunaga, Hannah De Groot, Erik C. von Rosenvinge, Guofeng Xie, and Leyla J. Ghazi Copyright © 2014 Derek M. Tang et al. All rights reserved. Surgical Cryoablation of Drug Resistant Ventricular Tachycardia and Aneurysmectomy of Postinfarction Left Ventricular Aneurysm Thu, 14 Aug 2014 09:20:43 +0000 Heart failure is usually associated with left ventricle remodelling, wall thickening, and worsening of the systolic function. Ventricular tachycardia is a common and a negative prognostic factor in patients with endocardial scarring following myocardial infarction and aneurysm formation. The authors present a case of a 51-year-old man with ischemic heart disease, who suffered myocardial infarction four years ago. The patient was admitted to the hospital with sustained ventricular tachycardia despite maximal pharmacotherapy and also underwent unsuccessful percutaneous radiofrequency ablation in the right ventricle. Transthoracic echocardiography revealed left ventricle dysfunction with ejection fraction of 25%, aneurysm of the apex of the left ventricle with thrombus formation inside the aneurysm. Surgical therapy consisted of the cryoablation applied at the transitional zone of the scar and viable tissue and the resection of the aneurysm. The patient remained free of any ventricular tachycardia four months later. Marek Pojar, Jan Harrer, Nedal Omran, and Martin Vobornik Copyright © 2014 Marek Pojar et al. All rights reserved. Squamous Cell Carcinoma (Marjolin’s Ulcer) Arising in a Sacral Decubitus Ulcer Resulting in Humoral Hypercalcemia of Malignancy Wed, 13 Aug 2014 12:37:57 +0000 Long-standing burns, fissures, and ulcers that undergo malignant transformation into a variety of malignancies, including squamous cell carcinoma, is commonly referred to as a Marjolin’s ulcer. It is well recognized that squamous cell carcinomas of the lung and esophagus can cause humoral hypercalcemia of malignancy secondary to paraneoplastic secretion of parathyroid hormone-related peptide. However, it is extremely rare for a squamous cell carcinoma developing in a sacral decubitus ulcer to cause humoral hypercalcemia of malignancy. We describe the first case of a patient found to have elevated serum levels of parathyroid hormone related peptide related to his Marjolin’s ulcer. A 45-year-old African American man with T6 paraplegia and a sacral decubitus ulcer present for 20 years was admitted for hypercalcemia of unclear etiology. He was subsequently found to have elevated parathyroid hormone related peptide and an excisional biopsy from the ulcer showed invasive squamous cell carcinoma suggestive of humoral hypercalcemia of malignancy. The patient ultimately succumbed to sepsis while receiving chemotherapy for his metastatic squamous cell carcinoma. Humoral hypercalcemia of malignancy is a rare and likely underrecognized complication that can occur in a Marjolin’s ulcer. John T. O’Malley, Candace Schoppe, Sameera Husain, and Marc E. Grossman Copyright © 2014 John T. O’Malley et al. All rights reserved. The Bee Sting That Was Not: An Unusual Case of Hymenoptera Anaphylaxis Averted in a Patient Treated with Omalizumab for Asthma Tue, 12 Aug 2014 00:00:00 +0000 This paper presents a case of hymenoptera venom anaphylaxis averted by omalizumab, a monoclonal antibody to IgE antibody. This case suggests a novel and unintentional effect of this therapy. Currently omalizumab is only FDA approved for the treatment of moderate-persistent allergic asthma. However case reports, such as ours have illustrated omalizumab’s efficacy in the treatment of a myriad immunologic and allergic diseases. These outcomes have broadened the understanding of omalizumab’s complex mechanism of action. Evelyn M. Slaughter, Nathan Boyer, and Steven Bennett Copyright © 2014 Evelyn M. Slaughter et al. All rights reserved. Collapsing Focal Segmental Glomerulosclerosis in a Patient with Systemic Lupus Erythematosus Mon, 11 Aug 2014 12:45:43 +0000 We present a case of a 36-year-old female from Ghana who presented with atypical chest pain and shortness of breath and was found to have bilateral transudative pleural effusion and trivial pericardial effusion. Further work-up revealed serological markers consistent with active lupus and negative HIV. She developed rapid deterioration of her renal function requiring dialysis. Her renal biopsy showed collapsing focal segmental glomerulosclerosis with diffuse mesangial proliferative glomerulonephritis, consistent with lupus nephritis class II along with tubular degenerative changes. She was started on high dose steroids and later on mycophenolate mofetil. Her renal function slowly recovered to baseline. Hassan Tariq, Arsalan Rafiq, and Giovanni Franchin Copyright © 2014 Hassan Tariq et al. All rights reserved. Pigmented Lesion of Buccal Mucosa Wed, 06 Aug 2014 00:00:00 +0000 Pigmented lesions are commonly found in the mouth. Such lesions represent a variety of clinical entities, ranging from physiologic changes to manifestation of systemic illness and malignant neoplasm. Diagnosis of such lesions requires a proper case history, extraoral and intraoral examination, and, in some cases, biopsy, aspiration cytology, and laboratory investigations. Here we present a case of purple lesion on the buccal mucosa of a 34-year-old male patient which was provisionally diagnosed as mucocele but on the basis of histopathological picture it was finally diagnosed as angiofibroma, and we also discuss the clinical and histopathological differential diagnosis. Manas Bajpai, Malay Kumar, Manish Kumar, and Deshant Agarwal Copyright © 2014 Manas Bajpai et al. All rights reserved. Gastric Dilation due to a Neuroleptic Agent in an Elderly Patient: A Case Report Tue, 05 Aug 2014 05:45:55 +0000 Neuroleptics may cause side effects, some of which are little known. We describe here a case of gastric dilation related to treatment with a neuroleptic in an elderly man. To our knowledge, such a case has never been reported in the literature. A 76-year-old man, living in a nursing home, was hospitalized for general weakness and abdominal pain. He had dementia with behavioral disorders treated with cyamemazine, a sedative and anxiolytic neuroleptic. Given a clinical suspicion of intestinal occlusion, an abdominopelvic computerized tomography scan was performed before the patient was admitted to our hospital. This computerized tomography scan did not show intestinal occlusion and there was no mention of gastric dilation in the computerized tomography scan report. Thus, acute gastroenteritis was suspected. The usual medications were stopped and symptomatic treatment for gastroenteritis was started. Quickly, his clinical state and biological parameters returned to normal and his usual treatment, including cyamemazine, was started again. The next day, the digestive symptoms, except for obstipation, reappeared. The abdominal X-ray showed gastric dilation without intestinal occlusion. The neuroleptic was stopped again and symptoms vanished the next day. This report underlines all of the necessary precautions and surveillance around drug prescription, especially in elderly persons. V. Parent, L. Popitean, A. Loctin, A. Camus, and P. Manckoundia Copyright © 2014 V. Parent et al. All rights reserved. A Case Report of Acute Acalculous Cholecystitis and Acute Hemorrhagic Cystitis due to Salmonella Typhi Mon, 04 Aug 2014 11:35:46 +0000 Acute acalculous cholecystitis and acute hemorrhagic cystitis due to Salmonella Typhi are a rare condition. A 24-year-old female patient was admitted to our clinic with abdominal pain, nausea, fever, headache, urinary burning, and bloody urine. Based on clinical, laboratory, and radiological evaluations, the patient was diagnosed with acute acalculous cholecystitis and acute hemorrhagic cystitis due to Salmonella Typhi. The patient was treated with intravenous ceftriaxone for two weeks. After the treatment, the patient's clinical and laboratory findings improved. Acute acalculous cholecystitis due to Salmonella Typhi concomitant with acute hemorrhagic cystitis is very rare and might be difficult to diagnose. Infectious agents such as Salmonella Typhi should be considered when acute acalculous cholecystitis and acute hemorrhagic cystitis are detected in adult patients with no underlying diseases. Hatice Beyazal Polat, Mehmet Beyazal, and Fatma Beyazal Çeliker Copyright © 2014 Hatice Beyazal Polat et al. All rights reserved. Reverse Abdominoplasty Flap in Reconstruction of Post-Bilateral Mastectomies Anterior Chest Wall Defect Mon, 04 Aug 2014 10:01:16 +0000 Reverse abdominoplasty was originally described for epigastric lift. Since the work by Baroudi and Huger in the 1970s, it has become clear that reverse abdominoplasty application can be extended beyond just aesthetic procedure. Through the knowledge of anterior abdominal wall vascularity, its application had included reconstructive prospect in the coverage of various chest wall defects. To date, reverse abdominoplasty flap has been used to reconstruct unilateral anterior chest wall defect or for larger defect but only in combination with other reconstructive techniques. Here, we presented a case where it is used as a standalone flap to reconstruct bilateral anterior chest wall soft tissue defect post-bilateral mastectomies in oncological resection. In conclusion, reverse abdominoplasty flap provided us with a simple, faster, and satisfactory reconstructive outcome. William HC Tiong and Normala Hj Basiron Copyright © 2014 William HC Tiong and Normala Hj Basiron. All rights reserved. Laryngeal Lymphoma: The High and Low Grades of Rare Lymphoma Involvement Sites Tue, 22 Jul 2014 12:02:38 +0000 The larynx is an extremely rare site of involvement by lymphomatous disease. We present two cases of isolated laryngeal high-grade and another low-grade lymphoma, together with a literature review of laryngeal lymphoma management. Charles Paul Azzopardi, James Degaetano, Alexandra Betts, Eric Farrugia, Claude Magri, Nicholas Refalo, Alexander Gatt, and David J. Camilleri Copyright © 2014 Charles Paul Azzopardi et al. All rights reserved. Acute Rhabdomyolysis Associated with Coadministration of Levofloxacin and Simvastatin in a Patient with Normal Renal Function Tue, 22 Jul 2014 08:06:05 +0000 We report a rare case of severe acute rhabdomyolysis in association with coadministration of levofloxacin and simvastatin in a patient with normal renal function. A 70-year-old Caucasian male was treated due to community acquired pneumonia with levofloxacin in a dosage of 500 mg once and then twice a day. On the 8th day of hospitalization the patient presented with acute severe rhabdomyolysis requiring an intensive care support. After discontinuation of levofloxacin and concomitant medication with simvastatin 80 mg/day, clinical and laboratory effects were totally reversible. Up to now, levofloxacin has been reported to induce rhabdomyolysis mainly in patients with impaired renal function, as the medication has a predominant renal elimination. In our case renal function remained normal during the severe clinical course. According to a recent case report rhabdomyolysis was observed due to interaction of simvastatin and ciprofloxacin. To our best knowledge this is the first case of interaction between simvastatin and levofloxacin to be reported. This case emphasizes the need of close monitoring of creatine kinase in patients under more than one potentially myotoxic medication especially when patients develop muscle weakness. Maria Paparoupa, Sebastian Pietrzak, and Adrian Gillissen Copyright © 2014 Maria Paparoupa et al. All rights reserved. Bilateral Upper Extremity DVT in a 43-Year-Old Man: Is It Thoracic Outlet Syndrome?! Tue, 22 Jul 2014 00:00:00 +0000 Recurrent deep venous thrombosis, involving bilateral upper extremities, is an extremely rare phenomenon. We are presenting a 43-year-old man who was diagnosed with left upper extremity deep vein thrombosis (UEDVT) and was treated with anticoagulation and surgical decompression in 2004. 9 years later, he presented with right arm swelling and was diagnosed with right UEDVT using US venous Doppler. Venogram showed compression of the subclavian vein by the first rib, diagnosing thoracic outlet syndrome (TOS). He was treated with anticoagulation and local venolysis and later by surgical decompression of the subclavian vein. Bilateral UEDVT, as mentioned above, is an extremely rare condition that is uncommonly caused by TOS. To our knowledge, we are reporting the first case of bilateral UEDVT due to TOS. Diagnosis usually starts with US venous Doppler to detect the thrombosis, followed by the gold standard venogram to locate the area of obstruction and lyse the thrombus if needed. The ultimate treatment for TOS remains surgical decompression of the vascular bundle at the thoracic outlet. Hadoun Jabri, Sarbajit Mukherjee, Devang Sanghavi, and Shyam Chalise Copyright © 2014 Hadoun Jabri et al. All rights reserved. Acute Zonal Occult Outer Retinopathy with Atypical Findings Mon, 21 Jul 2014 09:06:41 +0000 Background. To report a case of acute zonal occult outer retinopathy (AZOOR) with atypical electrophysiology findings. Case Presentation. A 23-year-old-female presented with visual acuity deterioration in her right eye accompanied by photopsia bilaterally. Corrected distance visual acuity at presentation was 20/50 in the right eye and 20/20 in the left eye. Fundus examination was unremarkable. Visual field (VF) testing revealed a large scotoma. Pattern and full-field electroretinograms (PERG and ERG) revealed macular involvement associated with generalized retinal dysfunction. Electrooculogram (EOG) light rise and the Arden ratio were within normal limits bilaterally. The patient was diagnosed with AZOOR due to clinical findings, visual field defect, and ERG findings. Conclusion. This is a case of AZOOR with characteristic VF defects and clinical symptoms presenting with atypical EOG findings. Dimitrios Karagiannis, Georgios A. Kontadakis, Artemios S. Kandarakis, Nikolaos Markomichelakis, Ilias Georgalas, Efstratios A. Parikakis, and Stamatina A. Kabanarou Copyright © 2014 Dimitrios Karagiannis et al. All rights reserved. Prophylactic Appendectomy during Laparoscopic Surgery for Other Conditions Sun, 20 Jul 2014 11:45:39 +0000 Acute appendicitis remains the most common surgical emergency. Laparoscopy has gained increasing favor as a method of both investigating right iliac fossa pain and treating the finding of appendicitis. A question arises: what to do with an apparent healthy appendix discovered during laparoscopic surgery for other pathology. We present a case of unilateral hydroureteronephrosis complicated with rupture of the renal pelvis, due to gangrenous appendicitis with abscess of the right iliopsoas muscle and periappendicular inflammation in a 67-year-old woman, who underwent laparoscopic right annessiectomy for right ovarian cyst few years earlier, in which a healthy appendix was left inside. There is a lack of consensus in the literature about what to do with a normal appendix. The main argument for removing an apparently normal appendix is that endoluminal appendicitis may not be recognized during surgery, leading to concern that an abnormal appendix is left in place. Because of a lack of evidence from randomized trials, it remains unclear whether the benefits of routine elective coincidental appendectomy outweigh the costs and risks of morbidity associated with this prophylactic procedure. Nevertheless, it appears, from limited data, that women aged 35 years and under benefit most from elective coincidental appendectomy. S. Occhionorelli, R. Stano, S. Targa, S. Maccatrozzo, L. Cappellari, and G. Vasquez Copyright © 2014 S. Occhionorelli et al. All rights reserved. Anatomic Variation of Subclavian Artery Visualized on Ultrasound-Guided Supraclavicular Brachial Plexus Block Sun, 20 Jul 2014 00:00:00 +0000 Use of ultrasonography for performance of nerve and plexus blocks has made the process simpler and safer. However, at times, variant anatomy of the visualized structures can lead to failure of blocks or complications such as intravascular injections. This is especially true in case of novice operators. We report a case of a variant branch of subclavian artery, possibly the dorsal scapular artery passing through the brachial plexus nerve bundles in the supraclavicular area. Since this variation in anatomy was visualized in the scout scan prior to the performance of the block, it was possible to avoid any accidental puncture. Hence, a thorough knowledge of the ultrasound anatomy is important in order to identify various aberrations and variations. It is also prudent to perform a preliminary scan, prior to performance of the block to localize the target area and avoid any inadvertent complications. Santvana Kohli, Naveen Yadav, Arunima Prasad, and Sumantra Sarathi Banerjee Copyright © 2014 Santvana Kohli et al. All rights reserved. Concomitant Factors Leading to an Atypical Osteonecrosis of the Jaw in a Patient with Multiple Myeloma Wed, 16 Jul 2014 09:16:49 +0000 Osteonecrosis of the jaw (ONJ) is a site specific osseous pathology, characterized by chronic exposed bone in the mouth, which needs to be reinforced periodically within the medical literature. ONJ is a clinical entity with many possible aetiologies and its pathogenesis is not well understood. The risk factors for ONJ include bisphosphonates treatments, head and neck radiotherapy, dental procedures involving bone surgery, and trauma. Management of ONJ has centred on efforts to eliminate or reduce severity of symptoms, to slow or prevent the progression of disease, and to eradicate diseased bone. This case describes a rare case of ONJ in a 64-year-old Caucasian male diagnosed with multiple myeloma stage III. The lesion was related to a traumatic injury during mastication. Eighteen months ago in the same area the molar 37 was extracted, achieving a complete satisfactory healing, when only 2 doses of zoledronic acid had been administered. Actinomyces bacterial aggregates were also identified in the microscopic analysis. The management of this osteonecrotic lesion included antibiotic treatment and chlorhexidine topical gel administration. The evolution was monitored every two weeks until patient’s death. The authors provide a discussion of the etiology, pathogenesis, diagnosis, and management. This case report may shed light on the controversies about concomitant factors and mechanisms inducing ONJ. Jaume Miranda-Rius, Lluís Brunet-Llobet, Eduard Lahor-Soler, and Josep Anton Giménez-Rubio Copyright © 2014 Jaume Miranda-Rius et al. All rights reserved. Successful Management of Coronary Artery Rupture with Stent-Graft: A Case Report Sun, 13 Jul 2014 11:50:05 +0000 Perforation of coronary arteries is a relatively rare yet life-threatening complication of percutaneus coronary interventions and is encountered in approximately 0.5% of these procedures. According to the type of coronary perforation, various methods of correction are employed, ranging from conservative approach to emergency cardiac surgery. Coronary stent-grafts are composed of two metal stents and a polytetrafluoroethylene layer between them. Advent of such stents enabled efficient endovascular repair of coronary artery perforation. We present a case of coronary artery perforation which had occurred during stent implantation for the treatment of a bridged segment in the distal portion of the left anterior descending artery. This perforation was successfully managed by implanting a stent-graft. Berkay Ekici, Aycan Fahri Erkan, Utku Kütük, and Hasan Fehmi Töre Copyright © 2014 Berkay Ekici et al. All rights reserved. Acute Abdominal Pain after Intercourse: Adrenal Hemorrhage as the First Sign of Metastatic Lung Cancer Sun, 13 Jul 2014 07:45:16 +0000 Although the adrenal glands are a common site of cancer metastases, they are often asymptomatic and discovered incidentally on CT scan or autopsy. Spontaneous adrenal hemorrhage associated with metastatic lung cancer is an exceedingly rare phenomenon, and diagnosis can be difficult due to its nonspecific symptoms and ability to mimic other intra-abdominal pathologies. We report a case of a 65-year-old man with a history of right upper lobectomy seven months earlier for stage IB non-small cell lung cancer who presented with acute abdominal pain after intercourse. CT scan revealed a new right adrenal mass with surrounding hemorrhage, and subsequent FDG-PET scan confirmed new metabolic adrenal metastases. The patient’s presentation of abdominal pain and adrenal hemorrhage immediately after sexual intercourse suggests that exertion, straining, or increased intra-abdominal pressure might be risk factors for precipitation of hemorrhage in patients with adrenal metastases. Management includes pain control and supportive treatment in mild cases, with arterial embolization or adrenalectomy being reserved for cases of severe hemorrhage. Jeremy Wang and Clifford D. Packer Copyright © 2014 Jeremy Wang and Clifford D. Packer. All rights reserved. Postpartum Ovarian Vein and Inferior Vena Cava Thrombosis Thu, 10 Jul 2014 10:00:26 +0000 Postpartum ovarian vein thrombosis (POVT), which generally occurs 2–15 days postpartum, is a rare complication. It can be confused with acute appendicitis, pelvic infection, ovarian torsion, tubo-ovarian abscess, and pyelonephritis. It is associated with morbidity and mortality. Here, we present a patient with postpartum OVT and IVC diagnosed by US and CT findings. She was treated successfully with no further need for any interventional procedures. Harun Arslan, Sibel Ada, Sebahattin Çelik, and Tayfur Toptaş Copyright © 2014 Harun Arslan et al. All rights reserved. Giant Solitary Fibrous Tumor of the Parotid Gland Thu, 10 Jul 2014 00:00:00 +0000 Solitary fibrous tumors (SFTs) are rare tumors that are mostly found arising from the pleura. SFT of the parotid gland is a rare tumor; only a few cases have been described in the literature. SFTs are benign in most cases. Clinically, SFTs usually manifest as well circumscribed, slow-growing, smooth, and painless masses. CT-Scan and MRI are the most sensitive imaging procedures used. The treatment of choice is complete surgical excision of the lesion. Since recurrence and metastasis can take place after several years, a lifelong clinical and imaging regular follow-up is compulsory. In this paper, we describe the diagnostic and therapeutic challenges of the up-to-now biggest parotid SFT. The clinical presentation, surgical management, and pathological and immunohistochemistry findings are described. Octavian Chis and Silviu Albu Copyright © 2014 Octavian Chis and Silviu Albu. All rights reserved. Wolff-Parkinson-White Syndrome Mimics a Conduction Disease Wed, 09 Jul 2014 09:35:10 +0000 Background. It is important to recognise Wolff-Parkinson-White (WPW) syndrome in electrocardiograms (ECG), as it may mimic ischaemic heart disease, ventricular hypertrophy, and bundle branch block. Recognising WPW syndrome allows for risk stratification, the identification of associated conditions, and the institution of appropriate management. Objective. The present case showed that electrophysiological study is indicated in patients with abnormal ECG and syncope. Case Report. A 40-year-old man with Wolff-Parkinson-White syndrome was presented to emergency with syncope. A baseline ECG was a complete right branch block and posterior left hemiblock. He was admitted to the cardiac care unit for pacemaker implantation. The atypical figure of complete right branch block and posterior left hemiblock was thought to be a “false positive” of conduction abnormality. But the long anterograde refractory period of the both accessory pathway and atrioventricular conduction may cause difficulty in diagnosing Wolff-Parkinson-White syndrome, Conclusion. A Wolff-Parkinson-White Syndrome may mimic a conduction disease. No reliable algorithm exists for making an ECG diagnosis of a preexcitation syndrome with conduction disorders. This can lead to diagnostic and therapeutic dilemmas in the context of syncope. S. Marrakchi, I. Kammoun, and S. Kachboura Copyright © 2014 S. Marrakchi et al. All rights reserved. Clinical Presentation and Magnetic Resonance Findings in Sellar Tuberculomas Wed, 09 Jul 2014 07:33:41 +0000 Background and Importance. Sellar tuberculomas are extremely rare lesions with nonspecific clinical manifestations. The tuberculous infection of the pituitary gland and sellar region is characterized by the presence of an acute or chronic inflammatory reaction and may occur in the absence of systemic tuberculosis. The diagnosis is difficult prior to the surgery. An adequate diagnostic and antituberculous drugs usually result in a good outcome. Clinical Presentation. We report four cases of sellar tuberculoma, 3/1 female/male, age range: 50–57 years. All patients had visual disturbances and low levels of cortisol. Conclusion. The clinical diagnosis of sellar tuberculoma is a challenge and should be suspected when a sellar lesion shows abnormal enhancement pattern and stalk involvement, and absence of signal suppression in FLAIR. Dulce Bonifacio-Delgadillo, Yolanda Aburto-Murrieta, Citlaltepetl Salinas-Lara, Julio Sotelo, Ivonne Montes-Mojarro, and Arturo Garcia-Marquez Copyright © 2014 Dulce Bonifacio-Delgadillo et al. All rights reserved. Cardiac Hemangioma of RVOT in a Patient with Atypical Chest Pain Tue, 08 Jul 2014 06:38:08 +0000 A 40-year-old man presented with atypical chest pain and fatigue from 15 days ago a suspicious mass in the right ventricle based on a bed side transthoracic echocardiography. Preoperative diagnosis of a cardiac hemangioma comes to mind in a minority of cases. In our case, a cardiac tumor was diagnosed and the vascular nature of the tumor was suggested by vascular blush on the coronary angiography. In addition, right ventriculotomy was the approach of choice in our case because of its inaccessibility and its particular location. Hossein Vakili, Isa Khaheshi, Mahnoosh Foroughi, Hamid Ghaderi, Shooka Esmaeeli, and Mostafa Jafari Copyright © 2014 Hossein Vakili et al. All rights reserved. Reversion of Hormone Treatment Resistance with the Addition of an mTOR Inhibitor in Endometrial Stromal Sarcoma Tue, 08 Jul 2014 00:00:00 +0000 Background. Endometrial stromal sarcomas (ESS) are a subtype of gynaecological sarcomas characterized by the overexpression of hormone receptors. Hormone treatment is widely used in ESS but primary or acquired resistance is common. The mammalian target of rapamycin (mTOR) pathway has been suggested to play a key role in the mechanisms of hormone resistance. Recent studies in breast and prostate cancer demonstrate that this resistance can be reversed with the addition of an mTOR inhibitor. This phenomenon has never been reported in ESS. Methods. We report the outcome of one patient with pretreated, progressing low grade metastatic ESS treated with medroxyprogesterone acetate in combination with the mTOR inhibitor sirolimus. Results. Partial response was achieved following the addition of sirolimus to the hormone treatment. Response has been maintained for more than 2 years with minimal toxicity and treatment is ongoing. Conclusion. This case suggests that the resistance to the hormone manipulation in ESS can be reversed by the addition of an mTOR pathway inhibitor. This observation is highly encouraging and deserves further investigation. J. Martin-Liberal, C. Benson, C. Messiou, C. Fisher, and I. Judson Copyright © 2014 J. Martin-Liberal et al. All rights reserved.