Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Malignant Granular Cell Tumor of the Back: A Case Report and Review of the Literature Mon, 24 Nov 2014 12:54:48 +0000 Malignant granular cell tumors are rare, intensely aggressive entities. This paper presents a case of a large rapidly recurrent malignant granular cell tumor with regional and distal metastases on the back of a 54-year-old Cuban man. The primary tumor recurred within six months of the original wide local excision and with satellite lesions apparent at twelve months, and the mass was diagnosed using the histological criteria established by Fanburg-Smith et al. for malignant granular cell tumors. By fifteen months, right axillary lymphadenopathy, multiple satellite lesions, pulmonary nodules, and distant metastasis in the right thigh were present. At sixteen months, wide local excision of recurrent mass and local satellite masses along with right axillary dissection and placement of Integra with subsequent split-thickness skin graft were performed by surgical oncology and plastic surgery teams. The surgical specimen measured 32.0 × 13.5 × 5.5 cm, containing multiple homogeneous masses with the largest mass 22.0 × 9.0 × 4.6 cm. Following surgery, patient was started on Pazopanib 800 mg/day based on phase III randomized trial data in the treatment of soft tissue sarcomas showing this as a potential novel therapy for malignant granular cell tumors. Laura Stone McGuire, Danny Yakoub, Mecker G. Möller, Andrew Rosenberg, and Alan Livingstone Copyright © 2014 Laura Stone McGuire et al. All rights reserved. Diagnostic Difficulties in Woman with Crohn’s Disease, Ascites, and Elevated Value of Serum CA125 Antigen Sun, 23 Nov 2014 07:27:36 +0000 Variety of symptoms and atypical clinical course of Crohn’s disease (CD) often create the need for additional diagnostic procedures. In the described case of woman with CD, there was a suspicion of coexistence of ovarian cancer. This issue is particularly important in patients treated with immunosuppressants and biological agents. The discussion focused on the usefulness of CA125 (cancer antigen 125, mucin 16) serum level estimation in clinical practice and draws attention to the possible reasons for the increase of its value which is not associated to ovarian cancer. Maria Kłopocka, Ariel Liebert, Joanna Bielińska, and Marcin Manerowski Copyright © 2014 Maria Kłopocka et al. All rights reserved. Successful Rehabilitation of Partial Edentulous Maxilla and Mandible with New Type of Implants: Molecular Precision Implants Wed, 19 Nov 2014 14:03:30 +0000 The extraction of teeth results in rapid bone resorption both vertically and horizontally in the first month. The loss of alveolar ridge reduces the chance of implant rehabilitation. Atraumatic extraction, implant placement in extraction socket, and an immediate prosthesis have been proposed as alternative therapies to maintain the volume and contours tissue and reduce time and cost of treatment. The immediate load of implants is a universally practiced procedure; nevertheless a successful procedure requires expertise in both the clinical and the reconstructive stages using a solid implant system. Excellent primary stability and high bone-implant contact are only minimal requirements for any type of implant procedure. In this paper we present a case report using a new type of implants. The new type of implants, due to its sophisticated control system of production, provides to the implantologist a safe and reliable implant, with a macromorphology designed to ensure a close contact with the surrounding bone. Matteo Danza, Dorina Lauritano, and Francesco Carinci Copyright © 2014 Matteo Danza et al. All rights reserved. Management of Varicella Gangrenosa: A Life-Threatening Condition from Chickenpox Wed, 19 Nov 2014 13:34:14 +0000 Varicella gangrenosa, in which gangrenous ulceration of the skin and/or deeper tissues is seen, is a rare but alarming complication of Varicella infection. An early surgical intervention is generally advised, especially in case of sepsis and/or the presence of large necrotic lesions. We describe a case of a previously healthy 12-month-old boy presenting with sepsis due to Varicella gangrenosa. He presented with moderate lesions of moist gangrene. We treated our patient initially with antibiotics (ceftriaxone and metronidazole) and later on flucloxacillin and antiviral therapy (acyclovir) whereupon his condition rapidly improved and all skin lesions healed entirely. This report highlights the possibility of conservative treatment and emphasizes the significance of acyclovir in the management of chickenpox complicated by moist gangrene due to bacterial superinfection. Judith P. M. Schots, Peter Moons, and Jan H. M. B. Stoot Copyright © 2014 Judith P. M. Schots et al. All rights reserved. Fecal Transplantation Treatment of Antibiotic-Induced, Noninfectious Colitis and Long-Term Microbiota Follow-Up Wed, 19 Nov 2014 00:00:00 +0000 Fecal microbiota transplantation (FMT) is an effective treatment for recurrent Clostridium difficile infection (CDI) and is considered as a treatment for other gastrointestinal (GI) diseases. We followed up the relief of symptoms and long-term, over-a-year microbiota stabilization in a 46-year-old man, who underwent FMT for antibiotic-induced, non-CDI colitis nine months after being treated for CDI by FMT. Fecal and mucosal microbiota was analyzed before the second FMT and during 14 months after FMT by using a high-throughput phylogenetic microarray. FMT resolved the symptoms and restored normal GI-function. Microbiota analysis revealed increased bacterial diversity in the rectal mucosa and a stable fecal microbiota up to three months after FMT. A number of mucosa-associated bacteria increased after FMT and some of these bacteria remained increased in feces up to 14 months. Notably, the increased bacteria included Bifidobacterium spp. and various representatives of Clostridium clusters IV and XIVa, such as Clostridium leptum, Oscillospira guillermondii, Sporobacter termitidis, Anaerotruncus colihominis, Ruminococcus callidus, R. bromii, Lachnospira pectinoschiza, and C. colinum, which are presumed to be anti-inflammatory. The presented case suggests a possible role of microbiota in restoring and maintaining normal GI-functionality and improves our knowledge on the etiology of antibiotic-induced, noninfectious colitis. Reetta Satokari, Susana Fuentes, Eero Mattila, Jonna Jalanka, Willem M. de Vos, and Perttu Arkkila Copyright © 2014 Reetta Satokari et al. All rights reserved. Argon Laser Photoablation for Postburn Conjunctival Pigmentation Tue, 18 Nov 2014 10:48:25 +0000 We report a case of an ocular burn injury from boiling water which resulted in conjunctival pigmentation, 1 week following injury. For cosmetic purposes, 2 sessions of argon laser photoablation were performed. One month after laser treatment, conjunctival pigmentation had been successfully removed and the patient was very satisfied with the results. Argon laser photoablation may be an effective way to remove postburn conjunctival pigmentation. Seong Joon Ahn, Jae Hoon Jeong, Hyo Jong Cho, Dong-Hoon Lee, and Hyun Chul Kim Copyright © 2014 Seong Joon Ahn et al. All rights reserved. Prick by Prick Induced Anaphylaxis in a Patient with Peanuts and Lupine Allergy: Awareness of Risks and Role of Component Resolved Diagnosis Tue, 18 Nov 2014 06:46:16 +0000 A case of anaphylaxis is reported in the course of a prick by prick with Lupinus albus and roasted peanut in a 20-year-old woman. We focused on some main topics. First of all it seems important to underscore the potential risks connected to the practice of the prick-by-prick with fresh foods in allergic patients, especially when testing cross-reactive substances, such as White Lupine, peanuts, or soy. It is important that clinicians who perform prick tests be aware of the risk related with in vivo tests in allergic patients. Second, we discuss the problem of the hidden allergens, such as White Lupine flour, or soy flour which are utilized to improve wheat flour because of their lower cost. Patients with a demonstrated allergy to peanuts should be assessed for lupine allergy and informed about the “hidden allergens” issue. Finally, we believe that component resolved diagnosis, the serum specific IgE against molecular components, that is normally considered a second-level diagnostic step has an important role even as a first line approach at least in some selected cases. Anna Ciccarelli, Claudia Calabrò, Clara Imperatore, and Guglielmo Scala Copyright © 2014 Anna Ciccarelli et al. All rights reserved. Tumour Calcification and Calciphylaxis in End-Stage Renal Disease Tue, 18 Nov 2014 06:21:45 +0000 Although soft tissue and vascular calcifications are common in CKD and progress as an independent risk factor of all-cause mortality, tumour calcification and calciphylaxis are uncommon in patients with end-stage renal disease (ESRD). Here, we discuss a rare case of a patient with tumour calcification complicated with calciphylaxis developed septic shock from infection. Our patient is a 57-year-old man in his late stage of renal disease who presented with a huge mass at the right hip and necrotic cutaneous ulcers on the lower legs followed by local and systemic infection and death due to septic shock. Jia Di, Zhenxing Jiang, and Min Yang Copyright © 2014 Jia Di et al. All rights reserved. Case of Thyrotoxic Periodic Paralysis in a Caucasian Male and Review of Literature Mon, 17 Nov 2014 13:44:46 +0000 Objective. Thyrotoxic periodic paralysis (TPP), a known condition in Asian men, is becoming increasingly common in men from Western countries. Since suspicion for TPP as a differential in diagnosis is of utmost importance to avoid overcorrection of hypokalemia and other complications, we are reporting a case of TPP in a 25-year-old Caucasian male. Methods. The patient presented with intermittent lower extremity weakness after consumption of a large high-carbohydrate meal. Clinical examination revealed diffusely enlarged thyroid gland, no muscle power in lower extremities, tremors, and brisk deep tendon reflexes. Results. Clinical and laboratory findings were consistent with Graves’ disease and the patient had hypokalemia. The patient responded to potassium repletion and was treated with propylthiouracil and propranolol. After treatment with radioactive iodine, the patient developed postablative hypothyroidism for which he was treated with levothyroxine. Conclusion. Since this condition is overlooked by physicians in Western countries, we present a case of TPP in a Caucasian male thus showing the importance of consideration of TPP in Caucasians despite its rare occurrence and the need for prompt diagnosis to avoid the danger of hyperkalemia in management of the paralytic attack in TPP patients. Tina K. Thethi, Rosemarie Parks, Bonnie Katalenich, Pankdeep Chhabra, Julie McCaw, Stephanie Syu, Tuyen Nguyen, Joshua Larrazolo, Kartik Munshi, Jay Waddadar, and Prathima Nagireddy Copyright © 2014 Tina K. Thethi et al. All rights reserved. Outcome of Two Corneal Collagen Crosslinking Methods in Bullous Keratopathy due to Fuchs’ Endothelial Dystrophy Mon, 17 Nov 2014 12:01:16 +0000 Four eyes of 2 patients with corneal edema due to Fuchs’ endothelial dystrophy were treated with CXL using the standard protocol. Since no improvement in visual acuity, corneal clarity, thickness, or pain sensation was evident in any eye at month 12, 2 eyes of the 2 patients were retreated, this time, following intraoperative corneal dehydration with glycerol 70% drops. This retreatment also failed to produce any significant effect on vision, corneal clarity, thickness, or pain in either eye. Collagen crosslinking with the current protocols may not be effective in the management of eyes with corneal edema due to Fuchs’ endothelial dystrophy. Further studies are required to establish the efficacy of CXL and optimize the technique and/or dehydration method utilized in these cases. Omur O. Ucakhan and Ayhan Saglik Copyright © 2014 Omur O. Ucakhan and Ayhan Saglik. All rights reserved. Mesenteric Inflammatory Venoocclusive Disease in a Patient with Sjögren’s Syndrome Sun, 16 Nov 2014 12:40:10 +0000 Mesenteric inflammatory venoocclusive disease is an uncommon cause of intestinal ischemia. Certain diseases, such as hypercoagulation disorders, autoimmune diseases, or drugs have been associated with the pathogenesis of mesenteric inflammatory venoocclusive disease. Here, we report a patient with Sjögren’s syndrome who underwent surgery for suspected acute appendicitis with a subsequent pathological diagnosis of mesenteric inflammatory venoocclusive disease. Raquel Rios-Fernández, José-Luis Callejas-Rubio, Mercedes Caba-Molina, Rosa Ríos-Peregrina, and Norberto Ortego-Centeno Copyright © 2014 Raquel Rios-Fernández et al. All rights reserved. Resolution of Left Ventricular Thrombus Secondary to Tachycardia-Induced Heart Failure with Rivaroxaban Thu, 13 Nov 2014 09:49:50 +0000 A 42-year-old man was admitted to our hospital because of lumbago and tachycardia-induced heart failure. Transthoracic echocardiography revealed impaired left ventricular function and a ball mass of thrombus in the left ventricle (LV). He was found to have systemic embolism in the spleen, kidneys, brain, and limbs. The patient was treated with limb thrombectomy followed by anticoagulation. Seven days after the direct factor Xa inhibitor, rivaroxaban, was initiated, transthoracic echocardiography was repeated, revealing disappearance of the LV thrombus without any clinical signs of cardiogenic embolism. His heart failure responded well and the LV wall motion had improved. This case suggests rivaroxaban has fibrinolytic effects on thrombi even in the LV. Kosuke Nakasuka, Shigenori Ito, Tsubasa Noda, Takahiro Hasuo, Satoru Sekimoto, Hiroyuki Ohmori, Masahiko Inomata, Takayuki Yoshida, Nozomu Tamai, Tomoaki Saeki, Shin Suzuki, Yoshimasa Murakami, and Koichi Sato Copyright © 2014 Kosuke Nakasuka et al. All rights reserved. A Case of Pulmonary Sarcoma with Significant Extension into the Right Lung Thu, 13 Nov 2014 08:47:59 +0000 A female patient in her 30s was referred to us with a mass approximately 8 centimeters in diameter in right lung segment 6. Bronchoscopy was done, and a tumorous lesion obstructing right B6 was found. Biopsy of this lesion supported suspicions of sarcoma or spindle cell carcinoma. Contrast-enhanced CT showed that the mass extended to and obstructed the right main pulmonary artery. A skip lesion was also suspected in the periphery of pulmonary artery trunk. The tumor was removed by right pneumonectomy accompanied by resection of the main and left pulmonary arteries under cardiopulmonary bypass. The pulmonary artery trunk and the left pulmonary artery were reconstructed with a vascular graft. Collectively, intimal sarcoma originating from the right main pulmonary artery with extension into the right lung was diagnosed. Significant extension of pulmonary artery sarcoma into the lung, as was observed in the present case, is considered to be rare, and to our knowledge this is the first report in which the primary lesion was biopsied by bronchoscopy. Yoshiaki Inoue, Yotaro Izumi, Kenjiro Sakaki, Keiko Abe, Teruaki Oka, Jun-Ichi Tamaru, Ato Sugiyama, Kohei Aoki, Hiroki Fukuda, Masatoshi Gika, Kazuhito Imanaka, and Mitsuo Nakayama Copyright © 2014 Yoshiaki Inoue et al. All rights reserved. Spinal Intramedullary Metastasis of Breast Cancer Thu, 13 Nov 2014 07:19:34 +0000 Objective. Breast cancer accounts for approximately one-third of all cancers in females. Approximately 8.5 % of all central nervous system metastases are located in the spinal cord. These patients have rapidly progressing neurological deficits and require immediate examination. The aim of surgery is decompression of neural tissue and histological evaluation of the tumor. In this paper, we present a case of breast cancer metastasis in thoracic spinal intramedullary area which had been partially excised and then given adjuvant radiotherapy. Case. A 43-year-old female patient with breast cancer for 8 years was admitted to our hospital with complaints of weakness in both legs. Eight years ago, she received chemotherapy and radiotherapy. On her neurological examination, she had paraparesis (left lower extremity: 2/5, right lower extremity: 3/5) and urinary incontinence. Spinal MRI revealed a gadolinium enhancing intramedullary lesion. Pathologic examination of the lesion was consistent with breast carcinoma metastasis. The patient has been taken into radiotherapy. Conclusion. Spinal intramedullary metastasis of breast cancer is an extremely rare situation, but it has a high morbidity and mortality rate. Microsurgical resection is necessary for preservation or amelioration of neurological state and also for increased life expectancy and quality. Recep Basaran, Mehmet Tiryaki, Dilek Yavuzer, Mustafa Efendioglu, Ece Balkuv, and Aydin Sav Copyright © 2014 Recep Basaran et al. All rights reserved. Amiodarone-Induced Thyrotoxic Thyroiditis: A Diagnostic and Therapeutic Challenge Wed, 12 Nov 2014 06:52:10 +0000 Amiodarone is an iodine-based, potent antiarrhythmic drug bearing a structural resemblance to thyroxine (T4). It is known to produce thyroid abnormalities ranging from abnormal thyroid function testing to overt hypothyroidism or hyperthyroidism. These adverse effects may occur in patients with or without preexisting thyroid disease. Amiodarone-induced thyrotoxicosis (AIT) is a clinically recognized condition commonly due to iodine-induced excessive synthesis of thyroid, also known as type 1 AIT. In rare instances, AIT is caused by amiodarone-induced inflammation of thyroid tissue, resulting in release of preformed thyroid hormones and a hyperthyroid state, known as type 2 AIT. Distinguishing between the two states is important, as both conditions have different treatment implications; however, a mixed presentation is not uncommon, posing diagnostic and treatment challenges. We describe a case of a patient with amiodarone-induced type 2 hyperthyroidism and review the current literature on the best practices for diagnostic and treatment approaches. Umang Barvalia, Barkha Amlani, and Ram Pathak Copyright © 2014 Umang Barvalia et al. All rights reserved. A Giant Verrucous Carcinoma of the Penis Presenting with Urinary Sepsis and Angina Wed, 12 Nov 2014 06:21:12 +0000 Penile verrucous carcinoma also known as Buschke-Löwenstein tumor in the genital region is an uncommon variant of penile carcinoma exhibiting slow, expansive growth. We present a case of a 63-year-old male who presented with a giant purulent penile mass causing urinary sepsis and angina. Regional lymph nodes were clinically negative and staging with CT scans of thorax and abdomen did not show any signs of lymph node or distant metastases. After resuscitation, radical penectomy was performed and a perineal urethrostomy was created. Histological examination revealed a Buschke-Löwenstein tumor of the penis with no invasion of corpus cavernosum and urethra. Michael Nomikos, Paschalis Barmpoutis, Eleni Papakonstantinou, Zacharias Chousianitis, Prodromos Ouzounoglou, Paraskevi Efstathiadou, and Charilaos Katsifotis Copyright © 2014 Michael Nomikos et al. All rights reserved. A Case with Repeated Recurrent Acute Coronary Syndrome due to Pseudoephedrine Use: Kounis Syndrome Tue, 11 Nov 2014 07:02:22 +0000 Allergic reaction-associated acute coronary syndrome picture is defined as Kounis syndrome. Although drug use is the most common cause of allergic reaction, foods and environmental factors may also play a role in the etiology. Herein, a case with acute coronary syndrome that developed two times at 8-month interval due to pseudoephedrine use for upper respiratory tract infection is presented. Metin Çeliker, Mustafa Tuncer, and Ali Şekeralmaz Copyright © 2014 Metin Çeliker et al. All rights reserved. Delayed Facial Paralysis following Uneventful KTP Laser Stapedotomy: Two Case Reports and a Review of the Literature Tue, 11 Nov 2014 06:29:20 +0000 Facial palsy that occurs immediately after middle ear surgery (stapedectomy, stapedotomy, and tympanoplasty) can be a consequence of the local anesthetics and it regresses completely within a few hours. In the case of delayed facial palsy, the alarming symptom occurs several days or even weeks after uneventful surgery. The mechanism of the neural dysfunction is not readily defined. Surgical stress, intraoperative trauma, or laceration of the chorda tympani nerve with a resultant retrograde facial nerve edema can all be provoking etiological factors. A dehiscent bony facial canal or a multiple microporotic fallopian canal (microtrauma or laser effect) can also contribute to the development of this rare phenomenon. The most popular theory related to the explanation of delayed facial palsy at present is the reactivation of dormant viruses. Both the thermal effect of the laser and the elevation of the tympanomeatal flap can reactivate viruses resting inside the ganglion geniculi, facial nerve, or facial nuclei. The authors report the case histories of a 55-year-old female, and a 45-year-old male who presented with a delayed facial palsy following laser stapedotomy. The clinical characteristics, the therapeutic options, and the possibility of prevention are discussed. P. Révész, Z. Piski, A. Burián, K. Harmat, and I. Gerlinger Copyright © 2014 P. Révész et al. All rights reserved. Nontuberculous Mycobacteria Immune Reconstitution Syndrome Tue, 11 Nov 2014 06:25:43 +0000 The prevalence of nontuberculous mycobacteria infection (NTM) in Sub-Saharan Africa is estimated to be less than 1%. NTM is often underdiagnosed or misdiagnosed as tuberculosis in patients who present with immune reconstitution syndrome (IRS) following initiation of antiretroviral treatment (ART). Immune reconstitution syndrome is common in patients who start ART with low CD4 counts and high HIV viral load. Furthermore, Mycobacterium avium complex (MAC) commonly infects those with CD4 counts less than 50 cells/mm3. Three patients, with low baseline CD4 counts, presenting with NTM following the initiation of antiretroviral treatment are described in this case series. The first patient presented with disseminated NTM two weeks after commencing antiretroviral treatment. Acid fast bacilli were found in the liver, duodenum, and bone marrow and were suggestive of MAC microscopically. The second developed cervical lymphadenitis following the initiation of ART. Lymph node aspirate culture grew NTM. The last patient developed pancytopenia after 3 months of ART. AFB was seen on bone marrow biopsy. Culture of the bone marrow aspirate was suggestive of NTM. All three patients improved on ethambutol, clarithromycin, and rifampicin. NTM may be underdiagnosed in areas with a high TB prevalence and should be actively excluded by culture. J. C. Mogambery, A. Motala, K. Padayachee, C. Jozi, and H. Dawood Copyright © 2014 J. C. Mogambery et al. All rights reserved. A Challenging Case of an Ectopic Cushing Syndrome Sun, 09 Nov 2014 12:22:17 +0000 Bronchopulmonary carcinoids are rare pulmonary neoplasms although they account for most cases of ectopic ACTH syndromes. When feasible, the mainstay treatment is surgical resection of the tumor. We report the case of a 52-year-old woman with signs and symptoms suggestive of hypercortisolism for 12 months, admitted to our department because of community acquired pneumonia. Blood hormone analysis showed increased levels of ACTH and urinary free cortisol and nonsuppressibility to high- and low-dose dexamethasone tests. Pituitary MRI showed no lesion and no central-to-peripheral ACTH gradient was present in bilateral inferior petrosal sinus sampling. CRH stimulation test suggested an ectopic ACTH source. Thoracic CT scan revealed a nodular region measuring 12 mm located in the inferior lingular lobule of the left superior lung with negative uptake by 18-FDG-PET scan and negative SRS. The patient was successfully treated with an atypical lung resection and histology revealed an atypical bronchial carcinoid tumor with positive ACTH immunoreactivity. This was an interesting case because the patient was admitted due to pneumonia that may have been associated with her untreated and chronic hypercortisolism and a challenging case of ectopic ACTH syndrome due to conflicting results on the diagnostic exams. Joana Menezes Nunes, Elika Pinho, Isabel Camões, João Maciel, Pedro Cabral Bastos, Conceição Souto de Moura, and Paulo Bettencourt Copyright © 2014 Joana Menezes Nunes et al. All rights reserved. Melanoma Arising after Imiquimod Use Sun, 09 Nov 2014 00:00:00 +0000 Imiquimod belongs to the class of 1H-imidazo-[4,5-c]quinolones—drugs originally developed as nucleoside analogues with the aim of finding new potential antiviral agents (Harrison et al., 1988). Indeed, Imiquimod was first released as treatment for genital warts before its actions against skin cancer were studied. Imiquimod is a relatively small sized molecule (Mr = 240.3) and is hydrophobic, allowing it to penetrate the skin epidermal barrier and therefore making it suitable for topical formulations (Gerster et al., 2005). Imiquimod has shown itself effective against skin cancers and precancerous lesions, especially basal cell cancers and actinic keratosis (Salasche et al., 2002, Beutner et al., 1999). There have been reports of Imiquimod being used as topical treatment against cutaneous metastases of melanoma and some authors have reported its use as first-line therapy against melanoma in situ (Smyth et al., 2011, Gagnon, 2011). We report a case of an invasive malignant melanoma arising de novo at the specific site of application of Imiquimod (Aldara cream 5%) for a biopsy-proven superficial BCC. Therefore while Imiquimod has added to our topical armamentarium against skin cancer, care must be exercised in prescribing this treatment and it is especially important to follow up patients regularly. Sharad P. Paul Copyright © 2014 Sharad P. Paul. All rights reserved. Hypernatremia: Correction Rate and Hemodialysis Sun, 09 Nov 2014 00:00:00 +0000 Severe hypernatremia is defined as serum sodium levels above 152 mEq/L, with a mortality rate ≥60%. 85-year-old gentleman was brought to the emergency room with altered level of consciousness after refusing to eat for a week at a skilled nursing facility. On admission patient was nonverbal with stable vital signs and was responsive only to painful stimuli. Laboratory evaluation was significant for serum sodium of 188 mmol/L and water deficit of 12.0 L. Patient was admitted to medicine intensive care unit and after inadequate response to suboptimal fluid repletion, hemodialysis was used to correct hypernatremia. Within the first fourteen hours, sodium concentration only changed 1 mEq/L with a fluid repletion; however, the concentration dropped greater than 20 mEq/L within two hours during hemodialysis. Despite such a drastic drop in sodium concentration, patient did not develop any neurological sequela and was at baseline mental status at the time of discharge. Saima Nur, Yasir Khan, Saadia Nur, and Hassan Boroujerdi Copyright © 2014 Saima Nur et al. All rights reserved. Rapunzel Syndrome: A Rare Presentation with Giant Gastric Ulcer Thu, 06 Nov 2014 09:05:04 +0000 The Rapunzel syndrome refers to an uncommon and rare form of trichobezoar that extends past the stomach into the small intestines. The Rapunzel syndrome is usually found in young female patients with a history of psychiatric disorders, mainly trichotillomania and trichophagia. We describe a case of Rapunzel syndrome in a 15-year-old girl who presented with abdominal pain, vomiting, and weight loss. We performed a surgical laparotomy and successfully removed a huge trichobezoar extending into the small intestine. Antonios Athanasiou, Adamantios Michalinos, Demetrios Moris, Eleftherios Spartalis, Nikolaos Dimitrokallis, Vaios Kaminiotis, Demetrios Oikonomou, John Griniatsos, and Evangelos Felekouras Copyright © 2014 Antonios Athanasiou et al. All rights reserved. An Adult Patient with Systemic Mastocytosis and B-Acute Lymphoblastic Leukemia Thu, 06 Nov 2014 00:00:00 +0000 Mastocytosis is a myeloproliferative neoplasm characterized by clonal expansion of abnormal mast cells, ranging from the cutaneous forms of the disease to mast cell leukemia. In a significant proportion of patients, systemic mastocytosis (SM) coexists with another hematologic malignancy, termed systemic mastocytosis with an associated hematologic nonmast cell lineage disorder (SM-AHNMD). Despite the pronounced predominance of concomitant myeloid neoplasms, the much more unusual coexistence of lymphoproliferative diseases has also been reported. Imatinib mesylate (IM) has a role in the treatment of SM in the absence of the KITD816V mutation. In the setting of SM-AHNMD, eradicating the nonmast cell malignant clone greatly affects prognosis. We report a case of an adult patient with SM associated with B-lineage acute lymphoblastic leukemia (B-ALL). Three cases of concurrent adult ALL and mastocytosis have been reported in the literature, one concerning SM and two concerning cutaneous mastocytosis (CM), as well as six cases of concomitant CM and ALL in children. Theodoros Iliakis, Niki Rougkala, Panagiotis T. Diamantopoulos, Vasiliki Papadopoulou, Fani Kalala, Konstantinos Zervakis, Nefeli Giannakopoulou, Polixeni Chatzinikolaou, Georgia Levidou, Eleftheria Lakiotaki, Penelope Korkolopoulou, Efstratios Patsouris, Eleni Variami, and Nora-Athina Viniou Copyright © 2014 Theodoros Iliakis et al. All rights reserved. Spontaneous Aching Pain and Peculiar Involuntary Movements: A Case Report of Painful Legs and Moving Toes and Review of the Literature Mon, 03 Nov 2014 09:43:25 +0000 Painful legs and moving toes (PLMT) is a rare syndrome characterized by spontaneous neuropathic pain and peculiar involuntary movements in the lower limbs, especially the toes and feet. As it is a relatively rare disorder worldwide, the exact pathophysiology still remains a mystery. Until recently, numerous methods of clinical treatments have been tried; however, the success rate of the therapies is still very low. Here, we report a case of PLMT and also summarize the recent clinical and research literatures regarding clinical presentation, electrophysiological features, etiology, treatment methods, and prognosis of this disorder. Doctors should be aware of this rare syndrome in a patient with painful and/or restless legs. On the other hand, multiple clinical treatments should be tried, even those which usually produce a poor outcome. Yang-yi Fan, Yan Xu, and Xu-guang Gao Copyright © 2014 Yang-yi Fan et al. All rights reserved. Acroparesthesia in a Female: Diagnostic Dilemma Sun, 02 Nov 2014 00:00:00 +0000 Fabry disease is an X-linked lysosomal storage disorder caused by deficient activity of a-galactosidase A (also known as ceramide trihexosidase) and resultant accumulation of globotriaosylceramide (Gb3) and related glycophospholipids. The disease affects nearly all major organ systems, with the primary sites damaged by Gb3 including renal glomeruli, myocardium, neurons of the dorsal ganglion and autonomic nervous system, and vascular endothelial and smooth muscle. Progressive deposition in these organ systems leads to renal and heart failure; debilitating pain as a result of nervous system involvement also occurs. Fnu Kelash, Lara Kujtan, and Padmaja V. Mallidi Copyright © 2014 Fnu Kelash et al. All rights reserved. A Case of Hemophagocytic Syndrome due to Tuberculosis: Uncommon Manifestation of a Common Disease Mon, 27 Oct 2014 09:30:53 +0000 Hemophagocytic syndrome, also known as hemophagocytic lymphohistiocytosis (HLH), is the manifestation of immune dysregulation. It is associated with ineffective but exaggerated immune response and infiltration of active lymphocytes and histiocytes in various organs. This devastating clinical condition has myriad of clinical and biochemical manifestations such as fever, splenomegaly, pancytopenia, hypertrygliceridemia, and hyperferritinemia. It can be either primary or secondary. Primary HLH usually presents in childhood. Secondary HLH occurs due to infection mostly viruses but other aetiologies are also important as early detection and treatment may improve survival. Hemophagocytosis due to tuberculosis is uncommon. Only handful of cases have been reported mostly in immunocompromised patients. We report a case of hemophagocytic syndrome associated with disseminated tuberculosis in an immunocompetent women highlighting early diagnosis and treatment is a demanding need in this devastating disease. Arijit Singha, Adreesh Mukherjee, Riddhi Dasgupta, and Tapas Das Copyright © 2014 Arijit Singha et al. All rights reserved. Conjunctival Metastasis as an Initial Sign of Small Cell Lung Cancer Thu, 23 Oct 2014 13:48:53 +0000 Introduction. To report a case of a conjunctival metastasis as the initial manifestation of small cell lung cancer. Methods. Observational case report. Results. A 50-year-old man without known systemic disease developed a conjunctival mass in his right eye. He underwent incisional biopsy of the tumor and systemic evaluation. Histopathologically, the conjunctival mass was a metastatic small cell carcinoma. Further evaluation revealed a primary small cell lung carcinoma with metastasis to liver and bones. The primary and metastatic tumors were treated with chemotherapy. Conclusion. Conjunctival metastasis may be the initial manifestation of lung cancer. It should be considered in the differential diagnosis of a deep conjunctival mass. Afsun Sahin, Nilgun Yildirim, Deniz Goren Sahin, Hikmet Basmak, and Mustafa Acikalin Copyright © 2014 Afsun Sahin et al. All rights reserved. Blastocystis and Schistosomiasis Coinfection in a Patient with Chronic Kidney Disease Sun, 19 Oct 2014 09:47:32 +0000 Chronic kidney disease (CKD) and end-stage renal disease (ESRD) represent a spectrum of impaired immunity with effects on cellular immunity, soluble immune factors, and inflammation. As a result, infections due to impaired immune system responses are responsible for significant morbidity in patients with kidney disease. Because of immune dysfunction in CKD, these patients have reduced probability to clear infections and are susceptible to pathogenic effects of common organisms. We present a case of a patient with CKD coinfected with Schistosoma mansoni and Blastocystis spp. This appears to be the first reported association of Schistosoma mansoni and Blastocystis spp. in a patient with CKD. Colin R. Young and Fred E. Yeo Copyright © 2014 Colin R. Young and Fred E. Yeo. All rights reserved. Coexisting Mantle Cell Lymphoma and Prostate Adenocarcinoma Thu, 16 Oct 2014 11:42:31 +0000 Prostatic mantle cell lymphoma (MCL) is a very rare entity with only 5 reported cases in the literature. We report a case of coexisting MCL and prostate adenocarcinoma (PCa) in an elderly male and review the morphologic features of classic and rare prostatic MCL subtypes. Careful morphologic evaluation and immunohistochemical findings of positive CD5, CD20, and cyclin D1 and negative CD23 and CD3 can guide us to the diagnosis of MCL. Given the fact that transurethral resection of prostate is done quite routinely, this paper draws attention to the manner in which long standing bladder outlet obstruction and postbiopsy prostate specimens with dense lymphoid infiltration can masquerade as lymphoma. It highlights the importance of exercising care while reviewing prostate specimens with evidence of chronic prostatitis so as not to miss this rare neoplasm. Ashish B. Rajput, Bruce Burns, Ronald Gerridzen, and Richard van der Jagt Copyright © 2014 Ashish B. Rajput et al. All rights reserved.