Primary diffuse large B-cell lymphoma of the fallopian tube treated with a combination of surgery and chemotherapy: Case report

Rationale:Primary female genital tract lymphomas are sporadic neoplasms, accounting for 0.2% to 1.1% of all cases of extranodal lymphoma. The most common genital localizations are the cervix, the uterine corpus and the ovary, while primary lymphomas of the fallopian tube are quite unusual. According to literature searching in PubMed, this is the first reported case of primary diffuse large B-cell lymphoma of the fallopian tube.Patient concerns:A 52-year-old woman presented with a more than 2 months history of intermittent lower abdominal pain. The gynecological examination showed that the uterus, as big as 3 months of pregnancy, had weak activity and no tenderness. The uterine rectum lacuna was like a hard nodule of about 3 × 2 cm, and an irregular solid mass was fixed and inactive in the right adnexa.Diagnoses:In accordance with Ann Arbor staging system, a stage IE primary diffuse large B-cell lymphoma of fallopian tube was diagnosed for this patient, based on the tumor pathology, the results of bone marrow biopsy and computed tomography (CT) scan.Interventions:After gynecological/urinary ultrasound, blood test, pelvic contrast enhanced CT scan and CT angiography of iliac artery, exploratory laparoscopy and following hysterectomy with bilateral salpingo-oophorectomy were performed. After the surgery, the patient was treated with combined Rituximab and chemotherapy and got complete response (CR).Outcomes:After the operation and R-CHPOP, following up for more than 1 year so far, the patient has no tumor recurrence and is still in good condition.Lessons:It is very difficult to diagnose the primary diffuse large B-cell lymphoma of fallopian tube, not only because of its rarity, but also because of its non-specific clinical manifestations. It easily be treated as late ovarian cancer by gynecologist. So the pathology diagnosis and surgeons’ decision is very important. Because lymphoma is pretty sensitive to chemotherapy and easy to get complete response, so we no need to do an operation like ovarian cancer and should put chemotherapy as a primary method for lymphomas of the female genital tract.     

A rare case of nevus sebaceous of the bilateral labia minora: A case report and review of literature

Rationale:Nevus sebaceous (NS) is a lesion caused by congenital hyperplastic disorder of the sebaceous glands. It commonly noted in the scalp and face and rarely in the trunk, neck, or oral mucosa. We present a rare case of a lesion arising in the genital region.Patient concerns:A 47-year-old woman complained of a gradual increase in the size of her bilateral labia minora over 2 years, which affected her sexual life and caused walking difficulty. She was admitted to the Department of Obstetrics and Gynecology. On physical examination, no ulcer, discharge, and vulval or vaginal bleeding were found. The bilateral inguinal lymph nodes were not palpable, bilateral labia minora were asymmetric, and the right side was evidently bigger than the left. The labia minora had serrated edges and numerous papillae with a maximum diameter of 0.5 cm. The vagina, cervix, and uterus with its attachments were normal. Blood samples tested negative for human immunodeficiency virus, human papilloma virus, hepatitis B virus, and hepatitis C virus.Diagnosis:A diagnosis of NS of the bilateral labia minora was made following histopathological examination of the resected specimen.Intervention:The bilateral labia minora lesions were resected general anesthesia on August 29, 2016. The operation was successful, and intraoperative blood loss was about 10 ml.Outcomes:After 40 months of postoperative follow-up, no recurrence or appearance of other tumors were noted.Lessons:We recommend surgical removal of lesions in the genital area during adolescence or before adulthood. Adolescence may be the best period for surgical intervention owing to a greater risk of malignant change in adulthood. On the other hand, surgical risk should be avoided in children considering the low incidence of malignant transformation.     

Risk factors and clinical characteristics associated with a ruptured ectopic pregnancy: A 19-year retrospective observational study

Ectopic pregnancy is the most common cause of maternal mortality in the first trimester of pregnancy. The aim of this study was to find risk factors and clinical characteristics associated with ruptured ectopic pregnancies at a medical center in eastern Taiwan in a 19-year period. This was a retrospective observational study that included patients diagnosed with ectopic pregnancy between August 1999 and December 2018. Data about the demographic variables, initial presentation, pre-treatment beta-human chorionic gonadotropin levels, treatment routes (laparoscopy or laparotomy), surgical methods (salpingostomy or salpingectomy), operation time, blood loss amount, the status of ectopic pregnancy (ruptured or unruptured), the requirement for transfusion, and duration of hospital stay were collected. The categorical and continuous variables were analyzed using the correlation coefficients. This study included 225 women who were diagnosed as having an ectopic pregnancy. There were 49 and 176 women with unruptured and ruptured ectopic pregnancies, respectively. The beta-human chorionic gonadotropin levels, history of previous ectopic pregnancy, pelvic inflammatory disease, tubal surgery, abdominal history, and vaginal bleeding were not significantly different between the 2 groups. The ratio of women with abdominal pain was significantly higher in the ruptured ectopic pregnancy group than in the unruptured group (89.1% vs. 63.8%, respectively, P < .001). Preoperative hemoglobin was lower in the ruptured group compared with the unruptured group (P < .001). Blood loss, postoperative hemoglobin, and blood transfusion were significantly higher in the ruptured group than in the unruptured group (P = .000 and P = .001 for blood loss and blood transfusion, respectively). Multiple logistic regression analysis revealed that abdominal pain and blood loss were associated with ruptured tubal pregnancies (adjusted odds ratio [95% confidence intervals]: 3.42 {1.40, 8.40}; 1.01 {1.005, 1.014}, respectively). In conclusion, early pregnancy with abdominal pain, more parity, and lower preoperative hemoglobin should be aware of the possibility of ruptured ectopic pregnancy. More blood loss, transfusion and lower postoperative hemoglobin were also noted with ruptured ectopic pregnancy.     

Successful treatment of radiotherapy and apatinib in patient with mediastinal mixed non-seminomatous germ cell tumor: A case report

Rationale:Mediastinal non-seminomatous germ cell tumors (MNSGCTs) are rare malignancies. Chemotherapy followed by surgical resection has been regarded as the standard management, but treatment options for chemotherapy-refractory patients or those with unresectable tumors are limited, resulting in a very poor prognosis.Patient concerns:An 18-year-old female presented with symptoms of cough, chest tightness, and shortness of breath for 2 months, and the symptoms gradually worsened.Diagnosis:Computed tomography (CT) revealed a large mediastinal mass invading the pericardium and great blood vessels. Serum human chorionic gonadotropin (HCG) and α-fetoprotein (AFP) levels were normal. Histopathological examination of biopsy specimens revealed mixed MNSGCT with embryonal carcinoma and immature teratoma components.Interventions:The patient achieved complete remission (CR) and long-term survival after multimodal therapy comprising chemotherapy, positron emission tomography/CT (PET/CT)-guided volumetric-modulated arc therapy (VMAT), and anti-angiogenic targeted therapy.Outcomes:The patient was followed up for more than 4 years without recurrence, metastasis, or treatment-related adverse effects.Lessons:The case presented here highlights the importance of multidisciplinary diagnosis and treatment, providing evidence that radiotherapy and anti-angiogenic therapy may play an important role in unresectable or residual tumors after failure of conventional treatments of MNSGCT. Percutaneous biopsy is necessary for diagnosis if the tumor is unresectable, and serum AFP and HCG levels are normal. Additionally, PET/CT is an effective method for evaluation of efficacy and radiotherapy guidance for patients with MNSGCTs.     

Anisocoria after scopolamine transdermal patch contamination: A case report

Rationale:We report a case of anisocoria that occurred after contamination with a scopolamine transdermal patch, and introduce a diagnostic approach for anisocoria patients.Patient concerns:A 35-year-old woman with no past ophthalmologic history presented to the ophthalmology department complaining of a dilated pupil in the right eye. Corrected visual acuities was 20/20 in both eyes, and the intraocular pressures were 20 and 18 mm Hg in the right and left eye, respectively. The anterior chambers in both eyes were unremarkable on slit-lamp examination. The pupil size was 5.0 mm in the right eye and 2.0 mm in the left eye, and the extraocular muscles of both eyes were intact.Diagnosis:The patient neither did present with facial anhidrosis nor did she present with ptosis. Furthermore, as we did not observe dilatation lag in the smaller pupil, we applied 1% apraclonidine in the left eye in order to rule out Horner syndrome and did not observe dilatation of the pupil. We then applied 0.125% and 1% pilocarpine to exclude oculomotor nerve palsy; however, it could not be ruled out as constriction of pupil to 3.1 mm in the right eye was observed after applying 1% pilocarpine. Moreover, upon further investigation, we discovered that the patient had a scopolamine transdermal patch applied for 2 days prior to the clinic visit.Interventions:Artificial tears were administered and the patient was observed and monitored.Outcomes:The pupil size in the right eye gradually decreased to 4.5 mm on the second day of observation and to 3.6 mm on the fourth day of observation.Lessons:A detailed history of the use of medications such as scopolamine patches in patients with unilateral dilated pupils without vision loss is of utmost importance. We report the exclusion of important diseases using pilocarpine and apraclonidine hydrochloride. It was confirmed that improvement naturally occurs over time.     

Primary hyperparathyroidism presenting as a brown tumor with hypercalcemia crisis in a second-trimester pregnant woman: A case report

Introduction:Primary hyperparathyroidism (PHPT) in pregnancy is rare and unrecognized because the maternal physiological adaptations blurs the symptoms. There is no standard treatment strategy for maternal PHPT. Early diagnosis and interventions can prevent catastrophic consequences to the mother and fetus.Patient concerns:A 31-year-old Chinese woman was admitted, due to a lump on the left lower leg for 4 months. The patient complained of mild pain in the left lower leg following exercise that could be relieved after a short rest. The patient was at 18 weeks of gestation, and the growth of the fetus was normal. The patient has a 3-year history of hypercalcemia and a 2-year history of nephrolithiasis. No family history of hypercalcemia and endocrine tumors were present.Diagnosis:Laboratory tests demonstrated high serum calcium level of 3.84 mmol/L, parathyroid hormone 1393 pg/mL, alkaline phosphatase 488 μ/L. Ultrasound showed a 22.4 mm × 7.8 mm solid nodule in the left lower lobe of the thyroid gland. Based on these findings, the patient was diagnosed with PHPT.Interventions:The patient accepted continuous renal replacement to reduce ironized calcium level. Parathyroidectomy was performed at the 19th week of gestation. Threatened abortion occurred 2 days after the surgery, and magnesium sulfate was used to prevent the abortion. Calcium gluconate, calcium carbonate and vitamin D3 were used to treat the hypocalcemia that occurred 5 days after the surgery.Outcomes:Pathology examination demonstrated the parathyroid adenoma. Abortion was prevented using magnesium sulfate and hypocalcemia was cured with calcium gluconate, calcium carbonate and vitamin D3. At 38-week of gestation, the patient (ionized calcium level: 2.16 mmol/L) delivered a healthy female baby weighing 2700 g with 10/10 Apgar. Till now, both the mother and infant showed no complications.Conclusion:Maternal PHPT is rare and challenging to diagnose, causing life-threatening complications to mother and fetus. Any decision regarding surgery for a pregnant woman with primary hyperparathyroidism is more complex than in men or nonpregnant women. The decision should be made based on the severity of hypercalcemia and symptoms.     

A rare case report of anal canal adenocarcinoma

Rationale:Anal canal adenocarcinoma is a kind of rare malignant tumor of the intestinal tract with a low incidence rate.Patient concerns:A 42-year-old man came to our department with anal tenderness accompanied by intermittent drainage of mucus discharge for 2 weeks.Diagnoses:The computer tomography showed a strip-shaped high-density shadow in the rectal wall. The magnetic resonance imaging showed a cyst-like mass of about 33 × 57 × 30 mm in the anal area. The lesion penetrated the anal canal, and plaque-shaped high signal shadow can be seen in the left side of the anus. The intraoperative pathology indicated the mass as anal canal adenocarcinoma.Interventions:The abdominal perineal resection was performed for this patient. The postsurgical pathology showed that the tumor was anal canal adenocarcinoma with large amounts of mucus.Outcomes:The patient recovered well and was discharged from our department at 12th day post-surgery. This patient received further pelvic radiotherapy.Lessons:Anal canal adenocarcinoma is a kind of malignant tumor that is extremely rare clinically. Computer tomography, magnetic resonance imaging, coloscopy, and histopathology are vital for the diagnosis of anal canal adenocarcinoma. Comprehensive treatment, including abdominal perineal resection, radiotherapy, and chemotherapy, is important for the treatment of anal canal adenocarcinoma.     

Changes in tapered endotracheal tube cuff pressure after changing position to hyperextension of neck: A randomized clinical trial

Background:Endotracheal tube (ETT) with a tapered-shaped cuff had an improved sealing effect when compared to ETTs with a conventional cylindrical-shaped cuff. Positional change and neck movement typically displace an ETT and change the intracuff pressure. The aim of the current study was to compare the ETT cuff pressure in the TaperGuard ETT vs the conventional ETT after a change from the supine, neutral position to the extension of the neck and semi-Fowler position for thyroid surgery.Methods:This prospective, randomized clinical trial included 50 patients undergoing thyroidectomy. Patients were randomly allocated into one of the 2 groups: tracheal intubation with the TaperGuard ETT or with a conventional ETT. The ETT cuff was inflated with air and the ETT cuff pressure was set initially at 20 cmH₂O using a calibrated cuff manometer. ETT cuff pressure and distance from carina to ETT tip were measured at supine and semi-Fowler positions with neck extension.Results:After the position change, the ETT tip migrated cephalad and cuff pressure increased in the majority of cases. ETT cuff pressure was significantly higher in the TaperGuard group than the conventional group (28.0 ± 6.6 cmH₂O and 22.8 ± 4.5 cmH₂O, respectively, P = .001). The degree of cephalad displacement of the ETT tip was comparable between the 2 groups (19.4 ± 6.31 mm in TaperGuard group and 21.9 ± 6.9 mm in conventional group, P = .12).Conclusions:After the position change from supine to hyperextension of the neck, the ETT cuff pressure was higher in the TaperGuard ETT than in the conventional ETT, although the extent of displacement of the ETT was comparable between the 2 groups.     

Conjoined twins in a spontaneous monochorionic triplet pregnancy: A case report and literature review

Rationale:Conjoined twins are a rare complication of monochorionic pregnancies and an extremely rare condition in spontaneous triplet pregnancies. We report a case of conjoined twins in a spontaneous monochorionic triplet pregnancy. The conjoined twins might have suffered from twin anemia-polycythemia sequence, which was reported to be extremely rare.Patient concerns:A 26-year-old woman conceived spontaneously with an obstetric history of invasive mole 4 years ago.Diagnoses:We initially misdiagnosed her as having monochorionic triamniotic triplets at 10 weeks of gestation. However, we confirmed conjoint twins with the monochorionic diamniotic triplet pregnancy at 12 weeks of gestation and classified them as omphalopagus.Interventions:As the woman decided to continue the pregnancy, regular and careful antenatal care was conducted.Outcomes:Unexpectedly, she had a stillbirth 3 weeks later and had to terminate the pregnancy at 15 weeks of gestation. After abortion, the diagnosis of omphalopagus was confirmed in the induced fetuses. Moreover, the skin colors of the conjoined twins were different: one was plethoric, and the other was pale. Additionally, the parents agreed to examine the chromosome of the fetuses, and the results were normal.Conclusion:Dichorionic triplet and monochorionic triplet pregnancies have a poorer prognosis than trichorionic triplet pregnancies. Surgery is the main therapy for conjoined twins; however, most conjoined twins in triplet pregnancies cannot survive, including omphalopagus twins. The conjoined twins may have suffered from twin anemia-polycythemia sequence, which could probably not be diagnosed intrauterine. Transvaginal probe and 3-dimensional ultrasound may be helpful for clarifying the diagnosis in early pregnancy.     

Uterine leiomyoma with fumarate hydratase deficiency: A case report

Rationale:Hereditary leiomyomatosis and renal cell carcinoma is an uncommon autosomal dominant disease caused by mutations in the fumarate hydratase (FH) gene. They usually demonstrated multiple uterine myomas and preformed surgical procedures for myomectomy and/or hysterectomy 10 years earlier than sporadic myomas due to early development. This case report describes a woman with multiple uterine leiomyomas diagnosed with FH deficiency.Patient concerns:A 37-year-old woman visited a gynecological clinic for the discovery of uterine leiomyoma for more than 1 year. The size of the largest grew from 42 × 27 × 46 to 98 × 85 × 113 mm in 1 year. She had a history of surgery for breast cancer and thyroid cancer but denied a history of uterine leiomyoma in her family.Diagnosis and Interventions:The patient underwent successful transabdominal hysterectomy. The pathological results showed multiple uterine leiomyomas (partly cellular leiomyomas) with scattered large bizarre giant cells. Immunohistochemistry results demonstrated FH deficiency.Outcomes:On follow-up, the patient did not have any complications. She was finally referred to the oncologists and urologists for follow-up.Lessons:Gynecologists should be aware that early onset uterine leiomyoma presenting as large, multiple, and symptomatic lesion, may be associated with FH deficiency.     

Preoperative neoadjuvant targeted therapy with apatinib for inoperable differentiated thyroid cancer: A case report

Rationale:Though the majority of differentiated thyroid cancer (DTC) patients have a good prognosis after careful and standardized therapy, approximately 13% to 15% of DTC cases show surprisingly aggressive behavior and invasion of the surrounding structures, and a few progress to unresectable diseases. In this study, we report a case of an inoperable locally advanced DTC patient who underwent a curative operation after treatment of preoperative monotherapy of apatinib in a short time.Patient concerns:A 64-year-old woman complained of dysphagia due to large cervical mass, which severely invaded the left esophagus at the junction of the neck and thorax.Diagnoses:The female patient was diagnosed with locally advanced papillary thyroid cancer (PTC) by cytopathology and it was difficult to perform a safe and complete removal.Interventions:Apatinib (500 mg orally once a day) was initially used to treat this patient as a neoadjuvant therapy.Outcomes:Six weeks later, the tumor dramatically shrunk from 56 × 37 mm to 29 × 26 mm with well-controlled mild hypertension. After a 10-day interval of apatinib withdrawal, complete tumor excision was accomplished through cervical incision without esophageal fistula. Postoperative thyroid stimulating hormone suppression and radioiodine ¹³¹I ablation therapy were performed. At the 1-year follow-up evaluation, no tumor recurrence or metastasis was observed.Lessons:Preoperative short term targeted treatment with apatinib for locally advanced inoperable DTC may become a promising neoadjuvant therapy that, can reduce the tumor size and decrease stage, thus making the complete and safe removal of the lesion feasible.     

Successful endovascular therapy for an adolescent patient with cerebral venous sinus thrombosis: A case report

Rationale:Cerebral venous sinus thrombosis associated with protein S deficiency is rare in adolescent patients and has high disability and fatality.Patient concerns: A 15-year-old male student presented in the hospital with sudden headache, nausea, and vomiting and was diagnosed with protein S deficiency by gene testing.Diagnoses:Cerebral venous sinus thrombosis due to protein S deficiency was diagnosed in this adolescent patient, who underwent successful endovascular therapy (EVT).Interventions:The patient was treated with standard anti-coagulation therapy including low-molecular-weight heparin (90 IU/kg/Q12 h) and dehydrant (mannitol 125 mL Q8 h); however, the symptoms were not alleviated. Successful EVT was implemented.Outcomes:Both the superior sagittal sinus and bilateral transverse sinus were recanalized after thrombus clearance. The patient achieved a complete recovery without any other stroke recurrence during follow-up.Lessons:EVT can be performed with favorable and effective clinical outcomes in adolescent cerebral venous sinus thrombosis patients with protein S deficiency. EVT associated with standard anti-coagulation therapy may improve the prognosis and reduce mortality among such patients.     

Clinicopathological characteristics of primary peritoneal epithelioid mesothelioma of clear cell type: A case report

Rationale:Primary peritoneal epithelioid mesothelioma of clear cell type is an extremely rare entity composed of clear cytoplasm. It is challenging to diagnose because of the morphological resemblance to clear cell tumor.Patient''s concerns:A 69-year-old male patient had swollen lymph nodes in the right inguinal region for 7 months and was constipated for 1 month.Diagnosis:The patient was diagnosed as peritoneal epithelioid mesothelioma of clear cell type based on computed tomography scan, pathology, immunohistochemistry, special staining and whole-exome sequencing. This patient harbored VHL gene alteration in exon 1 and homologous recombination defect (with a score of 45). This finding indicated that this patient might be sensitive to platinum-based therapy and Poly ADP-ribose Polymerase (PARP) inhibitor. This patient carried no microsatellite instability, a low level of tumor mutation burden, and a high extent of intratumoral heterogeneity. Eighteen neoantigens were detected.Interventions:The patient received surgery-based multidisciplinary treatment by integrating cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). HIPEC was administered with docetaxel 120 mg plus cisplatin 120 mg, at 43°C, for 60 minutes. After operation, the patient received intravenous (IV) chemotherapy with docetaxel 60 mg, pemetrexed 750 mg and cisplatin 100 mg, and then intraperitoneal (IP) chemotherapy with docetaxel 40 mg. The patient received interventional therapy of hepatic artery embolization for 5 times.Outcomes:Regular follow-up was performed until Oct 14, 2020. The patient died 31.6 months later owing to incomplete intestinal obstruction.Lessons:Primary peritoneal epithelioid mesothelioma of clear cell type needs to be differentiated from a variety of clear cell tumors. This disease is characterized by specific genetic alteration. Whole-exome sequencing contributes to guide individualized therapy. CRS-HIPEC helps achieve long-term overall survival.     

Staged vs simultaneous bilateral unicompartmental knee arthroplasty for clinical outcomes: A protocol of systematic review and meta-analysis

Background:Bilateral unicompartmental knee arthroplasty (UKA) can be divided into one or two stages clinically. Compared with staged bilateral UKA, whether simultaneous bilateral UKA has better clinical efficacy remains to be verified.Methods:PubMed, EBSCO, and Web of Science were searched by us for meta-analysis. Studies were considered eligible for inclusion if they included simultaneous and staged UKA. We excluded studies unrelated to the research question, studies in non-selected languages, and studies where the full-text was not available. The data were extracted by two independent investigators, and disagreements were resolved through discussions with a third party. If important data or information about the content of the paper were not available, authors were contacted. Publication bias in studies has been assessed. Meta-analysis was done using Review Manager 5.3.Results:The systematic review and meta-analysis identified 3370 trials, of which 8 studies (963 patients) compared simultaneous with staged bilateral UKA. The meta-analysis showed that the clinical outcomes of simultaneous bilateral UKA goes down in operating time (weighted mean difference [WMD] = −19.34, 95% confidence interval [CI] −22.44 to −16.25, P < .00001), postoperative hemoglobin (Std. mean difference [SMD] = −0.46, 95% CI −0.71 to −0.20, P = .0004), length of stay (LOS) (WMD = −4.73, 95% CI −6.39 to −3.06, P < .00001), hospital cost (SMD = −5.42, 95% CI −6.54 to −4.30, P < .00001). There were no significant difference in blood transfusion, venous thrombosis, infection, cardiac complications, pulmonary complications, Oxford Knee Score (OKS) between simultaneous and staged bilateral UKA.Conclusion:Simultaneous bilateral UKA can effectively reduce the operating time, LOS, and hospital cost without increasing postoperative complications compared to stage bilateral UKA.Registration number:CRD42020160056 (www.crd.york.ac.uk/prospero/).     

Acute autoimmune transverse myelitis following COVID-19 vaccination: A case report

Rationale:Transverse myelitis is an infectious or noninfectious inflammatory spinal cord syndrome. We report a rare case of transverse myelitis following vaccination against COVID-19.Patient concerns:A 70-year-old male presented with progressive sensorimotor dysfunction of the bilateral lower limbs 7 days after receiving the mRNA-1273 vaccine against COVID-19. Spinal magnetic resonance imaging revealed intramedullary lesions with gadolinium enhancement on the Th1/2 and Th5/6 vertebral levels. Cerebrospinal fluid (CSF) testing showed a mildly increased level of total protein and positive oligoclonal bands (OCB).Diagnosis:The patient was diagnosed with acute transverse myelitis.Intervention:The patient received 5 days of intravenous methylprednisolone pulse (1000 mg/day) followed by oral prednisolone (30 mg/day with gradual tapering).Outcomes:The patient fully recovered from muscle weakness of the lower limbs. He was discharged from our hospital and able to independently walk without unsteadiness.Lesson:This is a rare case of transverse myelitis following COVID-19 vaccination. Positive OCB in CSF in the present case highlights the possibility of autoimmune processes, including polyclonal activation of B lymphocytes, following vaccination.     

Cerebral large artery occlusion in chronic graft-versus-host disease: A case report

Rationale:Cerebral large artery occlusion in chronic central nervous system graft-versus-host disease after allogeneic hematopoietic stem cell transplantation (allo-HSCT) was very scarce. We described a young patient with bilateral white matter lesions and symptomatic internal carotid artery occlusion after allo-HSCT with the history of aplastic anemia.Patient concerns:A 17-year-old girl with the history of aplastic anemia developed recurrent headache and sudden hemiplegia of right limbs 2 years after allo-HSCT.Diagnoses:She was diagnosed with skin chronic graft-versus-host disease 19 months after allo-HSCT. Brain magnetic resonance imaging showed bilateral subcortical white matter abnormal signals and hyperintensity of left fronto-parietal lobe on diffusion weighted imaging and corresponding hypointense apparent diffusion coefficients indicating acute infarction. CT angiography revealed thrombosis in left internal carotid artery. Carotid plaque high-resolution magnetic resonance imaging showed annular enhancement of vascular wall revealing signs of vasculitis.Interventions:Intravenous immunoglobulin, methylprednisolone, and anticoagulant therapy were used to treat the patient.Outcomes:The patient''s symptoms gradually resolved and she could walk with assistance after 3 weeks before returned home.Lessons:Chronic graft-versus-host disease-associated vasculitis could involve cerebral large vessels which warrants further study.     

Anaphylactic shock in a patient with severe aortic stenosis treated with adrenaline and landiolol for circulatory management: A case report

Rationale:We present the first case of a patient with severe aortic stenosis who developed anaphylactic shock and was successfully treated with adrenaline and landiolol, a highly selective β1-receptor blocker, to prevent disruption of the myocardial oxygen supply–demand balance caused by tachycardia.Patient concerns:An 86-year-old woman was scheduled for simultaneous anterior–posterior fixation for a burst fracture of the 12th thoracic vertebra; 200 mg sugammadex, a neuromuscular blocking agent antagonist, was administered postoperatively, and she was extubated without complications. However, 6 min after extubation, her blood pressure decreased abruptly to 55/29 mm Hg, and her heart rate increased to 78 bpm. Then, we intervened with fluid loading, an increased dose of noradrenaline, and phenylephrine administration. However, her blood pressure did not increase.Diagnoses:A general observation revealed urticaria on the lower leg; thus, we suspected anaphylactic shock due to sugammadex administration.Interventions:We carefully administered 2 doses of 0.05 mg adrenaline and simultaneously administered landiolol at 60 μg/kg/min to suppress adrenaline-induced tachycardia. Adrenaline administration resulted in a rapid increase in blood pressure to 103/66 mm Hg and a maximum heart rate of 100 bpm, suppressing excessive tachycardia.Outcomes:The patient''s general condition was stable after the intervention, and circulatory agonists could be discontinued the following day. She was discharged from the intensive care unit on the fourth postoperative day.Lessons:Landiolol may help control the heart rate of patients with aortic stenosis and anaphylactic shock. The combined use of landiolol and adrenaline may improve patient outcomes; however, their efficacy and risks must be evaluated by studying additional cases.     

Keratinized mucosa augmentation guided by double xenogeneic collagen matrix membranes around implants in the posterior mandible: A case report

Rationale:Traditional free gingival graft (FGG) technique is usually used for patients with insufficient peri-implant keratinized mucosa. However, this technique often requires a second surgical area which increases the pain as well as the risk of infection in patients. Xenogeneic collagen matrix (XCM) membrane technique can obtain good results for keratinized mucosa increment.Patient concerns:The patient was a 66-year-old healthy female with loss of left mandibular first molar and second molar (FDI #36, #37) for 5 years. Two implants were placed submucosally for 3 months with no interference, while a stage II surgery was needed.Diagnosis:Probing depth measurements suggested that the mesial, medial, and distal widths of buccal keratinized mucosa within the edentulous area were 0.5, 0.5, and 1 mm, respectively, which were insufficient to maintain the health of peri-implant tissues.Interventions:Keratinized mucosa augmentation guided by XCM membranes was performed to increase the inadequate buccal keratinized mucosa.Outcomes:After 2 months of healing, the widths of mesial, medial, and distal buccal keratinized mucosa were 4, 3, and 3 mm, respectively, and the thickness of the augmented mucosa was 4 mm. Then a stage II surgery was followed. The patient was satisfied with the outcomes of keratinized mucosa augmentation.Lessons:Keratinized mucosa augmentation guided by double XCM membrane technique can be applied to cases with keratinized mucosa width within 2 mm around implants.