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Patient 3, a 10-year-old boy, was born by normal delivery. His parents did not show cutaneous anomalies. He was admitted for consultation due to episodes of generalized tonic-clonic seizures lasting several minutes: seizures had started at age 2 years. He showed neurodevelopmental delay from his first months of life: his current school performance is poor. An electroencephalographic (EEG) examination revealed spike and wave discharges in the temporal and parietal regions. Treatment with sodium valproate substantially reduced the frequency of seizures. At physical examination, he weighted 34 kg, with a height of 141 cm (75th percentile). The hypopigmented lesions were localized in the thorax and in the back, mainly on the left side. The diameter of the sural region of the lower left limb was 8 cm larger than the contralateral, and the diameter of the biceps region of the left limb was 3 cm larger than the contralateral. The left lower limb was 2 cm longer than the right. The asymmetry involved also the left hemiface. A lower-limb MRI showed increased growth in both long bones and soft tissues. Mild thoracolumbar right kyphoscoliosis was noticed. Brain MRI and ophthalmologic examination were both normal.

A 2-month-old girl was referred to the Department of Dermatology for the evaluation of extending hypopigmented skin lesions. At birth, she had multiple linear erythematous erosive skin defects, which became linear, hypopigmented patches with irregular border on the face, scalp, trunk, and both extremities (). We received the patient's consent form about publishing all photographic materials. The patient had a history of intrauterine growth retardation as a prenatal problem. There was no specific family history, and her two siblings were normal.\nThe patient also presented multiple congenital anomalies. Physical examination revealed patchy alopecia of the scalp, hypoplastic nails, and irregular gingiva with conical teeth. Ocular examination showed bilateral aniridia, moderate to severe microphthalmia, and unilateral corneal central opacity of the left eye (). The retinal vessels of both eyes were uncertain on fundus examination. Musculoskeletal examination revealed syndactyly of toes (), hypoplasia and clinodactyly of fingers, and coccyx deviation. Chromosomal analysis on peripheral blood lymphocytes showed normal karyotype (46, XX) (), and no mutation was found in IKBKG gene test. Therefore, the patient was diagnosed with HI with multiple congenital anomalies.\nTo manage the associated musculoskeletal anomalies, the patient was referred to the Department of Pediatric Orthopedic Surgery and underwent surgical treatment of toe syndactyly. For proper management of the other anomalies, she had been undergoing pediatric, ophthalmologic, and dermatological regular check-up.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 3, a 10-year-old boy, was born by normal delivery. His parents did not show cutaneous anomalies. He was admitted for consultation due to episodes of generalized tonic-clonic seizures lasting several minutes: seizures had started at age 2 years. He showed neurodevelopmental delay from his first months of life: his current school performance is poor. An electroencephalographic (EEG) examination revealed spike and wave discharges in the temporal and parietal regions. Treatment with sodium valproate substantially reduced the frequency of seizures. At physical examination, he weighted 34 kg, with a height of 141 cm (75th percentile). The hypopigmented lesions were localized in the thorax and in the back, mainly on the left side. The diameter of the sural region of the lower left limb was 8 cm larger than the contralateral, and the diameter of the biceps region of the left limb was 3 cm larger than the contralateral. The left lower limb was 2 cm longer than the right. The asymmetry involved also the left hemiface. A lower-limb MRI showed increased growth in both long bones and soft tissues. Mild thoracolumbar right kyphoscoliosis was noticed. Brain MRI and ophthalmologic examination were both normal.

Patient 4, a 15-year-old girl, was the only daughter of nonconsanguineous parents. Both her parents were healthy with no cutaneous anomalies. The girl was born at 40 weeks by normal delivery, with a birthweight of 3300 g, a height of 50 cm, and a head circumference of 35 cm. She first came to our observation at the age of 2 years, due to psychomotor delay. The parents noticed the presence of cutaneous spots at about 3 months of age. Since her first year of life, the girl showed mild body asymmetry. At physical examination, at age 2 years, the girl showed typical hypopigmented lesions along the lines of Blaschko, mainly in the trunk and the upper and lower limbs (particularly evident over the right part of the body). During these years, the girl manifested moderate cognitive delay, poor school performance, and generalized tonic-clonic seizures, with a frequency of 6 to 8 episodes per year despite valproate treatment. At the age of 6 years, clobazam was added to the valproate regimen and the frequency of seizures decreased. An EEG revealed generalized spike and wave discharges. Currently, her physical examination reveals a weight of 70 kg and a height of 174 cm (both falling in the 90th percentile). Her school performance remained poor. The diameter of the biceps region of the right limb was 3 cm larger than the contralateral. Her right thigh diameter was 66 cm and her left thigh diameter was 57 cm (Figure ): the sural right lower limb diameter was 43 cm, compared with the left, which measured 40 cm. The right lower limb length was 103 cm, whereas the left was 100 cm. Facial asymmetry was also present, but to a milder degree. She currently walks with unstable equilibrium with frequent falls down. A color Doppler ultrasound examination of her limbs showed normal laminar flow, with a wider diameter of the arteries in the affected right limb (Figure A and B). Brain MRI was normal as her ophthalmological examination. Spinal x-ray examination revealed mild left kyphoscoliosis. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 3, a 10-year-old boy, was born by normal delivery. His parents did not show cutaneous anomalies. He was admitted for consultation due to episodes of generalized tonic-clonic seizures lasting several minutes: seizures had started at age 2 years. He showed neurodevelopmental delay from his first months of life: his current school performance is poor. An electroencephalographic (EEG) examination revealed spike and wave discharges in the temporal and parietal regions. Treatment with sodium valproate substantially reduced the frequency of seizures. At physical examination, he weighted 34 kg, with a height of 141 cm (75th percentile). The hypopigmented lesions were localized in the thorax and in the back, mainly on the left side. The diameter of the sural region of the lower left limb was 8 cm larger than the contralateral, and the diameter of the biceps region of the left limb was 3 cm larger than the contralateral. The left lower limb was 2 cm longer than the right. The asymmetry involved also the left hemiface. A lower-limb MRI showed increased growth in both long bones and soft tissues. Mild thoracolumbar right kyphoscoliosis was noticed. Brain MRI and ophthalmologic examination were both normal.

Patient 1 was a 4-year-old male who first came to our observation at the age of 3 years, due to episodes of febrile seizures. The parents and the youngest sister were healthy and did not show cutaneous anomalies. He was born by Caesarean section with a birth weight of 3100 g. Psychomotor development was regular. At his first physical examination, he weighted 17 kg, with a height of 101 cm and a head circumference of 51 cm (all within the 50th percentile). The hypopigmented lesions, in the form of whorls, were localized on the upper side of the right trunk and showed a linear pattern in the right lower limb. Limbs were asymmetrical: the asymmetry involved the right lower limb, which was larger than the left of 1 cm in diameter, and of 0.5 cm in the right upper limb compared with its counterpart, the right lower limb was 1 cm longer than the left. No facial asymmetry was present. Apart from the hemi-body asymmetry, the patient did not show other anomalies. Neither cognitive delay nor spine anomalies were present. The right femoral bone age was 1 year older than the left side. No skin biopsy to check for genetic mosaicism was carried out.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 3, a 10-year-old boy, was born by normal delivery. His parents did not show cutaneous anomalies. He was admitted for consultation due to episodes of generalized tonic-clonic seizures lasting several minutes: seizures had started at age 2 years. He showed neurodevelopmental delay from his first months of life: his current school performance is poor. An electroencephalographic (EEG) examination revealed spike and wave discharges in the temporal and parietal regions. Treatment with sodium valproate substantially reduced the frequency of seizures. At physical examination, he weighted 34 kg, with a height of 141 cm (75th percentile). The hypopigmented lesions were localized in the thorax and in the back, mainly on the left side. The diameter of the sural region of the lower left limb was 8 cm larger than the contralateral, and the diameter of the biceps region of the left limb was 3 cm larger than the contralateral. The left lower limb was 2 cm longer than the right. The asymmetry involved also the left hemiface. A lower-limb MRI showed increased growth in both long bones and soft tissues. Mild thoracolumbar right kyphoscoliosis was noticed. Brain MRI and ophthalmologic examination were both normal.

A 5.5-year-old girl was brought to our hospital with a complaint of disproportionate overgrowth and lengthening of the right leg accompanied by marked hypopigmented lesions over the trunk and legs, which reportedly had become noticeable by 2-weeks postpartum and gradually increased and spread. She was born to non-consanguineous parents and had been under monitoring for delayed speech. On examination, her height and weight were 110 cm (10th to 25th percentile) and 23 kg (75th to 90th percentile), respectively. The dermatological examination was remarkable for hypopigmented patches following the Blaschko lines over the trunk and both legs, more prominently on the right leg (, ), which was thicker and longer (~2 cm) than the left (). Apart from these findings, the systemic examinations, routine haemogram and biochemical tests, and magnetic resonance scans of the cranium and lower extremities were normal. When the Denver Developmental Screening Test was administered for speech delay, it was graded as ‘delayed’, correlating with the age of 3.5 years. After consultation with the dermatology department, a skin biopsy was considered unnecessary.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 3, a 10-year-old boy, was born by normal delivery. His parents did not show cutaneous anomalies. He was admitted for consultation due to episodes of generalized tonic-clonic seizures lasting several minutes: seizures had started at age 2 years. He showed neurodevelopmental delay from his first months of life: his current school performance is poor. An electroencephalographic (EEG) examination revealed spike and wave discharges in the temporal and parietal regions. Treatment with sodium valproate substantially reduced the frequency of seizures. At physical examination, he weighted 34 kg, with a height of 141 cm (75th percentile). The hypopigmented lesions were localized in the thorax and in the back, mainly on the left side. The diameter of the sural region of the lower left limb was 8 cm larger than the contralateral, and the diameter of the biceps region of the left limb was 3 cm larger than the contralateral. The left lower limb was 2 cm longer than the right. The asymmetry involved also the left hemiface. A lower-limb MRI showed increased growth in both long bones and soft tissues. Mild thoracolumbar right kyphoscoliosis was noticed. Brain MRI and ophthalmologic examination were both normal.

Patient 5 was a 18-year-old female who first came to our observation at the age of 24 months due to language delay. Her psychomotor development was also delayed. Convergent strabismus was present, with no anomalies at fundoscopy. Mild dysmorphic features were present, including epicanthic folds and hypotelorism. Physical examination revealed that her height was 175 cm (in the 90th percentile). The hypopigmented lesions were widely diffused in the trunk, particularly on the right side. The right upper limb diameter was 4 cm larger than the left side, and the right lower limb diameter was 7 cm larger and 3 cm longer than the left. Also, the right hemiface was involved by the disturbed growth. EEG and brain MRI were unrevealing. Left kyphoscoliosis was recorded with 10 to 15 degree of Cobb scale.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 3, a 10-year-old boy, was born by normal delivery. His parents did not show cutaneous anomalies. He was admitted for consultation due to episodes of generalized tonic-clonic seizures lasting several minutes: seizures had started at age 2 years. He showed neurodevelopmental delay from his first months of life: his current school performance is poor. An electroencephalographic (EEG) examination revealed spike and wave discharges in the temporal and parietal regions. Treatment with sodium valproate substantially reduced the frequency of seizures. At physical examination, he weighted 34 kg, with a height of 141 cm (75th percentile). The hypopigmented lesions were localized in the thorax and in the back, mainly on the left side. The diameter of the sural region of the lower left limb was 8 cm larger than the contralateral, and the diameter of the biceps region of the left limb was 3 cm larger than the contralateral. The left lower limb was 2 cm longer than the right. The asymmetry involved also the left hemiface. A lower-limb MRI showed increased growth in both long bones and soft tissues. Mild thoracolumbar right kyphoscoliosis was noticed. Brain MRI and ophthalmologic examination were both normal.

Patient 7, a 22-year-old male, had no family history of cutaneous lesions. At physical examination, his height was 182 cm (75th percentile). The hypopigmented lesions were widely diffused over the trunk and with greater prevalence on the right side (Figure ). Left upper limb diameter was 2.5 cm larger than the right, whereas left lower limb diameter was 6 cm larger. The difference in the lower limb length was 4 cm (left > right). Right hemiface was importantly involved. Cognitive delay was present. An EEG revealed generalized spike and wave discharges, and the patient experiences epileptic seizures of the generalized tonic-clonic type. Fundus examination was normal. Convergent strabismus was noticed. Short and broad nose, macrocrania, and left kyphoscoliosis (20 degree of Cobb) were also recorded. Brain MRI was normal.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 3, a 10-year-old boy, was born by normal delivery. His parents did not show cutaneous anomalies. He was admitted for consultation due to episodes of generalized tonic-clonic seizures lasting several minutes: seizures had started at age 2 years. He showed neurodevelopmental delay from his first months of life: his current school performance is poor. An electroencephalographic (EEG) examination revealed spike and wave discharges in the temporal and parietal regions. Treatment with sodium valproate substantially reduced the frequency of seizures. At physical examination, he weighted 34 kg, with a height of 141 cm (75th percentile). The hypopigmented lesions were localized in the thorax and in the back, mainly on the left side. The diameter of the sural region of the lower left limb was 8 cm larger than the contralateral, and the diameter of the biceps region of the left limb was 3 cm larger than the contralateral. The left lower limb was 2 cm longer than the right. The asymmetry involved also the left hemiface. A lower-limb MRI showed increased growth in both long bones and soft tissues. Mild thoracolumbar right kyphoscoliosis was noticed. Brain MRI and ophthalmologic examination were both normal.

Patient 6, a 20-year-old male with no noticeable familial cutaneous anomalies, was first referred for a diagnostic work-up regarding his cutaneous manifestations, which were diffuse, as patches, and primarily found on his left side. He had been first referred at age 3 years due to his severe psychomotor delay and for generalized tonic-clonic seizures. The EEG, at that age, revealed spike and wave discharges, prevalent in the frontal regions. Moderate cognitive delay was present. At his most recent physical examination, his stature was 175 cm (50th percentile): his left upper limb was 3 cm larger than the right, and the left lower limb 6 cm larger than the right. The left lower limb was 2.5 cm longer than the right. The ears were bilaterally large and cupped with an enlargement of the left hemiface. Mild right kyphoscoliosis was recorded. Brain MRI was normal. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 2, a 6-year-old girl, was the first born to healthy parents (both parents did not have cutaneous anomalies). The asymmetry was first noticed at birth. Psychomotor development was within normal ranges. At physical examination, she weighted 24 kg (90th percentile), with a height of 115 cm (50th percentile) and a head circumference of 49 cm (50th percentile). The hypopigmented patterns, in the form of whorls and V-shaped arrangements, were more evident in the trunk and in the back, with a linear configuration in the right lower limb. The diameter of the right lower limb was 1 cm larger than the lower left limb; the difference in the upper limb was less pronounced (0.4 cm). The right lower limb was 0.8 cm longer than the left. No hemiface involvement, cognitive delay, epilepsy, or spine anomalies had been recorded. The right femoral bone age was advanced of 1 year compared with the left.

Patient 3, a 10-year-old boy, was born by normal delivery. His parents did not show cutaneous anomalies. He was admitted for consultation due to episodes of generalized tonic-clonic seizures lasting several minutes: seizures had started at age 2 years. He showed neurodevelopmental delay from his first months of life: his current school performance is poor. An electroencephalographic (EEG) examination revealed spike and wave discharges in the temporal and parietal regions. Treatment with sodium valproate substantially reduced the frequency of seizures. At physical examination, he weighted 34 kg, with a height of 141 cm (75th percentile). The hypopigmented lesions were localized in the thorax and in the back, mainly on the left side. The diameter of the sural region of the lower left limb was 8 cm larger than the contralateral, and the diameter of the biceps region of the left limb was 3 cm larger than the contralateral. The left lower limb was 2 cm longer than the right. The asymmetry involved also the left hemiface. A lower-limb MRI showed increased growth in both long bones and soft tissues. Mild thoracolumbar right kyphoscoliosis was noticed. Brain MRI and ophthalmologic examination were both normal.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 2-month-old girl was referred to the Department of Dermatology for the evaluation of extending hypopigmented skin lesions. At birth, she had multiple linear erythematous erosive skin defects, which became linear, hypopigmented patches with irregular border on the face, scalp, trunk, and both extremities (). We received the patient's consent form about publishing all photographic materials. The patient had a history of intrauterine growth retardation as a prenatal problem. There was no specific family history, and her two siblings were normal.\nThe patient also presented multiple congenital anomalies. Physical examination revealed patchy alopecia of the scalp, hypoplastic nails, and irregular gingiva with conical teeth. Ocular examination showed bilateral aniridia, moderate to severe microphthalmia, and unilateral corneal central opacity of the left eye (). The retinal vessels of both eyes were uncertain on fundus examination. Musculoskeletal examination revealed syndactyly of toes (), hypoplasia and clinodactyly of fingers, and coccyx deviation. Chromosomal analysis on peripheral blood lymphocytes showed normal karyotype (46, XX) (), and no mutation was found in IKBKG gene test. Therefore, the patient was diagnosed with HI with multiple congenital anomalies.\nTo manage the associated musculoskeletal anomalies, the patient was referred to the Department of Pediatric Orthopedic Surgery and underwent surgical treatment of toe syndactyly. For proper management of the other anomalies, she had been undergoing pediatric, ophthalmologic, and dermatological regular check-up.

Patient 4, a 15-year-old girl, was the only daughter of nonconsanguineous parents. Both her parents were healthy with no cutaneous anomalies. The girl was born at 40 weeks by normal delivery, with a birthweight of 3300 g, a height of 50 cm, and a head circumference of 35 cm. She first came to our observation at the age of 2 years, due to psychomotor delay. The parents noticed the presence of cutaneous spots at about 3 months of age. Since her first year of life, the girl showed mild body asymmetry. At physical examination, at age 2 years, the girl showed typical hypopigmented lesions along the lines of Blaschko, mainly in the trunk and the upper and lower limbs (particularly evident over the right part of the body). During these years, the girl manifested moderate cognitive delay, poor school performance, and generalized tonic-clonic seizures, with a frequency of 6 to 8 episodes per year despite valproate treatment. At the age of 6 years, clobazam was added to the valproate regimen and the frequency of seizures decreased. An EEG revealed generalized spike and wave discharges. Currently, her physical examination reveals a weight of 70 kg and a height of 174 cm (both falling in the 90th percentile). Her school performance remained poor. The diameter of the biceps region of the right limb was 3 cm larger than the contralateral. Her right thigh diameter was 66 cm and her left thigh diameter was 57 cm (Figure ): the sural right lower limb diameter was 43 cm, compared with the left, which measured 40 cm. The right lower limb length was 103 cm, whereas the left was 100 cm. Facial asymmetry was also present, but to a milder degree. She currently walks with unstable equilibrium with frequent falls down. A color Doppler ultrasound examination of her limbs showed normal laminar flow, with a wider diameter of the arteries in the affected right limb (Figure A and B). Brain MRI was normal as her ophthalmological examination. Spinal x-ray examination revealed mild left kyphoscoliosis. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 2-month-old girl was referred to the Department of Dermatology for the evaluation of extending hypopigmented skin lesions. At birth, she had multiple linear erythematous erosive skin defects, which became linear, hypopigmented patches with irregular border on the face, scalp, trunk, and both extremities (). We received the patient's consent form about publishing all photographic materials. The patient had a history of intrauterine growth retardation as a prenatal problem. There was no specific family history, and her two siblings were normal.\nThe patient also presented multiple congenital anomalies. Physical examination revealed patchy alopecia of the scalp, hypoplastic nails, and irregular gingiva with conical teeth. Ocular examination showed bilateral aniridia, moderate to severe microphthalmia, and unilateral corneal central opacity of the left eye (). The retinal vessels of both eyes were uncertain on fundus examination. Musculoskeletal examination revealed syndactyly of toes (), hypoplasia and clinodactyly of fingers, and coccyx deviation. Chromosomal analysis on peripheral blood lymphocytes showed normal karyotype (46, XX) (), and no mutation was found in IKBKG gene test. Therefore, the patient was diagnosed with HI with multiple congenital anomalies.\nTo manage the associated musculoskeletal anomalies, the patient was referred to the Department of Pediatric Orthopedic Surgery and underwent surgical treatment of toe syndactyly. For proper management of the other anomalies, she had been undergoing pediatric, ophthalmologic, and dermatological regular check-up.

Patient 1 was a 4-year-old male who first came to our observation at the age of 3 years, due to episodes of febrile seizures. The parents and the youngest sister were healthy and did not show cutaneous anomalies. He was born by Caesarean section with a birth weight of 3100 g. Psychomotor development was regular. At his first physical examination, he weighted 17 kg, with a height of 101 cm and a head circumference of 51 cm (all within the 50th percentile). The hypopigmented lesions, in the form of whorls, were localized on the upper side of the right trunk and showed a linear pattern in the right lower limb. Limbs were asymmetrical: the asymmetry involved the right lower limb, which was larger than the left of 1 cm in diameter, and of 0.5 cm in the right upper limb compared with its counterpart, the right lower limb was 1 cm longer than the left. No facial asymmetry was present. Apart from the hemi-body asymmetry, the patient did not show other anomalies. Neither cognitive delay nor spine anomalies were present. The right femoral bone age was 1 year older than the left side. No skin biopsy to check for genetic mosaicism was carried out.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 2-month-old girl was referred to the Department of Dermatology for the evaluation of extending hypopigmented skin lesions. At birth, she had multiple linear erythematous erosive skin defects, which became linear, hypopigmented patches with irregular border on the face, scalp, trunk, and both extremities (). We received the patient's consent form about publishing all photographic materials. The patient had a history of intrauterine growth retardation as a prenatal problem. There was no specific family history, and her two siblings were normal.\nThe patient also presented multiple congenital anomalies. Physical examination revealed patchy alopecia of the scalp, hypoplastic nails, and irregular gingiva with conical teeth. Ocular examination showed bilateral aniridia, moderate to severe microphthalmia, and unilateral corneal central opacity of the left eye (). The retinal vessels of both eyes were uncertain on fundus examination. Musculoskeletal examination revealed syndactyly of toes (), hypoplasia and clinodactyly of fingers, and coccyx deviation. Chromosomal analysis on peripheral blood lymphocytes showed normal karyotype (46, XX) (), and no mutation was found in IKBKG gene test. Therefore, the patient was diagnosed with HI with multiple congenital anomalies.\nTo manage the associated musculoskeletal anomalies, the patient was referred to the Department of Pediatric Orthopedic Surgery and underwent surgical treatment of toe syndactyly. For proper management of the other anomalies, she had been undergoing pediatric, ophthalmologic, and dermatological regular check-up.

A 5.5-year-old girl was brought to our hospital with a complaint of disproportionate overgrowth and lengthening of the right leg accompanied by marked hypopigmented lesions over the trunk and legs, which reportedly had become noticeable by 2-weeks postpartum and gradually increased and spread. She was born to non-consanguineous parents and had been under monitoring for delayed speech. On examination, her height and weight were 110 cm (10th to 25th percentile) and 23 kg (75th to 90th percentile), respectively. The dermatological examination was remarkable for hypopigmented patches following the Blaschko lines over the trunk and both legs, more prominently on the right leg (, ), which was thicker and longer (~2 cm) than the left (). Apart from these findings, the systemic examinations, routine haemogram and biochemical tests, and magnetic resonance scans of the cranium and lower extremities were normal. When the Denver Developmental Screening Test was administered for speech delay, it was graded as ‘delayed’, correlating with the age of 3.5 years. After consultation with the dermatology department, a skin biopsy was considered unnecessary.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 2-month-old girl was referred to the Department of Dermatology for the evaluation of extending hypopigmented skin lesions. At birth, she had multiple linear erythematous erosive skin defects, which became linear, hypopigmented patches with irregular border on the face, scalp, trunk, and both extremities (). We received the patient's consent form about publishing all photographic materials. The patient had a history of intrauterine growth retardation as a prenatal problem. There was no specific family history, and her two siblings were normal.\nThe patient also presented multiple congenital anomalies. Physical examination revealed patchy alopecia of the scalp, hypoplastic nails, and irregular gingiva with conical teeth. Ocular examination showed bilateral aniridia, moderate to severe microphthalmia, and unilateral corneal central opacity of the left eye (). The retinal vessels of both eyes were uncertain on fundus examination. Musculoskeletal examination revealed syndactyly of toes (), hypoplasia and clinodactyly of fingers, and coccyx deviation. Chromosomal analysis on peripheral blood lymphocytes showed normal karyotype (46, XX) (), and no mutation was found in IKBKG gene test. Therefore, the patient was diagnosed with HI with multiple congenital anomalies.\nTo manage the associated musculoskeletal anomalies, the patient was referred to the Department of Pediatric Orthopedic Surgery and underwent surgical treatment of toe syndactyly. For proper management of the other anomalies, she had been undergoing pediatric, ophthalmologic, and dermatological regular check-up.

Patient 5 was a 18-year-old female who first came to our observation at the age of 24 months due to language delay. Her psychomotor development was also delayed. Convergent strabismus was present, with no anomalies at fundoscopy. Mild dysmorphic features were present, including epicanthic folds and hypotelorism. Physical examination revealed that her height was 175 cm (in the 90th percentile). The hypopigmented lesions were widely diffused in the trunk, particularly on the right side. The right upper limb diameter was 4 cm larger than the left side, and the right lower limb diameter was 7 cm larger and 3 cm longer than the left. Also, the right hemiface was involved by the disturbed growth. EEG and brain MRI were unrevealing. Left kyphoscoliosis was recorded with 10 to 15 degree of Cobb scale.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 2-month-old girl was referred to the Department of Dermatology for the evaluation of extending hypopigmented skin lesions. At birth, she had multiple linear erythematous erosive skin defects, which became linear, hypopigmented patches with irregular border on the face, scalp, trunk, and both extremities (). We received the patient's consent form about publishing all photographic materials. The patient had a history of intrauterine growth retardation as a prenatal problem. There was no specific family history, and her two siblings were normal.\nThe patient also presented multiple congenital anomalies. Physical examination revealed patchy alopecia of the scalp, hypoplastic nails, and irregular gingiva with conical teeth. Ocular examination showed bilateral aniridia, moderate to severe microphthalmia, and unilateral corneal central opacity of the left eye (). The retinal vessels of both eyes were uncertain on fundus examination. Musculoskeletal examination revealed syndactyly of toes (), hypoplasia and clinodactyly of fingers, and coccyx deviation. Chromosomal analysis on peripheral blood lymphocytes showed normal karyotype (46, XX) (), and no mutation was found in IKBKG gene test. Therefore, the patient was diagnosed with HI with multiple congenital anomalies.\nTo manage the associated musculoskeletal anomalies, the patient was referred to the Department of Pediatric Orthopedic Surgery and underwent surgical treatment of toe syndactyly. For proper management of the other anomalies, she had been undergoing pediatric, ophthalmologic, and dermatological regular check-up.

Patient 7, a 22-year-old male, had no family history of cutaneous lesions. At physical examination, his height was 182 cm (75th percentile). The hypopigmented lesions were widely diffused over the trunk and with greater prevalence on the right side (Figure ). Left upper limb diameter was 2.5 cm larger than the right, whereas left lower limb diameter was 6 cm larger. The difference in the lower limb length was 4 cm (left > right). Right hemiface was importantly involved. Cognitive delay was present. An EEG revealed generalized spike and wave discharges, and the patient experiences epileptic seizures of the generalized tonic-clonic type. Fundus examination was normal. Convergent strabismus was noticed. Short and broad nose, macrocrania, and left kyphoscoliosis (20 degree of Cobb) were also recorded. Brain MRI was normal.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 2-month-old girl was referred to the Department of Dermatology for the evaluation of extending hypopigmented skin lesions. At birth, she had multiple linear erythematous erosive skin defects, which became linear, hypopigmented patches with irregular border on the face, scalp, trunk, and both extremities (). We received the patient's consent form about publishing all photographic materials. The patient had a history of intrauterine growth retardation as a prenatal problem. There was no specific family history, and her two siblings were normal.\nThe patient also presented multiple congenital anomalies. Physical examination revealed patchy alopecia of the scalp, hypoplastic nails, and irregular gingiva with conical teeth. Ocular examination showed bilateral aniridia, moderate to severe microphthalmia, and unilateral corneal central opacity of the left eye (). The retinal vessels of both eyes were uncertain on fundus examination. Musculoskeletal examination revealed syndactyly of toes (), hypoplasia and clinodactyly of fingers, and coccyx deviation. Chromosomal analysis on peripheral blood lymphocytes showed normal karyotype (46, XX) (), and no mutation was found in IKBKG gene test. Therefore, the patient was diagnosed with HI with multiple congenital anomalies.\nTo manage the associated musculoskeletal anomalies, the patient was referred to the Department of Pediatric Orthopedic Surgery and underwent surgical treatment of toe syndactyly. For proper management of the other anomalies, she had been undergoing pediatric, ophthalmologic, and dermatological regular check-up.

Patient 6, a 20-year-old male with no noticeable familial cutaneous anomalies, was first referred for a diagnostic work-up regarding his cutaneous manifestations, which were diffuse, as patches, and primarily found on his left side. He had been first referred at age 3 years due to his severe psychomotor delay and for generalized tonic-clonic seizures. The EEG, at that age, revealed spike and wave discharges, prevalent in the frontal regions. Moderate cognitive delay was present. At his most recent physical examination, his stature was 175 cm (50th percentile): his left upper limb was 3 cm larger than the right, and the left lower limb 6 cm larger than the right. The left lower limb was 2.5 cm longer than the right. The ears were bilaterally large and cupped with an enlargement of the left hemiface. Mild right kyphoscoliosis was recorded. Brain MRI was normal. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 2-month-old girl was referred to the Department of Dermatology for the evaluation of extending hypopigmented skin lesions. At birth, she had multiple linear erythematous erosive skin defects, which became linear, hypopigmented patches with irregular border on the face, scalp, trunk, and both extremities (). We received the patient's consent form about publishing all photographic materials. The patient had a history of intrauterine growth retardation as a prenatal problem. There was no specific family history, and her two siblings were normal.\nThe patient also presented multiple congenital anomalies. Physical examination revealed patchy alopecia of the scalp, hypoplastic nails, and irregular gingiva with conical teeth. Ocular examination showed bilateral aniridia, moderate to severe microphthalmia, and unilateral corneal central opacity of the left eye (). The retinal vessels of both eyes were uncertain on fundus examination. Musculoskeletal examination revealed syndactyly of toes (), hypoplasia and clinodactyly of fingers, and coccyx deviation. Chromosomal analysis on peripheral blood lymphocytes showed normal karyotype (46, XX) (), and no mutation was found in IKBKG gene test. Therefore, the patient was diagnosed with HI with multiple congenital anomalies.\nTo manage the associated musculoskeletal anomalies, the patient was referred to the Department of Pediatric Orthopedic Surgery and underwent surgical treatment of toe syndactyly. For proper management of the other anomalies, she had been undergoing pediatric, ophthalmologic, and dermatological regular check-up.

Patient 2, a 6-year-old girl, was the first born to healthy parents (both parents did not have cutaneous anomalies). The asymmetry was first noticed at birth. Psychomotor development was within normal ranges. At physical examination, she weighted 24 kg (90th percentile), with a height of 115 cm (50th percentile) and a head circumference of 49 cm (50th percentile). The hypopigmented patterns, in the form of whorls and V-shaped arrangements, were more evident in the trunk and in the back, with a linear configuration in the right lower limb. The diameter of the right lower limb was 1 cm larger than the lower left limb; the difference in the upper limb was less pronounced (0.4 cm). The right lower limb was 0.8 cm longer than the left. No hemiface involvement, cognitive delay, epilepsy, or spine anomalies had been recorded. The right femoral bone age was advanced of 1 year compared with the left.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 4, a 15-year-old girl, was the only daughter of nonconsanguineous parents. Both her parents were healthy with no cutaneous anomalies. The girl was born at 40 weeks by normal delivery, with a birthweight of 3300 g, a height of 50 cm, and a head circumference of 35 cm. She first came to our observation at the age of 2 years, due to psychomotor delay. The parents noticed the presence of cutaneous spots at about 3 months of age. Since her first year of life, the girl showed mild body asymmetry. At physical examination, at age 2 years, the girl showed typical hypopigmented lesions along the lines of Blaschko, mainly in the trunk and the upper and lower limbs (particularly evident over the right part of the body). During these years, the girl manifested moderate cognitive delay, poor school performance, and generalized tonic-clonic seizures, with a frequency of 6 to 8 episodes per year despite valproate treatment. At the age of 6 years, clobazam was added to the valproate regimen and the frequency of seizures decreased. An EEG revealed generalized spike and wave discharges. Currently, her physical examination reveals a weight of 70 kg and a height of 174 cm (both falling in the 90th percentile). Her school performance remained poor. The diameter of the biceps region of the right limb was 3 cm larger than the contralateral. Her right thigh diameter was 66 cm and her left thigh diameter was 57 cm (Figure ): the sural right lower limb diameter was 43 cm, compared with the left, which measured 40 cm. The right lower limb length was 103 cm, whereas the left was 100 cm. Facial asymmetry was also present, but to a milder degree. She currently walks with unstable equilibrium with frequent falls down. A color Doppler ultrasound examination of her limbs showed normal laminar flow, with a wider diameter of the arteries in the affected right limb (Figure A and B). Brain MRI was normal as her ophthalmological examination. Spinal x-ray examination revealed mild left kyphoscoliosis. Skin biopsy was not performed.

Patient 1 was a 4-year-old male who first came to our observation at the age of 3 years, due to episodes of febrile seizures. The parents and the youngest sister were healthy and did not show cutaneous anomalies. He was born by Caesarean section with a birth weight of 3100 g. Psychomotor development was regular. At his first physical examination, he weighted 17 kg, with a height of 101 cm and a head circumference of 51 cm (all within the 50th percentile). The hypopigmented lesions, in the form of whorls, were localized on the upper side of the right trunk and showed a linear pattern in the right lower limb. Limbs were asymmetrical: the asymmetry involved the right lower limb, which was larger than the left of 1 cm in diameter, and of 0.5 cm in the right upper limb compared with its counterpart, the right lower limb was 1 cm longer than the left. No facial asymmetry was present. Apart from the hemi-body asymmetry, the patient did not show other anomalies. Neither cognitive delay nor spine anomalies were present. The right femoral bone age was 1 year older than the left side. No skin biopsy to check for genetic mosaicism was carried out.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 4, a 15-year-old girl, was the only daughter of nonconsanguineous parents. Both her parents were healthy with no cutaneous anomalies. The girl was born at 40 weeks by normal delivery, with a birthweight of 3300 g, a height of 50 cm, and a head circumference of 35 cm. She first came to our observation at the age of 2 years, due to psychomotor delay. The parents noticed the presence of cutaneous spots at about 3 months of age. Since her first year of life, the girl showed mild body asymmetry. At physical examination, at age 2 years, the girl showed typical hypopigmented lesions along the lines of Blaschko, mainly in the trunk and the upper and lower limbs (particularly evident over the right part of the body). During these years, the girl manifested moderate cognitive delay, poor school performance, and generalized tonic-clonic seizures, with a frequency of 6 to 8 episodes per year despite valproate treatment. At the age of 6 years, clobazam was added to the valproate regimen and the frequency of seizures decreased. An EEG revealed generalized spike and wave discharges. Currently, her physical examination reveals a weight of 70 kg and a height of 174 cm (both falling in the 90th percentile). Her school performance remained poor. The diameter of the biceps region of the right limb was 3 cm larger than the contralateral. Her right thigh diameter was 66 cm and her left thigh diameter was 57 cm (Figure ): the sural right lower limb diameter was 43 cm, compared with the left, which measured 40 cm. The right lower limb length was 103 cm, whereas the left was 100 cm. Facial asymmetry was also present, but to a milder degree. She currently walks with unstable equilibrium with frequent falls down. A color Doppler ultrasound examination of her limbs showed normal laminar flow, with a wider diameter of the arteries in the affected right limb (Figure A and B). Brain MRI was normal as her ophthalmological examination. Spinal x-ray examination revealed mild left kyphoscoliosis. Skin biopsy was not performed.

A 5.5-year-old girl was brought to our hospital with a complaint of disproportionate overgrowth and lengthening of the right leg accompanied by marked hypopigmented lesions over the trunk and legs, which reportedly had become noticeable by 2-weeks postpartum and gradually increased and spread. She was born to non-consanguineous parents and had been under monitoring for delayed speech. On examination, her height and weight were 110 cm (10th to 25th percentile) and 23 kg (75th to 90th percentile), respectively. The dermatological examination was remarkable for hypopigmented patches following the Blaschko lines over the trunk and both legs, more prominently on the right leg (, ), which was thicker and longer (~2 cm) than the left (). Apart from these findings, the systemic examinations, routine haemogram and biochemical tests, and magnetic resonance scans of the cranium and lower extremities were normal. When the Denver Developmental Screening Test was administered for speech delay, it was graded as ‘delayed’, correlating with the age of 3.5 years. After consultation with the dermatology department, a skin biopsy was considered unnecessary.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 4, a 15-year-old girl, was the only daughter of nonconsanguineous parents. Both her parents were healthy with no cutaneous anomalies. The girl was born at 40 weeks by normal delivery, with a birthweight of 3300 g, a height of 50 cm, and a head circumference of 35 cm. She first came to our observation at the age of 2 years, due to psychomotor delay. The parents noticed the presence of cutaneous spots at about 3 months of age. Since her first year of life, the girl showed mild body asymmetry. At physical examination, at age 2 years, the girl showed typical hypopigmented lesions along the lines of Blaschko, mainly in the trunk and the upper and lower limbs (particularly evident over the right part of the body). During these years, the girl manifested moderate cognitive delay, poor school performance, and generalized tonic-clonic seizures, with a frequency of 6 to 8 episodes per year despite valproate treatment. At the age of 6 years, clobazam was added to the valproate regimen and the frequency of seizures decreased. An EEG revealed generalized spike and wave discharges. Currently, her physical examination reveals a weight of 70 kg and a height of 174 cm (both falling in the 90th percentile). Her school performance remained poor. The diameter of the biceps region of the right limb was 3 cm larger than the contralateral. Her right thigh diameter was 66 cm and her left thigh diameter was 57 cm (Figure ): the sural right lower limb diameter was 43 cm, compared with the left, which measured 40 cm. The right lower limb length was 103 cm, whereas the left was 100 cm. Facial asymmetry was also present, but to a milder degree. She currently walks with unstable equilibrium with frequent falls down. A color Doppler ultrasound examination of her limbs showed normal laminar flow, with a wider diameter of the arteries in the affected right limb (Figure A and B). Brain MRI was normal as her ophthalmological examination. Spinal x-ray examination revealed mild left kyphoscoliosis. Skin biopsy was not performed.

Patient 5 was a 18-year-old female who first came to our observation at the age of 24 months due to language delay. Her psychomotor development was also delayed. Convergent strabismus was present, with no anomalies at fundoscopy. Mild dysmorphic features were present, including epicanthic folds and hypotelorism. Physical examination revealed that her height was 175 cm (in the 90th percentile). The hypopigmented lesions were widely diffused in the trunk, particularly on the right side. The right upper limb diameter was 4 cm larger than the left side, and the right lower limb diameter was 7 cm larger and 3 cm longer than the left. Also, the right hemiface was involved by the disturbed growth. EEG and brain MRI were unrevealing. Left kyphoscoliosis was recorded with 10 to 15 degree of Cobb scale.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 4, a 15-year-old girl, was the only daughter of nonconsanguineous parents. Both her parents were healthy with no cutaneous anomalies. The girl was born at 40 weeks by normal delivery, with a birthweight of 3300 g, a height of 50 cm, and a head circumference of 35 cm. She first came to our observation at the age of 2 years, due to psychomotor delay. The parents noticed the presence of cutaneous spots at about 3 months of age. Since her first year of life, the girl showed mild body asymmetry. At physical examination, at age 2 years, the girl showed typical hypopigmented lesions along the lines of Blaschko, mainly in the trunk and the upper and lower limbs (particularly evident over the right part of the body). During these years, the girl manifested moderate cognitive delay, poor school performance, and generalized tonic-clonic seizures, with a frequency of 6 to 8 episodes per year despite valproate treatment. At the age of 6 years, clobazam was added to the valproate regimen and the frequency of seizures decreased. An EEG revealed generalized spike and wave discharges. Currently, her physical examination reveals a weight of 70 kg and a height of 174 cm (both falling in the 90th percentile). Her school performance remained poor. The diameter of the biceps region of the right limb was 3 cm larger than the contralateral. Her right thigh diameter was 66 cm and her left thigh diameter was 57 cm (Figure ): the sural right lower limb diameter was 43 cm, compared with the left, which measured 40 cm. The right lower limb length was 103 cm, whereas the left was 100 cm. Facial asymmetry was also present, but to a milder degree. She currently walks with unstable equilibrium with frequent falls down. A color Doppler ultrasound examination of her limbs showed normal laminar flow, with a wider diameter of the arteries in the affected right limb (Figure A and B). Brain MRI was normal as her ophthalmological examination. Spinal x-ray examination revealed mild left kyphoscoliosis. Skin biopsy was not performed.

Patient 7, a 22-year-old male, had no family history of cutaneous lesions. At physical examination, his height was 182 cm (75th percentile). The hypopigmented lesions were widely diffused over the trunk and with greater prevalence on the right side (Figure ). Left upper limb diameter was 2.5 cm larger than the right, whereas left lower limb diameter was 6 cm larger. The difference in the lower limb length was 4 cm (left > right). Right hemiface was importantly involved. Cognitive delay was present. An EEG revealed generalized spike and wave discharges, and the patient experiences epileptic seizures of the generalized tonic-clonic type. Fundus examination was normal. Convergent strabismus was noticed. Short and broad nose, macrocrania, and left kyphoscoliosis (20 degree of Cobb) were also recorded. Brain MRI was normal.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 4, a 15-year-old girl, was the only daughter of nonconsanguineous parents. Both her parents were healthy with no cutaneous anomalies. The girl was born at 40 weeks by normal delivery, with a birthweight of 3300 g, a height of 50 cm, and a head circumference of 35 cm. She first came to our observation at the age of 2 years, due to psychomotor delay. The parents noticed the presence of cutaneous spots at about 3 months of age. Since her first year of life, the girl showed mild body asymmetry. At physical examination, at age 2 years, the girl showed typical hypopigmented lesions along the lines of Blaschko, mainly in the trunk and the upper and lower limbs (particularly evident over the right part of the body). During these years, the girl manifested moderate cognitive delay, poor school performance, and generalized tonic-clonic seizures, with a frequency of 6 to 8 episodes per year despite valproate treatment. At the age of 6 years, clobazam was added to the valproate regimen and the frequency of seizures decreased. An EEG revealed generalized spike and wave discharges. Currently, her physical examination reveals a weight of 70 kg and a height of 174 cm (both falling in the 90th percentile). Her school performance remained poor. The diameter of the biceps region of the right limb was 3 cm larger than the contralateral. Her right thigh diameter was 66 cm and her left thigh diameter was 57 cm (Figure ): the sural right lower limb diameter was 43 cm, compared with the left, which measured 40 cm. The right lower limb length was 103 cm, whereas the left was 100 cm. Facial asymmetry was also present, but to a milder degree. She currently walks with unstable equilibrium with frequent falls down. A color Doppler ultrasound examination of her limbs showed normal laminar flow, with a wider diameter of the arteries in the affected right limb (Figure A and B). Brain MRI was normal as her ophthalmological examination. Spinal x-ray examination revealed mild left kyphoscoliosis. Skin biopsy was not performed.

Patient 6, a 20-year-old male with no noticeable familial cutaneous anomalies, was first referred for a diagnostic work-up regarding his cutaneous manifestations, which were diffuse, as patches, and primarily found on his left side. He had been first referred at age 3 years due to his severe psychomotor delay and for generalized tonic-clonic seizures. The EEG, at that age, revealed spike and wave discharges, prevalent in the frontal regions. Moderate cognitive delay was present. At his most recent physical examination, his stature was 175 cm (50th percentile): his left upper limb was 3 cm larger than the right, and the left lower limb 6 cm larger than the right. The left lower limb was 2.5 cm longer than the right. The ears were bilaterally large and cupped with an enlargement of the left hemiface. Mild right kyphoscoliosis was recorded. Brain MRI was normal. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 2, a 6-year-old girl, was the first born to healthy parents (both parents did not have cutaneous anomalies). The asymmetry was first noticed at birth. Psychomotor development was within normal ranges. At physical examination, she weighted 24 kg (90th percentile), with a height of 115 cm (50th percentile) and a head circumference of 49 cm (50th percentile). The hypopigmented patterns, in the form of whorls and V-shaped arrangements, were more evident in the trunk and in the back, with a linear configuration in the right lower limb. The diameter of the right lower limb was 1 cm larger than the lower left limb; the difference in the upper limb was less pronounced (0.4 cm). The right lower limb was 0.8 cm longer than the left. No hemiface involvement, cognitive delay, epilepsy, or spine anomalies had been recorded. The right femoral bone age was advanced of 1 year compared with the left.

Patient 4, a 15-year-old girl, was the only daughter of nonconsanguineous parents. Both her parents were healthy with no cutaneous anomalies. The girl was born at 40 weeks by normal delivery, with a birthweight of 3300 g, a height of 50 cm, and a head circumference of 35 cm. She first came to our observation at the age of 2 years, due to psychomotor delay. The parents noticed the presence of cutaneous spots at about 3 months of age. Since her first year of life, the girl showed mild body asymmetry. At physical examination, at age 2 years, the girl showed typical hypopigmented lesions along the lines of Blaschko, mainly in the trunk and the upper and lower limbs (particularly evident over the right part of the body). During these years, the girl manifested moderate cognitive delay, poor school performance, and generalized tonic-clonic seizures, with a frequency of 6 to 8 episodes per year despite valproate treatment. At the age of 6 years, clobazam was added to the valproate regimen and the frequency of seizures decreased. An EEG revealed generalized spike and wave discharges. Currently, her physical examination reveals a weight of 70 kg and a height of 174 cm (both falling in the 90th percentile). Her school performance remained poor. The diameter of the biceps region of the right limb was 3 cm larger than the contralateral. Her right thigh diameter was 66 cm and her left thigh diameter was 57 cm (Figure ): the sural right lower limb diameter was 43 cm, compared with the left, which measured 40 cm. The right lower limb length was 103 cm, whereas the left was 100 cm. Facial asymmetry was also present, but to a milder degree. She currently walks with unstable equilibrium with frequent falls down. A color Doppler ultrasound examination of her limbs showed normal laminar flow, with a wider diameter of the arteries in the affected right limb (Figure A and B). Brain MRI was normal as her ophthalmological examination. Spinal x-ray examination revealed mild left kyphoscoliosis. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 1 was a 4-year-old male who first came to our observation at the age of 3 years, due to episodes of febrile seizures. The parents and the youngest sister were healthy and did not show cutaneous anomalies. He was born by Caesarean section with a birth weight of 3100 g. Psychomotor development was regular. At his first physical examination, he weighted 17 kg, with a height of 101 cm and a head circumference of 51 cm (all within the 50th percentile). The hypopigmented lesions, in the form of whorls, were localized on the upper side of the right trunk and showed a linear pattern in the right lower limb. Limbs were asymmetrical: the asymmetry involved the right lower limb, which was larger than the left of 1 cm in diameter, and of 0.5 cm in the right upper limb compared with its counterpart, the right lower limb was 1 cm longer than the left. No facial asymmetry was present. Apart from the hemi-body asymmetry, the patient did not show other anomalies. Neither cognitive delay nor spine anomalies were present. The right femoral bone age was 1 year older than the left side. No skin biopsy to check for genetic mosaicism was carried out.

A 5.5-year-old girl was brought to our hospital with a complaint of disproportionate overgrowth and lengthening of the right leg accompanied by marked hypopigmented lesions over the trunk and legs, which reportedly had become noticeable by 2-weeks postpartum and gradually increased and spread. She was born to non-consanguineous parents and had been under monitoring for delayed speech. On examination, her height and weight were 110 cm (10th to 25th percentile) and 23 kg (75th to 90th percentile), respectively. The dermatological examination was remarkable for hypopigmented patches following the Blaschko lines over the trunk and both legs, more prominently on the right leg (, ), which was thicker and longer (~2 cm) than the left (). Apart from these findings, the systemic examinations, routine haemogram and biochemical tests, and magnetic resonance scans of the cranium and lower extremities were normal. When the Denver Developmental Screening Test was administered for speech delay, it was graded as ‘delayed’, correlating with the age of 3.5 years. After consultation with the dermatology department, a skin biopsy was considered unnecessary.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 1 was a 4-year-old male who first came to our observation at the age of 3 years, due to episodes of febrile seizures. The parents and the youngest sister were healthy and did not show cutaneous anomalies. He was born by Caesarean section with a birth weight of 3100 g. Psychomotor development was regular. At his first physical examination, he weighted 17 kg, with a height of 101 cm and a head circumference of 51 cm (all within the 50th percentile). The hypopigmented lesions, in the form of whorls, were localized on the upper side of the right trunk and showed a linear pattern in the right lower limb. Limbs were asymmetrical: the asymmetry involved the right lower limb, which was larger than the left of 1 cm in diameter, and of 0.5 cm in the right upper limb compared with its counterpart, the right lower limb was 1 cm longer than the left. No facial asymmetry was present. Apart from the hemi-body asymmetry, the patient did not show other anomalies. Neither cognitive delay nor spine anomalies were present. The right femoral bone age was 1 year older than the left side. No skin biopsy to check for genetic mosaicism was carried out.

Patient 5 was a 18-year-old female who first came to our observation at the age of 24 months due to language delay. Her psychomotor development was also delayed. Convergent strabismus was present, with no anomalies at fundoscopy. Mild dysmorphic features were present, including epicanthic folds and hypotelorism. Physical examination revealed that her height was 175 cm (in the 90th percentile). The hypopigmented lesions were widely diffused in the trunk, particularly on the right side. The right upper limb diameter was 4 cm larger than the left side, and the right lower limb diameter was 7 cm larger and 3 cm longer than the left. Also, the right hemiface was involved by the disturbed growth. EEG and brain MRI were unrevealing. Left kyphoscoliosis was recorded with 10 to 15 degree of Cobb scale.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 1 was a 4-year-old male who first came to our observation at the age of 3 years, due to episodes of febrile seizures. The parents and the youngest sister were healthy and did not show cutaneous anomalies. He was born by Caesarean section with a birth weight of 3100 g. Psychomotor development was regular. At his first physical examination, he weighted 17 kg, with a height of 101 cm and a head circumference of 51 cm (all within the 50th percentile). The hypopigmented lesions, in the form of whorls, were localized on the upper side of the right trunk and showed a linear pattern in the right lower limb. Limbs were asymmetrical: the asymmetry involved the right lower limb, which was larger than the left of 1 cm in diameter, and of 0.5 cm in the right upper limb compared with its counterpart, the right lower limb was 1 cm longer than the left. No facial asymmetry was present. Apart from the hemi-body asymmetry, the patient did not show other anomalies. Neither cognitive delay nor spine anomalies were present. The right femoral bone age was 1 year older than the left side. No skin biopsy to check for genetic mosaicism was carried out.

Patient 7, a 22-year-old male, had no family history of cutaneous lesions. At physical examination, his height was 182 cm (75th percentile). The hypopigmented lesions were widely diffused over the trunk and with greater prevalence on the right side (Figure ). Left upper limb diameter was 2.5 cm larger than the right, whereas left lower limb diameter was 6 cm larger. The difference in the lower limb length was 4 cm (left > right). Right hemiface was importantly involved. Cognitive delay was present. An EEG revealed generalized spike and wave discharges, and the patient experiences epileptic seizures of the generalized tonic-clonic type. Fundus examination was normal. Convergent strabismus was noticed. Short and broad nose, macrocrania, and left kyphoscoliosis (20 degree of Cobb) were also recorded. Brain MRI was normal.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 1 was a 4-year-old male who first came to our observation at the age of 3 years, due to episodes of febrile seizures. The parents and the youngest sister were healthy and did not show cutaneous anomalies. He was born by Caesarean section with a birth weight of 3100 g. Psychomotor development was regular. At his first physical examination, he weighted 17 kg, with a height of 101 cm and a head circumference of 51 cm (all within the 50th percentile). The hypopigmented lesions, in the form of whorls, were localized on the upper side of the right trunk and showed a linear pattern in the right lower limb. Limbs were asymmetrical: the asymmetry involved the right lower limb, which was larger than the left of 1 cm in diameter, and of 0.5 cm in the right upper limb compared with its counterpart, the right lower limb was 1 cm longer than the left. No facial asymmetry was present. Apart from the hemi-body asymmetry, the patient did not show other anomalies. Neither cognitive delay nor spine anomalies were present. The right femoral bone age was 1 year older than the left side. No skin biopsy to check for genetic mosaicism was carried out.

Patient 6, a 20-year-old male with no noticeable familial cutaneous anomalies, was first referred for a diagnostic work-up regarding his cutaneous manifestations, which were diffuse, as patches, and primarily found on his left side. He had been first referred at age 3 years due to his severe psychomotor delay and for generalized tonic-clonic seizures. The EEG, at that age, revealed spike and wave discharges, prevalent in the frontal regions. Moderate cognitive delay was present. At his most recent physical examination, his stature was 175 cm (50th percentile): his left upper limb was 3 cm larger than the right, and the left lower limb 6 cm larger than the right. The left lower limb was 2.5 cm longer than the right. The ears were bilaterally large and cupped with an enlargement of the left hemiface. Mild right kyphoscoliosis was recorded. Brain MRI was normal. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 2, a 6-year-old girl, was the first born to healthy parents (both parents did not have cutaneous anomalies). The asymmetry was first noticed at birth. Psychomotor development was within normal ranges. At physical examination, she weighted 24 kg (90th percentile), with a height of 115 cm (50th percentile) and a head circumference of 49 cm (50th percentile). The hypopigmented patterns, in the form of whorls and V-shaped arrangements, were more evident in the trunk and in the back, with a linear configuration in the right lower limb. The diameter of the right lower limb was 1 cm larger than the lower left limb; the difference in the upper limb was less pronounced (0.4 cm). The right lower limb was 0.8 cm longer than the left. No hemiface involvement, cognitive delay, epilepsy, or spine anomalies had been recorded. The right femoral bone age was advanced of 1 year compared with the left.

Patient 1 was a 4-year-old male who first came to our observation at the age of 3 years, due to episodes of febrile seizures. The parents and the youngest sister were healthy and did not show cutaneous anomalies. He was born by Caesarean section with a birth weight of 3100 g. Psychomotor development was regular. At his first physical examination, he weighted 17 kg, with a height of 101 cm and a head circumference of 51 cm (all within the 50th percentile). The hypopigmented lesions, in the form of whorls, were localized on the upper side of the right trunk and showed a linear pattern in the right lower limb. Limbs were asymmetrical: the asymmetry involved the right lower limb, which was larger than the left of 1 cm in diameter, and of 0.5 cm in the right upper limb compared with its counterpart, the right lower limb was 1 cm longer than the left. No facial asymmetry was present. Apart from the hemi-body asymmetry, the patient did not show other anomalies. Neither cognitive delay nor spine anomalies were present. The right femoral bone age was 1 year older than the left side. No skin biopsy to check for genetic mosaicism was carried out.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 5.5-year-old girl was brought to our hospital with a complaint of disproportionate overgrowth and lengthening of the right leg accompanied by marked hypopigmented lesions over the trunk and legs, which reportedly had become noticeable by 2-weeks postpartum and gradually increased and spread. She was born to non-consanguineous parents and had been under monitoring for delayed speech. On examination, her height and weight were 110 cm (10th to 25th percentile) and 23 kg (75th to 90th percentile), respectively. The dermatological examination was remarkable for hypopigmented patches following the Blaschko lines over the trunk and both legs, more prominently on the right leg (, ), which was thicker and longer (~2 cm) than the left (). Apart from these findings, the systemic examinations, routine haemogram and biochemical tests, and magnetic resonance scans of the cranium and lower extremities were normal. When the Denver Developmental Screening Test was administered for speech delay, it was graded as ‘delayed’, correlating with the age of 3.5 years. After consultation with the dermatology department, a skin biopsy was considered unnecessary.

Patient 5 was a 18-year-old female who first came to our observation at the age of 24 months due to language delay. Her psychomotor development was also delayed. Convergent strabismus was present, with no anomalies at fundoscopy. Mild dysmorphic features were present, including epicanthic folds and hypotelorism. Physical examination revealed that her height was 175 cm (in the 90th percentile). The hypopigmented lesions were widely diffused in the trunk, particularly on the right side. The right upper limb diameter was 4 cm larger than the left side, and the right lower limb diameter was 7 cm larger and 3 cm longer than the left. Also, the right hemiface was involved by the disturbed growth. EEG and brain MRI were unrevealing. Left kyphoscoliosis was recorded with 10 to 15 degree of Cobb scale.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 5.5-year-old girl was brought to our hospital with a complaint of disproportionate overgrowth and lengthening of the right leg accompanied by marked hypopigmented lesions over the trunk and legs, which reportedly had become noticeable by 2-weeks postpartum and gradually increased and spread. She was born to non-consanguineous parents and had been under monitoring for delayed speech. On examination, her height and weight were 110 cm (10th to 25th percentile) and 23 kg (75th to 90th percentile), respectively. The dermatological examination was remarkable for hypopigmented patches following the Blaschko lines over the trunk and both legs, more prominently on the right leg (, ), which was thicker and longer (~2 cm) than the left (). Apart from these findings, the systemic examinations, routine haemogram and biochemical tests, and magnetic resonance scans of the cranium and lower extremities were normal. When the Denver Developmental Screening Test was administered for speech delay, it was graded as ‘delayed’, correlating with the age of 3.5 years. After consultation with the dermatology department, a skin biopsy was considered unnecessary.

Patient 7, a 22-year-old male, had no family history of cutaneous lesions. At physical examination, his height was 182 cm (75th percentile). The hypopigmented lesions were widely diffused over the trunk and with greater prevalence on the right side (Figure ). Left upper limb diameter was 2.5 cm larger than the right, whereas left lower limb diameter was 6 cm larger. The difference in the lower limb length was 4 cm (left > right). Right hemiface was importantly involved. Cognitive delay was present. An EEG revealed generalized spike and wave discharges, and the patient experiences epileptic seizures of the generalized tonic-clonic type. Fundus examination was normal. Convergent strabismus was noticed. Short and broad nose, macrocrania, and left kyphoscoliosis (20 degree of Cobb) were also recorded. Brain MRI was normal.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 5.5-year-old girl was brought to our hospital with a complaint of disproportionate overgrowth and lengthening of the right leg accompanied by marked hypopigmented lesions over the trunk and legs, which reportedly had become noticeable by 2-weeks postpartum and gradually increased and spread. She was born to non-consanguineous parents and had been under monitoring for delayed speech. On examination, her height and weight were 110 cm (10th to 25th percentile) and 23 kg (75th to 90th percentile), respectively. The dermatological examination was remarkable for hypopigmented patches following the Blaschko lines over the trunk and both legs, more prominently on the right leg (, ), which was thicker and longer (~2 cm) than the left (). Apart from these findings, the systemic examinations, routine haemogram and biochemical tests, and magnetic resonance scans of the cranium and lower extremities were normal. When the Denver Developmental Screening Test was administered for speech delay, it was graded as ‘delayed’, correlating with the age of 3.5 years. After consultation with the dermatology department, a skin biopsy was considered unnecessary.

Patient 6, a 20-year-old male with no noticeable familial cutaneous anomalies, was first referred for a diagnostic work-up regarding his cutaneous manifestations, which were diffuse, as patches, and primarily found on his left side. He had been first referred at age 3 years due to his severe psychomotor delay and for generalized tonic-clonic seizures. The EEG, at that age, revealed spike and wave discharges, prevalent in the frontal regions. Moderate cognitive delay was present. At his most recent physical examination, his stature was 175 cm (50th percentile): his left upper limb was 3 cm larger than the right, and the left lower limb 6 cm larger than the right. The left lower limb was 2.5 cm longer than the right. The ears were bilaterally large and cupped with an enlargement of the left hemiface. Mild right kyphoscoliosis was recorded. Brain MRI was normal. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 2, a 6-year-old girl, was the first born to healthy parents (both parents did not have cutaneous anomalies). The asymmetry was first noticed at birth. Psychomotor development was within normal ranges. At physical examination, she weighted 24 kg (90th percentile), with a height of 115 cm (50th percentile) and a head circumference of 49 cm (50th percentile). The hypopigmented patterns, in the form of whorls and V-shaped arrangements, were more evident in the trunk and in the back, with a linear configuration in the right lower limb. The diameter of the right lower limb was 1 cm larger than the lower left limb; the difference in the upper limb was less pronounced (0.4 cm). The right lower limb was 0.8 cm longer than the left. No hemiface involvement, cognitive delay, epilepsy, or spine anomalies had been recorded. The right femoral bone age was advanced of 1 year compared with the left.

A 5.5-year-old girl was brought to our hospital with a complaint of disproportionate overgrowth and lengthening of the right leg accompanied by marked hypopigmented lesions over the trunk and legs, which reportedly had become noticeable by 2-weeks postpartum and gradually increased and spread. She was born to non-consanguineous parents and had been under monitoring for delayed speech. On examination, her height and weight were 110 cm (10th to 25th percentile) and 23 kg (75th to 90th percentile), respectively. The dermatological examination was remarkable for hypopigmented patches following the Blaschko lines over the trunk and both legs, more prominently on the right leg (, ), which was thicker and longer (~2 cm) than the left (). Apart from these findings, the systemic examinations, routine haemogram and biochemical tests, and magnetic resonance scans of the cranium and lower extremities were normal. When the Denver Developmental Screening Test was administered for speech delay, it was graded as ‘delayed’, correlating with the age of 3.5 years. After consultation with the dermatology department, a skin biopsy was considered unnecessary.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 7, a 22-year-old male, had no family history of cutaneous lesions. At physical examination, his height was 182 cm (75th percentile). The hypopigmented lesions were widely diffused over the trunk and with greater prevalence on the right side (Figure ). Left upper limb diameter was 2.5 cm larger than the right, whereas left lower limb diameter was 6 cm larger. The difference in the lower limb length was 4 cm (left > right). Right hemiface was importantly involved. Cognitive delay was present. An EEG revealed generalized spike and wave discharges, and the patient experiences epileptic seizures of the generalized tonic-clonic type. Fundus examination was normal. Convergent strabismus was noticed. Short and broad nose, macrocrania, and left kyphoscoliosis (20 degree of Cobb) were also recorded. Brain MRI was normal.

Patient 5 was a 18-year-old female who first came to our observation at the age of 24 months due to language delay. Her psychomotor development was also delayed. Convergent strabismus was present, with no anomalies at fundoscopy. Mild dysmorphic features were present, including epicanthic folds and hypotelorism. Physical examination revealed that her height was 175 cm (in the 90th percentile). The hypopigmented lesions were widely diffused in the trunk, particularly on the right side. The right upper limb diameter was 4 cm larger than the left side, and the right lower limb diameter was 7 cm larger and 3 cm longer than the left. Also, the right hemiface was involved by the disturbed growth. EEG and brain MRI were unrevealing. Left kyphoscoliosis was recorded with 10 to 15 degree of Cobb scale.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 5 was a 18-year-old female who first came to our observation at the age of 24 months due to language delay. Her psychomotor development was also delayed. Convergent strabismus was present, with no anomalies at fundoscopy. Mild dysmorphic features were present, including epicanthic folds and hypotelorism. Physical examination revealed that her height was 175 cm (in the 90th percentile). The hypopigmented lesions were widely diffused in the trunk, particularly on the right side. The right upper limb diameter was 4 cm larger than the left side, and the right lower limb diameter was 7 cm larger and 3 cm longer than the left. Also, the right hemiface was involved by the disturbed growth. EEG and brain MRI were unrevealing. Left kyphoscoliosis was recorded with 10 to 15 degree of Cobb scale.

Patient 6, a 20-year-old male with no noticeable familial cutaneous anomalies, was first referred for a diagnostic work-up regarding his cutaneous manifestations, which were diffuse, as patches, and primarily found on his left side. He had been first referred at age 3 years due to his severe psychomotor delay and for generalized tonic-clonic seizures. The EEG, at that age, revealed spike and wave discharges, prevalent in the frontal regions. Moderate cognitive delay was present. At his most recent physical examination, his stature was 175 cm (50th percentile): his left upper limb was 3 cm larger than the right, and the left lower limb 6 cm larger than the right. The left lower limb was 2.5 cm longer than the right. The ears were bilaterally large and cupped with an enlargement of the left hemiface. Mild right kyphoscoliosis was recorded. Brain MRI was normal. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 2, a 6-year-old girl, was the first born to healthy parents (both parents did not have cutaneous anomalies). The asymmetry was first noticed at birth. Psychomotor development was within normal ranges. At physical examination, she weighted 24 kg (90th percentile), with a height of 115 cm (50th percentile) and a head circumference of 49 cm (50th percentile). The hypopigmented patterns, in the form of whorls and V-shaped arrangements, were more evident in the trunk and in the back, with a linear configuration in the right lower limb. The diameter of the right lower limb was 1 cm larger than the lower left limb; the difference in the upper limb was less pronounced (0.4 cm). The right lower limb was 0.8 cm longer than the left. No hemiface involvement, cognitive delay, epilepsy, or spine anomalies had been recorded. The right femoral bone age was advanced of 1 year compared with the left.

Patient 5 was a 18-year-old female who first came to our observation at the age of 24 months due to language delay. Her psychomotor development was also delayed. Convergent strabismus was present, with no anomalies at fundoscopy. Mild dysmorphic features were present, including epicanthic folds and hypotelorism. Physical examination revealed that her height was 175 cm (in the 90th percentile). The hypopigmented lesions were widely diffused in the trunk, particularly on the right side. The right upper limb diameter was 4 cm larger than the left side, and the right lower limb diameter was 7 cm larger and 3 cm longer than the left. Also, the right hemiface was involved by the disturbed growth. EEG and brain MRI were unrevealing. Left kyphoscoliosis was recorded with 10 to 15 degree of Cobb scale.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 7, a 22-year-old male, had no family history of cutaneous lesions. At physical examination, his height was 182 cm (75th percentile). The hypopigmented lesions were widely diffused over the trunk and with greater prevalence on the right side (Figure ). Left upper limb diameter was 2.5 cm larger than the right, whereas left lower limb diameter was 6 cm larger. The difference in the lower limb length was 4 cm (left > right). Right hemiface was importantly involved. Cognitive delay was present. An EEG revealed generalized spike and wave discharges, and the patient experiences epileptic seizures of the generalized tonic-clonic type. Fundus examination was normal. Convergent strabismus was noticed. Short and broad nose, macrocrania, and left kyphoscoliosis (20 degree of Cobb) were also recorded. Brain MRI was normal.

Patient 6, a 20-year-old male with no noticeable familial cutaneous anomalies, was first referred for a diagnostic work-up regarding his cutaneous manifestations, which were diffuse, as patches, and primarily found on his left side. He had been first referred at age 3 years due to his severe psychomotor delay and for generalized tonic-clonic seizures. The EEG, at that age, revealed spike and wave discharges, prevalent in the frontal regions. Moderate cognitive delay was present. At his most recent physical examination, his stature was 175 cm (50th percentile): his left upper limb was 3 cm larger than the right, and the left lower limb 6 cm larger than the right. The left lower limb was 2.5 cm longer than the right. The ears were bilaterally large and cupped with an enlargement of the left hemiface. Mild right kyphoscoliosis was recorded. Brain MRI was normal. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 2, a 6-year-old girl, was the first born to healthy parents (both parents did not have cutaneous anomalies). The asymmetry was first noticed at birth. Psychomotor development was within normal ranges. At physical examination, she weighted 24 kg (90th percentile), with a height of 115 cm (50th percentile) and a head circumference of 49 cm (50th percentile). The hypopigmented patterns, in the form of whorls and V-shaped arrangements, were more evident in the trunk and in the back, with a linear configuration in the right lower limb. The diameter of the right lower limb was 1 cm larger than the lower left limb; the difference in the upper limb was less pronounced (0.4 cm). The right lower limb was 0.8 cm longer than the left. No hemiface involvement, cognitive delay, epilepsy, or spine anomalies had been recorded. The right femoral bone age was advanced of 1 year compared with the left.

Patient 7, a 22-year-old male, had no family history of cutaneous lesions. At physical examination, his height was 182 cm (75th percentile). The hypopigmented lesions were widely diffused over the trunk and with greater prevalence on the right side (Figure ). Left upper limb diameter was 2.5 cm larger than the right, whereas left lower limb diameter was 6 cm larger. The difference in the lower limb length was 4 cm (left > right). Right hemiface was importantly involved. Cognitive delay was present. An EEG revealed generalized spike and wave discharges, and the patient experiences epileptic seizures of the generalized tonic-clonic type. Fundus examination was normal. Convergent strabismus was noticed. Short and broad nose, macrocrania, and left kyphoscoliosis (20 degree of Cobb) were also recorded. Brain MRI was normal.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

Patient 2, a 6-year-old girl, was the first born to healthy parents (both parents did not have cutaneous anomalies). The asymmetry was first noticed at birth. Psychomotor development was within normal ranges. At physical examination, she weighted 24 kg (90th percentile), with a height of 115 cm (50th percentile) and a head circumference of 49 cm (50th percentile). The hypopigmented patterns, in the form of whorls and V-shaped arrangements, were more evident in the trunk and in the back, with a linear configuration in the right lower limb. The diameter of the right lower limb was 1 cm larger than the lower left limb; the difference in the upper limb was less pronounced (0.4 cm). The right lower limb was 0.8 cm longer than the left. No hemiface involvement, cognitive delay, epilepsy, or spine anomalies had been recorded. The right femoral bone age was advanced of 1 year compared with the left.

Patient 6, a 20-year-old male with no noticeable familial cutaneous anomalies, was first referred for a diagnostic work-up regarding his cutaneous manifestations, which were diffuse, as patches, and primarily found on his left side. He had been first referred at age 3 years due to his severe psychomotor delay and for generalized tonic-clonic seizures. The EEG, at that age, revealed spike and wave discharges, prevalent in the frontal regions. Moderate cognitive delay was present. At his most recent physical examination, his stature was 175 cm (50th percentile): his left upper limb was 3 cm larger than the right, and the left lower limb 6 cm larger than the right. The left lower limb was 2.5 cm longer than the right. The ears were bilaterally large and cupped with an enlargement of the left hemiface. Mild right kyphoscoliosis was recorded. Brain MRI was normal. Skin biopsy was not performed.

Write a detailed clinical case vignette based on the following key phrases: Hypopigmented lesions, Body asymmetry, Developmental delays

A 62-year-old female presented for the evaluation of a symptomatic soft tissue mass involving the right plantar medial arch. Her symptomatology was relatively insidious by history and what prompted her visit was gradual intolerance of a certain shoe gear. She reported the mass was present for over a year but symptomology escalated about four months prior to initial evaluation. Her past medical history included hypertension, thyroid disease, Factor V Leiden pathology with a history of deep vein thrombosis, degenerative joint disease, and morbid obesity. Social history was unremarkable. Her physical exam was largely unremarkable except for significant pes planovalgus changes in both feet and a painful mass involving the right foot. Specific examination of the soft tissue mass revealed a mildly firm, slightly mobile, tender soft tissue mass in the medial plantar arch. Plain films demonstrated no acute process. Both non-operative and operative treatment options were offered and the patient chose the latter, electing for wide en bloc excision instead of complete fasciectomy. Prior to surgery, an MRI was ordered that demonstrated changes consistent with a solitary plantar fibroma lesion (Figures , ). Her surgery was without compromise and included perioperative anticoagulation bridge management in light of her history of deep vein thrombosis. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. At bandage takedown, the incison was observed to be well coapted with no complications (Figure ). The device remained in place for one week and was then removed. No drainage strikethrough was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. A walking boot was used for two weeks after suture removal. Healing progressed uneventfully with gradual increase in weight bearing and activities. Dorsal foot swelling on the operative foot persisted but eventually resolved. She ultimately returned to normal shoe gear at three months and was discharged from care without symptoms or signs of recurrence at six months.

A 56-year-old female presented for the evaluation of gradual onset bilateral soft tissue masses involving the plantar surface of both feet, with the left foot being significantly more symptomatic. Her past medical history included hypertension and high cholesterol. Social history included gainful employment in a moderately labor-intensive type job and several-year history of smoking. Her physical exam was essentially normal with the exception of somewhat firm, slightly mobile nodular masses involving both plantar foot surfaces in the region of the plantar medical arch (Figure ). Tenderness was only noted involving the two masses on the left foot. Plain radiographs were negative. Conservative therapies were discussed and tried that included shoe gear and activity modification as well as analgesics. The patient declined injection therapy. An MRI was ordered that revealed two discrete soft tissue masses within the plantar fascia consistent with PF lesions without neurovascular encroachment (Figures , ). Surgery was proposed and she wished to proceed with surgery on her symptomatic left foot (Figure ). Risks and benefits were outlined for both complete fasciectomy and wide en bloc resection. The patient chose the latter technique and was advised to refrain from smoking that she did for several days both pre- and post-operatively. Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging (Figure ). The device remained in place for one week and then was removed. No significant erythema or swelling was seen. Surgical pathology was consistent with two, benign PF lesions. Sutures remained in place for a total of three weeks and were then removed. At this time, the incision was found to be negligibly tender, flat and well coapted. She was non-weight bearing immediately post-operatively through suture removal at which time she was transitioned to a walking boot with instructions to gradually increase weight-bearing activities to tolerance. Rechecks were unremarkable with the exception of a small area of dehiscence that was seen one week after suture removal. Complete incisional healing was appreciated about a week after suture removal. She returned to normal, daily activities including unrestricted work just over two months with no symptomatology or recurrence at the one-year mark.

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 56-year-old female presented for the evaluation of gradual onset bilateral soft tissue masses involving the plantar surface of both feet, with the left foot being significantly more symptomatic. Her past medical history included hypertension and high cholesterol. Social history included gainful employment in a moderately labor-intensive type job and several-year history of smoking. Her physical exam was essentially normal with the exception of somewhat firm, slightly mobile nodular masses involving both plantar foot surfaces in the region of the plantar medical arch (Figure ). Tenderness was only noted involving the two masses on the left foot. Plain radiographs were negative. Conservative therapies were discussed and tried that included shoe gear and activity modification as well as analgesics. The patient declined injection therapy. An MRI was ordered that revealed two discrete soft tissue masses within the plantar fascia consistent with PF lesions without neurovascular encroachment (Figures , ). Surgery was proposed and she wished to proceed with surgery on her symptomatic left foot (Figure ). Risks and benefits were outlined for both complete fasciectomy and wide en bloc resection. The patient chose the latter technique and was advised to refrain from smoking that she did for several days both pre- and post-operatively. Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging (Figure ). The device remained in place for one week and then was removed. No significant erythema or swelling was seen. Surgical pathology was consistent with two, benign PF lesions. Sutures remained in place for a total of three weeks and were then removed. At this time, the incision was found to be negligibly tender, flat and well coapted. She was non-weight bearing immediately post-operatively through suture removal at which time she was transitioned to a walking boot with instructions to gradually increase weight-bearing activities to tolerance. Rechecks were unremarkable with the exception of a small area of dehiscence that was seen one week after suture removal. Complete incisional healing was appreciated about a week after suture removal. She returned to normal, daily activities including unrestricted work just over two months with no symptomatology or recurrence at the one-year mark.

A 30-year-old man presented painful bilateral plantar nodules. Physical examination showed multiple and bilateral fixed and solid nodules measuring 1 cm each on the plantar and medial side of his feet (\n). Five years earlier, the first painless nodule appeared in his right foot, and the number of nodules increased and become painful over the following years. He had using orthopedic insoles for the last 6 months. He was not taking any medication, and there was no family history of those nodules. Routine laboratory tests and blood glucose levels were normal. He did not have Dupuytren disease, diabetes mellitus, alcohol addiction, penile fibromatosis, epilepsy, or frozen shoulder. Ultrasound was performed, and hypoechoic homogeneous nodules were detected. The patient underwent surgery, and the nodes were removed via a plantar incision with 2-cm safety distance (\n). There was no skin or muscle infiltration. The skin was closured primarily, wound dressing was changed once a day, and touching the ground was banned for 1 day. We continue to follow the patient (\n).

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 56-year-old female presented for the evaluation of gradual onset bilateral soft tissue masses involving the plantar surface of both feet, with the left foot being significantly more symptomatic. Her past medical history included hypertension and high cholesterol. Social history included gainful employment in a moderately labor-intensive type job and several-year history of smoking. Her physical exam was essentially normal with the exception of somewhat firm, slightly mobile nodular masses involving both plantar foot surfaces in the region of the plantar medical arch (Figure ). Tenderness was only noted involving the two masses on the left foot. Plain radiographs were negative. Conservative therapies were discussed and tried that included shoe gear and activity modification as well as analgesics. The patient declined injection therapy. An MRI was ordered that revealed two discrete soft tissue masses within the plantar fascia consistent with PF lesions without neurovascular encroachment (Figures , ). Surgery was proposed and she wished to proceed with surgery on her symptomatic left foot (Figure ). Risks and benefits were outlined for both complete fasciectomy and wide en bloc resection. The patient chose the latter technique and was advised to refrain from smoking that she did for several days both pre- and post-operatively. Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging (Figure ). The device remained in place for one week and then was removed. No significant erythema or swelling was seen. Surgical pathology was consistent with two, benign PF lesions. Sutures remained in place for a total of three weeks and were then removed. At this time, the incision was found to be negligibly tender, flat and well coapted. She was non-weight bearing immediately post-operatively through suture removal at which time she was transitioned to a walking boot with instructions to gradually increase weight-bearing activities to tolerance. Rechecks were unremarkable with the exception of a small area of dehiscence that was seen one week after suture removal. Complete incisional healing was appreciated about a week after suture removal. She returned to normal, daily activities including unrestricted work just over two months with no symptomatology or recurrence at the one-year mark.

A 50-year-old male came to our department with walking difficulties because of painful bilateral plantar nodules. Visual inspection revealed solid nodules with 4 cm in diameter bilaterally in the medial plantar regions (). About 15 years ago, the asymptomatic nodules were simultaneously noticed being the size of a grain of rice, although the growing nodules caused difficulties and pain with footwear. Additionally, he also had Dupuytren’s contracture in his right palm (). Conversely, Doppler auscultation revealed arteriosus vascular sound on the mass in the bilateral plantar.\nA plain magnetic resonance imaging (MRI) scan revealed soft subcutaneous mass in the bilateral plantar with a dark signal on T1-weighted images, while a brighter signal than muscles on T2-weighted images (). In turn, MR angiography visualized symmetrical mass bilaterally as a high density area (). In contrast, MRI scan of his right palm showed a thick cord with a dark signal on both T1- and T2- weighted images (). To rule out the possibility of hemangioma, a biopsy was performed, resulting in the diagnosis that PF was strongly suspected.\nHe had neither family history of PF nor history of diabetes/epilepsy. He is a LGBT person and orchiectomy was performed 7 years ago. Instead of lost androgenic hormone, female hormone therapy had been prescribed with 1 mg of norgestrel and 0.1 mg of ethinyl estradiol per day.\nSince the patient wanted surgical treatment, operation under general anesthesia was performed (). Skin incision enabled the observation that the medial plantar neurovascular bundles were involved in the mass in the right foot. Therefore, it was necessary to dissect the medial plantar neurovascular bundles from the mass before excising the mass en bloc with a 1 cm safety margin. In contrast, there was no such finding in the left plantar. The primary wound closure was performed and suction drains were left. The patient was instructed to prevent the operation sites from bearing weight for 2 weeks. The skin wound healed uneventfully and he was released from the hospital 15 days after his operation. The final pathological diagnosis was PF. After 6 months, the patient is free of pain and is able to wear his shoes without any trouble ().

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 56-year-old female presented for the evaluation of gradual onset bilateral soft tissue masses involving the plantar surface of both feet, with the left foot being significantly more symptomatic. Her past medical history included hypertension and high cholesterol. Social history included gainful employment in a moderately labor-intensive type job and several-year history of smoking. Her physical exam was essentially normal with the exception of somewhat firm, slightly mobile nodular masses involving both plantar foot surfaces in the region of the plantar medical arch (Figure ). Tenderness was only noted involving the two masses on the left foot. Plain radiographs were negative. Conservative therapies were discussed and tried that included shoe gear and activity modification as well as analgesics. The patient declined injection therapy. An MRI was ordered that revealed two discrete soft tissue masses within the plantar fascia consistent with PF lesions without neurovascular encroachment (Figures , ). Surgery was proposed and she wished to proceed with surgery on her symptomatic left foot (Figure ). Risks and benefits were outlined for both complete fasciectomy and wide en bloc resection. The patient chose the latter technique and was advised to refrain from smoking that she did for several days both pre- and post-operatively. Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging (Figure ). The device remained in place for one week and then was removed. No significant erythema or swelling was seen. Surgical pathology was consistent with two, benign PF lesions. Sutures remained in place for a total of three weeks and were then removed. At this time, the incision was found to be negligibly tender, flat and well coapted. She was non-weight bearing immediately post-operatively through suture removal at which time she was transitioned to a walking boot with instructions to gradually increase weight-bearing activities to tolerance. Rechecks were unremarkable with the exception of a small area of dehiscence that was seen one week after suture removal. Complete incisional healing was appreciated about a week after suture removal. She returned to normal, daily activities including unrestricted work just over two months with no symptomatology or recurrence at the one-year mark.

A 44-year-old man with no significant medical history presented with an 8-year history of painless plantar nodule of the right foot. In the previous 6 months the patient felt discomfort while walking. On examination, he had subcutaneous nodules on the medial aspect of the plantar surface of the right foot. There was no family history of similar nodules. The patient was not taking any medication and was otherwise healthy. Vital signs and laboratory tests were normal.\nAn ultrasound () of the plantar arch was made using 13–5 MHz array transducer and showed a hypoechoic and homogeneous nodule of the plantar fascia with increased color Doppler flow. MRI of the foot confirmed the ultrasound data, showing a hyperintense nodule on proton density images () which was hypointense on T1-weighted images (), at the distal part of the superficial medial plantar fascia. The lesion was intensely enhanced after injection of Gadolinium ().\nThe diagnosis of Ledderhose disease was suspected based on the clinical-radiographic data. However, because of the flow inside the lesion at color Doppler, a biopsy was performed to rule out malignancies. Histological examination () of the nodule demonstrated increased fibroblastic activity and a reduction of the collagen network. Our patient received conservative treatment with anti-inflammatory drugs, physiotherapy, and orthotic support with satisfactory evolution.

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 56-year-old female presented for the evaluation of gradual onset bilateral soft tissue masses involving the plantar surface of both feet, with the left foot being significantly more symptomatic. Her past medical history included hypertension and high cholesterol. Social history included gainful employment in a moderately labor-intensive type job and several-year history of smoking. Her physical exam was essentially normal with the exception of somewhat firm, slightly mobile nodular masses involving both plantar foot surfaces in the region of the plantar medical arch (Figure ). Tenderness was only noted involving the two masses on the left foot. Plain radiographs were negative. Conservative therapies were discussed and tried that included shoe gear and activity modification as well as analgesics. The patient declined injection therapy. An MRI was ordered that revealed two discrete soft tissue masses within the plantar fascia consistent with PF lesions without neurovascular encroachment (Figures , ). Surgery was proposed and she wished to proceed with surgery on her symptomatic left foot (Figure ). Risks and benefits were outlined for both complete fasciectomy and wide en bloc resection. The patient chose the latter technique and was advised to refrain from smoking that she did for several days both pre- and post-operatively. Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging (Figure ). The device remained in place for one week and then was removed. No significant erythema or swelling was seen. Surgical pathology was consistent with two, benign PF lesions. Sutures remained in place for a total of three weeks and were then removed. At this time, the incision was found to be negligibly tender, flat and well coapted. She was non-weight bearing immediately post-operatively through suture removal at which time she was transitioned to a walking boot with instructions to gradually increase weight-bearing activities to tolerance. Rechecks were unremarkable with the exception of a small area of dehiscence that was seen one week after suture removal. Complete incisional healing was appreciated about a week after suture removal. She returned to normal, daily activities including unrestricted work just over two months with no symptomatology or recurrence at the one-year mark.

Nearly a decade ago, a 58-year-old male presented for the evaluation of a painful soft tissue mass involving the left plantar foot. After conservative means were exhausted, he opted for surgery and elected to have a wide en bloc excisional removal of the mass. Pathology was consistent with PF. His post-operative period was uneventful and he remained asymptomatic for several years until November 2019. He presented again at this time for the evaluation of a gradually enlarging, symptomatic soft tissue mass in the same area as the original mass (Figure ). Upon examination and further history, it was felt that this mass was consistent with a recurrent plantar fibroma. His past medical history was particularly remarkable for Type II diabetes and morbid obesity. Other problems included high cholesterol, anxiety, and depression. Social history included controlled substance abuse. His physical exam was normal. Specific exam of the soft tissue mass revealed a firm, tender, nodular mass involving the left plantar medial arch in the same region of a well-healed, mildly hyperkeratotic surgical scar. Plain radiographs were negative. When he opted for surgery, the risks and benefits were outlined of both complete fasciectomy and wide en bloc resection. He chose the latter technique. An MRI was ordered that revealed changes consistent with a PF mass (Figures , ). Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. The device remained in place for one week and was then removed. No significant swelling or erythema was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. At this time, the incision was found to be negligibly tender, flat and well coapted. Partial weight bearing in a walking boot was initiated. At two weeks from the time of suture removal, he was transitioned to full weight bearing. At just over three months, he was discharged from care symptom free without signs of recurrence.

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 62-year-old female presented for the evaluation of a symptomatic soft tissue mass involving the right plantar medial arch. Her symptomatology was relatively insidious by history and what prompted her visit was gradual intolerance of a certain shoe gear. She reported the mass was present for over a year but symptomology escalated about four months prior to initial evaluation. Her past medical history included hypertension, thyroid disease, Factor V Leiden pathology with a history of deep vein thrombosis, degenerative joint disease, and morbid obesity. Social history was unremarkable. Her physical exam was largely unremarkable except for significant pes planovalgus changes in both feet and a painful mass involving the right foot. Specific examination of the soft tissue mass revealed a mildly firm, slightly mobile, tender soft tissue mass in the medial plantar arch. Plain films demonstrated no acute process. Both non-operative and operative treatment options were offered and the patient chose the latter, electing for wide en bloc excision instead of complete fasciectomy. Prior to surgery, an MRI was ordered that demonstrated changes consistent with a solitary plantar fibroma lesion (Figures , ). Her surgery was without compromise and included perioperative anticoagulation bridge management in light of her history of deep vein thrombosis. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. At bandage takedown, the incison was observed to be well coapted with no complications (Figure ). The device remained in place for one week and was then removed. No drainage strikethrough was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. A walking boot was used for two weeks after suture removal. Healing progressed uneventfully with gradual increase in weight bearing and activities. Dorsal foot swelling on the operative foot persisted but eventually resolved. She ultimately returned to normal shoe gear at three months and was discharged from care without symptoms or signs of recurrence at six months.

A 30-year-old man presented painful bilateral plantar nodules. Physical examination showed multiple and bilateral fixed and solid nodules measuring 1 cm each on the plantar and medial side of his feet (\n). Five years earlier, the first painless nodule appeared in his right foot, and the number of nodules increased and become painful over the following years. He had using orthopedic insoles for the last 6 months. He was not taking any medication, and there was no family history of those nodules. Routine laboratory tests and blood glucose levels were normal. He did not have Dupuytren disease, diabetes mellitus, alcohol addiction, penile fibromatosis, epilepsy, or frozen shoulder. Ultrasound was performed, and hypoechoic homogeneous nodules were detected. The patient underwent surgery, and the nodes were removed via a plantar incision with 2-cm safety distance (\n). There was no skin or muscle infiltration. The skin was closured primarily, wound dressing was changed once a day, and touching the ground was banned for 1 day. We continue to follow the patient (\n).

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 62-year-old female presented for the evaluation of a symptomatic soft tissue mass involving the right plantar medial arch. Her symptomatology was relatively insidious by history and what prompted her visit was gradual intolerance of a certain shoe gear. She reported the mass was present for over a year but symptomology escalated about four months prior to initial evaluation. Her past medical history included hypertension, thyroid disease, Factor V Leiden pathology with a history of deep vein thrombosis, degenerative joint disease, and morbid obesity. Social history was unremarkable. Her physical exam was largely unremarkable except for significant pes planovalgus changes in both feet and a painful mass involving the right foot. Specific examination of the soft tissue mass revealed a mildly firm, slightly mobile, tender soft tissue mass in the medial plantar arch. Plain films demonstrated no acute process. Both non-operative and operative treatment options were offered and the patient chose the latter, electing for wide en bloc excision instead of complete fasciectomy. Prior to surgery, an MRI was ordered that demonstrated changes consistent with a solitary plantar fibroma lesion (Figures , ). Her surgery was without compromise and included perioperative anticoagulation bridge management in light of her history of deep vein thrombosis. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. At bandage takedown, the incison was observed to be well coapted with no complications (Figure ). The device remained in place for one week and was then removed. No drainage strikethrough was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. A walking boot was used for two weeks after suture removal. Healing progressed uneventfully with gradual increase in weight bearing and activities. Dorsal foot swelling on the operative foot persisted but eventually resolved. She ultimately returned to normal shoe gear at three months and was discharged from care without symptoms or signs of recurrence at six months.

A 50-year-old male came to our department with walking difficulties because of painful bilateral plantar nodules. Visual inspection revealed solid nodules with 4 cm in diameter bilaterally in the medial plantar regions (). About 15 years ago, the asymptomatic nodules were simultaneously noticed being the size of a grain of rice, although the growing nodules caused difficulties and pain with footwear. Additionally, he also had Dupuytren’s contracture in his right palm (). Conversely, Doppler auscultation revealed arteriosus vascular sound on the mass in the bilateral plantar.\nA plain magnetic resonance imaging (MRI) scan revealed soft subcutaneous mass in the bilateral plantar with a dark signal on T1-weighted images, while a brighter signal than muscles on T2-weighted images (). In turn, MR angiography visualized symmetrical mass bilaterally as a high density area (). In contrast, MRI scan of his right palm showed a thick cord with a dark signal on both T1- and T2- weighted images (). To rule out the possibility of hemangioma, a biopsy was performed, resulting in the diagnosis that PF was strongly suspected.\nHe had neither family history of PF nor history of diabetes/epilepsy. He is a LGBT person and orchiectomy was performed 7 years ago. Instead of lost androgenic hormone, female hormone therapy had been prescribed with 1 mg of norgestrel and 0.1 mg of ethinyl estradiol per day.\nSince the patient wanted surgical treatment, operation under general anesthesia was performed (). Skin incision enabled the observation that the medial plantar neurovascular bundles were involved in the mass in the right foot. Therefore, it was necessary to dissect the medial plantar neurovascular bundles from the mass before excising the mass en bloc with a 1 cm safety margin. In contrast, there was no such finding in the left plantar. The primary wound closure was performed and suction drains were left. The patient was instructed to prevent the operation sites from bearing weight for 2 weeks. The skin wound healed uneventfully and he was released from the hospital 15 days after his operation. The final pathological diagnosis was PF. After 6 months, the patient is free of pain and is able to wear his shoes without any trouble ().

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 62-year-old female presented for the evaluation of a symptomatic soft tissue mass involving the right plantar medial arch. Her symptomatology was relatively insidious by history and what prompted her visit was gradual intolerance of a certain shoe gear. She reported the mass was present for over a year but symptomology escalated about four months prior to initial evaluation. Her past medical history included hypertension, thyroid disease, Factor V Leiden pathology with a history of deep vein thrombosis, degenerative joint disease, and morbid obesity. Social history was unremarkable. Her physical exam was largely unremarkable except for significant pes planovalgus changes in both feet and a painful mass involving the right foot. Specific examination of the soft tissue mass revealed a mildly firm, slightly mobile, tender soft tissue mass in the medial plantar arch. Plain films demonstrated no acute process. Both non-operative and operative treatment options were offered and the patient chose the latter, electing for wide en bloc excision instead of complete fasciectomy. Prior to surgery, an MRI was ordered that demonstrated changes consistent with a solitary plantar fibroma lesion (Figures , ). Her surgery was without compromise and included perioperative anticoagulation bridge management in light of her history of deep vein thrombosis. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. At bandage takedown, the incison was observed to be well coapted with no complications (Figure ). The device remained in place for one week and was then removed. No drainage strikethrough was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. A walking boot was used for two weeks after suture removal. Healing progressed uneventfully with gradual increase in weight bearing and activities. Dorsal foot swelling on the operative foot persisted but eventually resolved. She ultimately returned to normal shoe gear at three months and was discharged from care without symptoms or signs of recurrence at six months.

A 44-year-old man with no significant medical history presented with an 8-year history of painless plantar nodule of the right foot. In the previous 6 months the patient felt discomfort while walking. On examination, he had subcutaneous nodules on the medial aspect of the plantar surface of the right foot. There was no family history of similar nodules. The patient was not taking any medication and was otherwise healthy. Vital signs and laboratory tests were normal.\nAn ultrasound () of the plantar arch was made using 13–5 MHz array transducer and showed a hypoechoic and homogeneous nodule of the plantar fascia with increased color Doppler flow. MRI of the foot confirmed the ultrasound data, showing a hyperintense nodule on proton density images () which was hypointense on T1-weighted images (), at the distal part of the superficial medial plantar fascia. The lesion was intensely enhanced after injection of Gadolinium ().\nThe diagnosis of Ledderhose disease was suspected based on the clinical-radiographic data. However, because of the flow inside the lesion at color Doppler, a biopsy was performed to rule out malignancies. Histological examination () of the nodule demonstrated increased fibroblastic activity and a reduction of the collagen network. Our patient received conservative treatment with anti-inflammatory drugs, physiotherapy, and orthotic support with satisfactory evolution.

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 62-year-old female presented for the evaluation of a symptomatic soft tissue mass involving the right plantar medial arch. Her symptomatology was relatively insidious by history and what prompted her visit was gradual intolerance of a certain shoe gear. She reported the mass was present for over a year but symptomology escalated about four months prior to initial evaluation. Her past medical history included hypertension, thyroid disease, Factor V Leiden pathology with a history of deep vein thrombosis, degenerative joint disease, and morbid obesity. Social history was unremarkable. Her physical exam was largely unremarkable except for significant pes planovalgus changes in both feet and a painful mass involving the right foot. Specific examination of the soft tissue mass revealed a mildly firm, slightly mobile, tender soft tissue mass in the medial plantar arch. Plain films demonstrated no acute process. Both non-operative and operative treatment options were offered and the patient chose the latter, electing for wide en bloc excision instead of complete fasciectomy. Prior to surgery, an MRI was ordered that demonstrated changes consistent with a solitary plantar fibroma lesion (Figures , ). Her surgery was without compromise and included perioperative anticoagulation bridge management in light of her history of deep vein thrombosis. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. At bandage takedown, the incison was observed to be well coapted with no complications (Figure ). The device remained in place for one week and was then removed. No drainage strikethrough was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. A walking boot was used for two weeks after suture removal. Healing progressed uneventfully with gradual increase in weight bearing and activities. Dorsal foot swelling on the operative foot persisted but eventually resolved. She ultimately returned to normal shoe gear at three months and was discharged from care without symptoms or signs of recurrence at six months.

Nearly a decade ago, a 58-year-old male presented for the evaluation of a painful soft tissue mass involving the left plantar foot. After conservative means were exhausted, he opted for surgery and elected to have a wide en bloc excisional removal of the mass. Pathology was consistent with PF. His post-operative period was uneventful and he remained asymptomatic for several years until November 2019. He presented again at this time for the evaluation of a gradually enlarging, symptomatic soft tissue mass in the same area as the original mass (Figure ). Upon examination and further history, it was felt that this mass was consistent with a recurrent plantar fibroma. His past medical history was particularly remarkable for Type II diabetes and morbid obesity. Other problems included high cholesterol, anxiety, and depression. Social history included controlled substance abuse. His physical exam was normal. Specific exam of the soft tissue mass revealed a firm, tender, nodular mass involving the left plantar medial arch in the same region of a well-healed, mildly hyperkeratotic surgical scar. Plain radiographs were negative. When he opted for surgery, the risks and benefits were outlined of both complete fasciectomy and wide en bloc resection. He chose the latter technique. An MRI was ordered that revealed changes consistent with a PF mass (Figures , ). Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. The device remained in place for one week and was then removed. No significant swelling or erythema was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. At this time, the incision was found to be negligibly tender, flat and well coapted. Partial weight bearing in a walking boot was initiated. At two weeks from the time of suture removal, he was transitioned to full weight bearing. At just over three months, he was discharged from care symptom free without signs of recurrence.

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 50-year-old male came to our department with walking difficulties because of painful bilateral plantar nodules. Visual inspection revealed solid nodules with 4 cm in diameter bilaterally in the medial plantar regions (). About 15 years ago, the asymptomatic nodules were simultaneously noticed being the size of a grain of rice, although the growing nodules caused difficulties and pain with footwear. Additionally, he also had Dupuytren’s contracture in his right palm (). Conversely, Doppler auscultation revealed arteriosus vascular sound on the mass in the bilateral plantar.\nA plain magnetic resonance imaging (MRI) scan revealed soft subcutaneous mass in the bilateral plantar with a dark signal on T1-weighted images, while a brighter signal than muscles on T2-weighted images (). In turn, MR angiography visualized symmetrical mass bilaterally as a high density area (). In contrast, MRI scan of his right palm showed a thick cord with a dark signal on both T1- and T2- weighted images (). To rule out the possibility of hemangioma, a biopsy was performed, resulting in the diagnosis that PF was strongly suspected.\nHe had neither family history of PF nor history of diabetes/epilepsy. He is a LGBT person and orchiectomy was performed 7 years ago. Instead of lost androgenic hormone, female hormone therapy had been prescribed with 1 mg of norgestrel and 0.1 mg of ethinyl estradiol per day.\nSince the patient wanted surgical treatment, operation under general anesthesia was performed (). Skin incision enabled the observation that the medial plantar neurovascular bundles were involved in the mass in the right foot. Therefore, it was necessary to dissect the medial plantar neurovascular bundles from the mass before excising the mass en bloc with a 1 cm safety margin. In contrast, there was no such finding in the left plantar. The primary wound closure was performed and suction drains were left. The patient was instructed to prevent the operation sites from bearing weight for 2 weeks. The skin wound healed uneventfully and he was released from the hospital 15 days after his operation. The final pathological diagnosis was PF. After 6 months, the patient is free of pain and is able to wear his shoes without any trouble ().

A 30-year-old man presented painful bilateral plantar nodules. Physical examination showed multiple and bilateral fixed and solid nodules measuring 1 cm each on the plantar and medial side of his feet (\n). Five years earlier, the first painless nodule appeared in his right foot, and the number of nodules increased and become painful over the following years. He had using orthopedic insoles for the last 6 months. He was not taking any medication, and there was no family history of those nodules. Routine laboratory tests and blood glucose levels were normal. He did not have Dupuytren disease, diabetes mellitus, alcohol addiction, penile fibromatosis, epilepsy, or frozen shoulder. Ultrasound was performed, and hypoechoic homogeneous nodules were detected. The patient underwent surgery, and the nodes were removed via a plantar incision with 2-cm safety distance (\n). There was no skin or muscle infiltration. The skin was closured primarily, wound dressing was changed once a day, and touching the ground was banned for 1 day. We continue to follow the patient (\n).

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 44-year-old man with no significant medical history presented with an 8-year history of painless plantar nodule of the right foot. In the previous 6 months the patient felt discomfort while walking. On examination, he had subcutaneous nodules on the medial aspect of the plantar surface of the right foot. There was no family history of similar nodules. The patient was not taking any medication and was otherwise healthy. Vital signs and laboratory tests were normal.\nAn ultrasound () of the plantar arch was made using 13–5 MHz array transducer and showed a hypoechoic and homogeneous nodule of the plantar fascia with increased color Doppler flow. MRI of the foot confirmed the ultrasound data, showing a hyperintense nodule on proton density images () which was hypointense on T1-weighted images (), at the distal part of the superficial medial plantar fascia. The lesion was intensely enhanced after injection of Gadolinium ().\nThe diagnosis of Ledderhose disease was suspected based on the clinical-radiographic data. However, because of the flow inside the lesion at color Doppler, a biopsy was performed to rule out malignancies. Histological examination () of the nodule demonstrated increased fibroblastic activity and a reduction of the collagen network. Our patient received conservative treatment with anti-inflammatory drugs, physiotherapy, and orthotic support with satisfactory evolution.

A 30-year-old man presented painful bilateral plantar nodules. Physical examination showed multiple and bilateral fixed and solid nodules measuring 1 cm each on the plantar and medial side of his feet (\n). Five years earlier, the first painless nodule appeared in his right foot, and the number of nodules increased and become painful over the following years. He had using orthopedic insoles for the last 6 months. He was not taking any medication, and there was no family history of those nodules. Routine laboratory tests and blood glucose levels were normal. He did not have Dupuytren disease, diabetes mellitus, alcohol addiction, penile fibromatosis, epilepsy, or frozen shoulder. Ultrasound was performed, and hypoechoic homogeneous nodules were detected. The patient underwent surgery, and the nodes were removed via a plantar incision with 2-cm safety distance (\n). There was no skin or muscle infiltration. The skin was closured primarily, wound dressing was changed once a day, and touching the ground was banned for 1 day. We continue to follow the patient (\n).

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

Nearly a decade ago, a 58-year-old male presented for the evaluation of a painful soft tissue mass involving the left plantar foot. After conservative means were exhausted, he opted for surgery and elected to have a wide en bloc excisional removal of the mass. Pathology was consistent with PF. His post-operative period was uneventful and he remained asymptomatic for several years until November 2019. He presented again at this time for the evaluation of a gradually enlarging, symptomatic soft tissue mass in the same area as the original mass (Figure ). Upon examination and further history, it was felt that this mass was consistent with a recurrent plantar fibroma. His past medical history was particularly remarkable for Type II diabetes and morbid obesity. Other problems included high cholesterol, anxiety, and depression. Social history included controlled substance abuse. His physical exam was normal. Specific exam of the soft tissue mass revealed a firm, tender, nodular mass involving the left plantar medial arch in the same region of a well-healed, mildly hyperkeratotic surgical scar. Plain radiographs were negative. When he opted for surgery, the risks and benefits were outlined of both complete fasciectomy and wide en bloc resection. He chose the latter technique. An MRI was ordered that revealed changes consistent with a PF mass (Figures , ). Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. The device remained in place for one week and was then removed. No significant swelling or erythema was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. At this time, the incision was found to be negligibly tender, flat and well coapted. Partial weight bearing in a walking boot was initiated. At two weeks from the time of suture removal, he was transitioned to full weight bearing. At just over three months, he was discharged from care symptom free without signs of recurrence.

A 30-year-old man presented painful bilateral plantar nodules. Physical examination showed multiple and bilateral fixed and solid nodules measuring 1 cm each on the plantar and medial side of his feet (\n). Five years earlier, the first painless nodule appeared in his right foot, and the number of nodules increased and become painful over the following years. He had using orthopedic insoles for the last 6 months. He was not taking any medication, and there was no family history of those nodules. Routine laboratory tests and blood glucose levels were normal. He did not have Dupuytren disease, diabetes mellitus, alcohol addiction, penile fibromatosis, epilepsy, or frozen shoulder. Ultrasound was performed, and hypoechoic homogeneous nodules were detected. The patient underwent surgery, and the nodes were removed via a plantar incision with 2-cm safety distance (\n). There was no skin or muscle infiltration. The skin was closured primarily, wound dressing was changed once a day, and touching the ground was banned for 1 day. We continue to follow the patient (\n).

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 50-year-old male came to our department with walking difficulties because of painful bilateral plantar nodules. Visual inspection revealed solid nodules with 4 cm in diameter bilaterally in the medial plantar regions (). About 15 years ago, the asymptomatic nodules were simultaneously noticed being the size of a grain of rice, although the growing nodules caused difficulties and pain with footwear. Additionally, he also had Dupuytren’s contracture in his right palm (). Conversely, Doppler auscultation revealed arteriosus vascular sound on the mass in the bilateral plantar.\nA plain magnetic resonance imaging (MRI) scan revealed soft subcutaneous mass in the bilateral plantar with a dark signal on T1-weighted images, while a brighter signal than muscles on T2-weighted images (). In turn, MR angiography visualized symmetrical mass bilaterally as a high density area (). In contrast, MRI scan of his right palm showed a thick cord with a dark signal on both T1- and T2- weighted images (). To rule out the possibility of hemangioma, a biopsy was performed, resulting in the diagnosis that PF was strongly suspected.\nHe had neither family history of PF nor history of diabetes/epilepsy. He is a LGBT person and orchiectomy was performed 7 years ago. Instead of lost androgenic hormone, female hormone therapy had been prescribed with 1 mg of norgestrel and 0.1 mg of ethinyl estradiol per day.\nSince the patient wanted surgical treatment, operation under general anesthesia was performed (). Skin incision enabled the observation that the medial plantar neurovascular bundles were involved in the mass in the right foot. Therefore, it was necessary to dissect the medial plantar neurovascular bundles from the mass before excising the mass en bloc with a 1 cm safety margin. In contrast, there was no such finding in the left plantar. The primary wound closure was performed and suction drains were left. The patient was instructed to prevent the operation sites from bearing weight for 2 weeks. The skin wound healed uneventfully and he was released from the hospital 15 days after his operation. The final pathological diagnosis was PF. After 6 months, the patient is free of pain and is able to wear his shoes without any trouble ().

A 44-year-old man with no significant medical history presented with an 8-year history of painless plantar nodule of the right foot. In the previous 6 months the patient felt discomfort while walking. On examination, he had subcutaneous nodules on the medial aspect of the plantar surface of the right foot. There was no family history of similar nodules. The patient was not taking any medication and was otherwise healthy. Vital signs and laboratory tests were normal.\nAn ultrasound () of the plantar arch was made using 13–5 MHz array transducer and showed a hypoechoic and homogeneous nodule of the plantar fascia with increased color Doppler flow. MRI of the foot confirmed the ultrasound data, showing a hyperintense nodule on proton density images () which was hypointense on T1-weighted images (), at the distal part of the superficial medial plantar fascia. The lesion was intensely enhanced after injection of Gadolinium ().\nThe diagnosis of Ledderhose disease was suspected based on the clinical-radiographic data. However, because of the flow inside the lesion at color Doppler, a biopsy was performed to rule out malignancies. Histological examination () of the nodule demonstrated increased fibroblastic activity and a reduction of the collagen network. Our patient received conservative treatment with anti-inflammatory drugs, physiotherapy, and orthotic support with satisfactory evolution.

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

Nearly a decade ago, a 58-year-old male presented for the evaluation of a painful soft tissue mass involving the left plantar foot. After conservative means were exhausted, he opted for surgery and elected to have a wide en bloc excisional removal of the mass. Pathology was consistent with PF. His post-operative period was uneventful and he remained asymptomatic for several years until November 2019. He presented again at this time for the evaluation of a gradually enlarging, symptomatic soft tissue mass in the same area as the original mass (Figure ). Upon examination and further history, it was felt that this mass was consistent with a recurrent plantar fibroma. His past medical history was particularly remarkable for Type II diabetes and morbid obesity. Other problems included high cholesterol, anxiety, and depression. Social history included controlled substance abuse. His physical exam was normal. Specific exam of the soft tissue mass revealed a firm, tender, nodular mass involving the left plantar medial arch in the same region of a well-healed, mildly hyperkeratotic surgical scar. Plain radiographs were negative. When he opted for surgery, the risks and benefits were outlined of both complete fasciectomy and wide en bloc resection. He chose the latter technique. An MRI was ordered that revealed changes consistent with a PF mass (Figures , ). Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. The device remained in place for one week and was then removed. No significant swelling or erythema was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. At this time, the incision was found to be negligibly tender, flat and well coapted. Partial weight bearing in a walking boot was initiated. At two weeks from the time of suture removal, he was transitioned to full weight bearing. At just over three months, he was discharged from care symptom free without signs of recurrence.

A 50-year-old male came to our department with walking difficulties because of painful bilateral plantar nodules. Visual inspection revealed solid nodules with 4 cm in diameter bilaterally in the medial plantar regions (). About 15 years ago, the asymptomatic nodules were simultaneously noticed being the size of a grain of rice, although the growing nodules caused difficulties and pain with footwear. Additionally, he also had Dupuytren’s contracture in his right palm (). Conversely, Doppler auscultation revealed arteriosus vascular sound on the mass in the bilateral plantar.\nA plain magnetic resonance imaging (MRI) scan revealed soft subcutaneous mass in the bilateral plantar with a dark signal on T1-weighted images, while a brighter signal than muscles on T2-weighted images (). In turn, MR angiography visualized symmetrical mass bilaterally as a high density area (). In contrast, MRI scan of his right palm showed a thick cord with a dark signal on both T1- and T2- weighted images (). To rule out the possibility of hemangioma, a biopsy was performed, resulting in the diagnosis that PF was strongly suspected.\nHe had neither family history of PF nor history of diabetes/epilepsy. He is a LGBT person and orchiectomy was performed 7 years ago. Instead of lost androgenic hormone, female hormone therapy had been prescribed with 1 mg of norgestrel and 0.1 mg of ethinyl estradiol per day.\nSince the patient wanted surgical treatment, operation under general anesthesia was performed (). Skin incision enabled the observation that the medial plantar neurovascular bundles were involved in the mass in the right foot. Therefore, it was necessary to dissect the medial plantar neurovascular bundles from the mass before excising the mass en bloc with a 1 cm safety margin. In contrast, there was no such finding in the left plantar. The primary wound closure was performed and suction drains were left. The patient was instructed to prevent the operation sites from bearing weight for 2 weeks. The skin wound healed uneventfully and he was released from the hospital 15 days after his operation. The final pathological diagnosis was PF. After 6 months, the patient is free of pain and is able to wear his shoes without any trouble ().

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 44-year-old man with no significant medical history presented with an 8-year history of painless plantar nodule of the right foot. In the previous 6 months the patient felt discomfort while walking. On examination, he had subcutaneous nodules on the medial aspect of the plantar surface of the right foot. There was no family history of similar nodules. The patient was not taking any medication and was otherwise healthy. Vital signs and laboratory tests were normal.\nAn ultrasound () of the plantar arch was made using 13–5 MHz array transducer and showed a hypoechoic and homogeneous nodule of the plantar fascia with increased color Doppler flow. MRI of the foot confirmed the ultrasound data, showing a hyperintense nodule on proton density images () which was hypointense on T1-weighted images (), at the distal part of the superficial medial plantar fascia. The lesion was intensely enhanced after injection of Gadolinium ().\nThe diagnosis of Ledderhose disease was suspected based on the clinical-radiographic data. However, because of the flow inside the lesion at color Doppler, a biopsy was performed to rule out malignancies. Histological examination () of the nodule demonstrated increased fibroblastic activity and a reduction of the collagen network. Our patient received conservative treatment with anti-inflammatory drugs, physiotherapy, and orthotic support with satisfactory evolution.

Nearly a decade ago, a 58-year-old male presented for the evaluation of a painful soft tissue mass involving the left plantar foot. After conservative means were exhausted, he opted for surgery and elected to have a wide en bloc excisional removal of the mass. Pathology was consistent with PF. His post-operative period was uneventful and he remained asymptomatic for several years until November 2019. He presented again at this time for the evaluation of a gradually enlarging, symptomatic soft tissue mass in the same area as the original mass (Figure ). Upon examination and further history, it was felt that this mass was consistent with a recurrent plantar fibroma. His past medical history was particularly remarkable for Type II diabetes and morbid obesity. Other problems included high cholesterol, anxiety, and depression. Social history included controlled substance abuse. His physical exam was normal. Specific exam of the soft tissue mass revealed a firm, tender, nodular mass involving the left plantar medial arch in the same region of a well-healed, mildly hyperkeratotic surgical scar. Plain radiographs were negative. When he opted for surgery, the risks and benefits were outlined of both complete fasciectomy and wide en bloc resection. He chose the latter technique. An MRI was ordered that revealed changes consistent with a PF mass (Figures , ). Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging. The device remained in place for one week and was then removed. No significant swelling or erythema was seen (Figure ). Surgical pathology was consistent with a solitary benign plantar fibromatosis lesion. Sutures remained in place for a total of three weeks. At this time, the incision was found to be negligibly tender, flat and well coapted. Partial weight bearing in a walking boot was initiated. At two weeks from the time of suture removal, he was transitioned to full weight bearing. At just over three months, he was discharged from care symptom free without signs of recurrence.

Write a detailed clinical case vignette based on the following key phrases: plantar fibroma, soft tissue mass, surgical excision

A 38 year old male with no identifiable co-morbidities presented to the emergency department complaining of a 2-day history of progressively worsening abdominal pain, nausea, intractable vomiting and shortness of breath. Examination reveals tachycardia, respiratory distress, and abdominal pain out of proportion to the palpation. Apart from mild leukocytosis and a lactate of 2.2 mmol/L, D-Dimer 2100 ng/ml. All other laboratory investigations were normal. After normal plain films of the abdomen and chest, the patient underwent a computed tomography (CT) scan of the abdomen with contrast.\nThe scan revealed extensive thrombosis of the portal, splenic, superior and inferior mesenteric veins. The mid-portion of the small bowel was suggestive of venous ischemia. No pneumatosis intestinalis was noted. An incidental finding of a totally occluded right pulmonary artery consistent with a pulmonary embolism was noted.\nThe patient received heparin therapy prior to a diagnostic laparoscopy. Intra-operatively a markedly dusky jejunal segment was identified along with turbid fluid in all quadrants. Conversion to open laparotomy ensued followed by resection of the diseased segment with temporary abdominal closure (). The patient was admitted to the ICU for resuscitation and anticoagulation. The patient was later taken to theatre for a side to side anastomosis. The patient was subsequently placed on extracorporeal membrane oxygenation (ECMO) and is currently under care in the intensive care unit (ICU).

A 48 year old male with a history of asthma presented to our institution with a cough, shortness of breath and a fever. The patient subsequently tested positive for Covid-19 and was intubated and admitted to the ICU with hypoxic respiratory failure after failure to improve with initial therapy. The patient was started on therapeutic enoxaparin treatment.\nOn the 10th day the patient was on high ventilator settings and minimal inotropic support. On examination, lower limbs showed unsalvageable ischemia with no palpable pulses (). Urgent CT angiography revealed complete occlusion of the left arterial tree from the aortic bifurcation descending down to the infra-popliteal arteries. Contralaterally, distal occlusion of the superficial femoral artery down to the infra-popliteal arteries. CT of the lung displayed ground glass appearance of the lungs associated with consolidation. After consulting the next of kin and the risk; benefit of proceeding to surgery. The joint decision to provide supportive care was made. The patient was declared dead on the same day.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 64-year-old male with a past medical history of type 2 diabetes mellitus and essential hypertension presented in the emergency department with a history of intermittent fever of 102 degrees Fahrenheit for the last five days along with numbness and discoloration in his right leg for the last three days and shortness of breath. On examination, his Glasgow coma scale (GCS) score was 15/15 and his mental status was normal on gross neurological examination. His oxygen saturation (SpO2) at room air was 85% (indicative of severe disease) and 94% SpO2 at 15 L oxygen via a non-breather mask (NRM).\nOn physical examination, his right leg had a blackish discoloration (Figure ).\nIt was cold, clammy, with an absent femoral pulse. Arterial Doppler ultrasound of the right lower limb showed no flow in the femoral, popliteal, anterior tibial, posterior tibial, and dorsalis pedis arteries although no plaque or echogenic thrombus was seen. A CT angiogram of the lower limb was performed, which showed no contrast opacification beyond the right common femoral artery (Figure ).\nA Vascular surgeon was consulted and a diagnosis of acute limb ischemia was made. It was classified as Rutherford stage III, which was three days old. The limb was declared as non-salvageable. Keeping in view the clinical picture and CT angiogram findings, the Vascular surgeon advised an above-knee amputation of the affected limb.\nThe patient's real-time SARS-CoV-2 polymerase chain reaction (PCR) test was positive. His arterial blood gases (ABGs) showed metabolic acidosis with respiratory compensation with a pH of 7.4, bicarbonate (HCO3-) of 17.9, and pCO2 of 25.9. His high-resolution computerized tomography (HRCT) of the chest gave a severity score of 31/40 for COVID-19 pneumonia (Figure ), indicative of severe disease.\nHis serum ferritin levels were 1,279 ng/mL (N=15-200 ng/mL), serum D-dimer 1,650 ng/mL (N≤250 ng/mL), serum LDH 861 U/L (N=135-225 U/L), serum CK 4,252 U/L (N= up to 192 U/L), INR=1, IL-6=14.8 pg/mL (N≤7.0 pg/mL). CBC showed WBC count of 29.0 x 109/L with neutrophil-lymphocyte ratio (NLR) of 22.25 (N=1-3). His HbA1c was 12.4 (N=4.5%-6.5%).\nThe patient's above-knee amputation was done under spinal anesthesia, and he was subsequently moved to the COVID-19 Intensive Care Unit, where he was started on injection meronem, dexamethasone, and remdesevir, as per local protocol. He was also given intravenous fluids, pain medication, and insulin according to a sliding scale. After 12 hours of surgery, he was given therapeutic anticoagulation with enoxaparin.\nAfter eight days, the patient's clinical state improved, with oxygen saturation increasing to 94% on room air. His inflammatory markers were within the normal range following 12 days of sickness. On day 15, he was discharged with instructions for chest physiotherapy and incentive spirometry, as well as wound care and pulmonology, vascular surgery, and rehabilitation clinic follow-up.

A 48 year old male with a history of asthma presented to our institution with a cough, shortness of breath and a fever. The patient subsequently tested positive for Covid-19 and was intubated and admitted to the ICU with hypoxic respiratory failure after failure to improve with initial therapy. The patient was started on therapeutic enoxaparin treatment.\nOn the 10th day the patient was on high ventilator settings and minimal inotropic support. On examination, lower limbs showed unsalvageable ischemia with no palpable pulses (). Urgent CT angiography revealed complete occlusion of the left arterial tree from the aortic bifurcation descending down to the infra-popliteal arteries. Contralaterally, distal occlusion of the superficial femoral artery down to the infra-popliteal arteries. CT of the lung displayed ground glass appearance of the lungs associated with consolidation. After consulting the next of kin and the risk; benefit of proceeding to surgery. The joint decision to provide supportive care was made. The patient was declared dead on the same day.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 38 year old previously healthy male presented to our ER complaining of a 2 day history of worsening left arm pain and mild shortness of breath. On examination a discolored left arm was noted and markedly reduced/absent pulses. The patient was afebrile and the only abnormal laboratory investigations was a D-Dimer of 1500 ng/ml. CT-angiography showed a totally occluded left axillary artery and partial occlusion of the brachial artery - likely embolic. Bilateral pulmonary embolism noted on subsequent CT scan.\nHeparin infusion was initiated and a surgical embolectomy performed successfully. The patient was admitted to the ICU for observation management. The patient recovered and was discharged after 2 weeks.

A 48 year old male with a history of asthma presented to our institution with a cough, shortness of breath and a fever. The patient subsequently tested positive for Covid-19 and was intubated and admitted to the ICU with hypoxic respiratory failure after failure to improve with initial therapy. The patient was started on therapeutic enoxaparin treatment.\nOn the 10th day the patient was on high ventilator settings and minimal inotropic support. On examination, lower limbs showed unsalvageable ischemia with no palpable pulses (). Urgent CT angiography revealed complete occlusion of the left arterial tree from the aortic bifurcation descending down to the infra-popliteal arteries. Contralaterally, distal occlusion of the superficial femoral artery down to the infra-popliteal arteries. CT of the lung displayed ground glass appearance of the lungs associated with consolidation. After consulting the next of kin and the risk; benefit of proceeding to surgery. The joint decision to provide supportive care was made. The patient was declared dead on the same day.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 60 year old hypertensive male presented to our institution with significant respiratory distress. He was subsequently intubated in the ER due to deteriorating respiratory status and reduced level of consciousness. On day 8 of his ICU course, the left lower limb appeared dusky and mottled up to the mid-thigh (). The right distal forefoot displayed a well demarcated discoloration.\nCT angiography revealed; Infra-renal aortic left sided eccentric, non-calcified atheromatous plaque. Significant occlusion of the left common iliac artery extending to infra-popliteal arteries. A joint decision was made to avoid surgery given the poor prognosis associated with severe acute respiratory distress syndrome and high inotropic support. The patient expired the following morning.

A 48 year old male with a history of asthma presented to our institution with a cough, shortness of breath and a fever. The patient subsequently tested positive for Covid-19 and was intubated and admitted to the ICU with hypoxic respiratory failure after failure to improve with initial therapy. The patient was started on therapeutic enoxaparin treatment.\nOn the 10th day the patient was on high ventilator settings and minimal inotropic support. On examination, lower limbs showed unsalvageable ischemia with no palpable pulses (). Urgent CT angiography revealed complete occlusion of the left arterial tree from the aortic bifurcation descending down to the infra-popliteal arteries. Contralaterally, distal occlusion of the superficial femoral artery down to the infra-popliteal arteries. CT of the lung displayed ground glass appearance of the lungs associated with consolidation. After consulting the next of kin and the risk; benefit of proceeding to surgery. The joint decision to provide supportive care was made. The patient was declared dead on the same day.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 48 year old male with a history of asthma presented to our institution with a cough, shortness of breath and a fever. The patient subsequently tested positive for Covid-19 and was intubated and admitted to the ICU with hypoxic respiratory failure after failure to improve with initial therapy. The patient was started on therapeutic enoxaparin treatment.\nOn the 10th day the patient was on high ventilator settings and minimal inotropic support. On examination, lower limbs showed unsalvageable ischemia with no palpable pulses (). Urgent CT angiography revealed complete occlusion of the left arterial tree from the aortic bifurcation descending down to the infra-popliteal arteries. Contralaterally, distal occlusion of the superficial femoral artery down to the infra-popliteal arteries. CT of the lung displayed ground glass appearance of the lungs associated with consolidation. After consulting the next of kin and the risk; benefit of proceeding to surgery. The joint decision to provide supportive care was made. The patient was declared dead on the same day.

A 58 year old previously healthy male who presented to us after being diagnosed with Covid-19 pneumonia. On arrival the patient was displaying signs of severe respiratory distress with exhaustion. He was immediately intubated and transferred to the ICU. During his stay he was on high ventilatory and inotropic support. On day 11, all distal extremities showed non salvageable ischemia with no palpable distal pulses (). Urgent CT angiography revealed extensive thrombosis affecting aortic bifurcation and bilateral iliac systems. Despite aggressive anticoagulation the patient subsequently expired secondary to refractory shock. The patient was anti-coagulated for the entire duration of his hospital stay ().

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 38 year old male with no identifiable co-morbidities presented to the emergency department complaining of a 2-day history of progressively worsening abdominal pain, nausea, intractable vomiting and shortness of breath. Examination reveals tachycardia, respiratory distress, and abdominal pain out of proportion to the palpation. Apart from mild leukocytosis and a lactate of 2.2 mmol/L, D-Dimer 2100 ng/ml. All other laboratory investigations were normal. After normal plain films of the abdomen and chest, the patient underwent a computed tomography (CT) scan of the abdomen with contrast.\nThe scan revealed extensive thrombosis of the portal, splenic, superior and inferior mesenteric veins. The mid-portion of the small bowel was suggestive of venous ischemia. No pneumatosis intestinalis was noted. An incidental finding of a totally occluded right pulmonary artery consistent with a pulmonary embolism was noted.\nThe patient received heparin therapy prior to a diagnostic laparoscopy. Intra-operatively a markedly dusky jejunal segment was identified along with turbid fluid in all quadrants. Conversion to open laparotomy ensued followed by resection of the diseased segment with temporary abdominal closure (). The patient was admitted to the ICU for resuscitation and anticoagulation. The patient was later taken to theatre for a side to side anastomosis. The patient was subsequently placed on extracorporeal membrane oxygenation (ECMO) and is currently under care in the intensive care unit (ICU).

A 64-year-old male with a past medical history of type 2 diabetes mellitus and essential hypertension presented in the emergency department with a history of intermittent fever of 102 degrees Fahrenheit for the last five days along with numbness and discoloration in his right leg for the last three days and shortness of breath. On examination, his Glasgow coma scale (GCS) score was 15/15 and his mental status was normal on gross neurological examination. His oxygen saturation (SpO2) at room air was 85% (indicative of severe disease) and 94% SpO2 at 15 L oxygen via a non-breather mask (NRM).\nOn physical examination, his right leg had a blackish discoloration (Figure ).\nIt was cold, clammy, with an absent femoral pulse. Arterial Doppler ultrasound of the right lower limb showed no flow in the femoral, popliteal, anterior tibial, posterior tibial, and dorsalis pedis arteries although no plaque or echogenic thrombus was seen. A CT angiogram of the lower limb was performed, which showed no contrast opacification beyond the right common femoral artery (Figure ).\nA Vascular surgeon was consulted and a diagnosis of acute limb ischemia was made. It was classified as Rutherford stage III, which was three days old. The limb was declared as non-salvageable. Keeping in view the clinical picture and CT angiogram findings, the Vascular surgeon advised an above-knee amputation of the affected limb.\nThe patient's real-time SARS-CoV-2 polymerase chain reaction (PCR) test was positive. His arterial blood gases (ABGs) showed metabolic acidosis with respiratory compensation with a pH of 7.4, bicarbonate (HCO3-) of 17.9, and pCO2 of 25.9. His high-resolution computerized tomography (HRCT) of the chest gave a severity score of 31/40 for COVID-19 pneumonia (Figure ), indicative of severe disease.\nHis serum ferritin levels were 1,279 ng/mL (N=15-200 ng/mL), serum D-dimer 1,650 ng/mL (N≤250 ng/mL), serum LDH 861 U/L (N=135-225 U/L), serum CK 4,252 U/L (N= up to 192 U/L), INR=1, IL-6=14.8 pg/mL (N≤7.0 pg/mL). CBC showed WBC count of 29.0 x 109/L with neutrophil-lymphocyte ratio (NLR) of 22.25 (N=1-3). His HbA1c was 12.4 (N=4.5%-6.5%).\nThe patient's above-knee amputation was done under spinal anesthesia, and he was subsequently moved to the COVID-19 Intensive Care Unit, where he was started on injection meronem, dexamethasone, and remdesevir, as per local protocol. He was also given intravenous fluids, pain medication, and insulin according to a sliding scale. After 12 hours of surgery, he was given therapeutic anticoagulation with enoxaparin.\nAfter eight days, the patient's clinical state improved, with oxygen saturation increasing to 94% on room air. His inflammatory markers were within the normal range following 12 days of sickness. On day 15, he was discharged with instructions for chest physiotherapy and incentive spirometry, as well as wound care and pulmonology, vascular surgery, and rehabilitation clinic follow-up.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 38 year old male with no identifiable co-morbidities presented to the emergency department complaining of a 2-day history of progressively worsening abdominal pain, nausea, intractable vomiting and shortness of breath. Examination reveals tachycardia, respiratory distress, and abdominal pain out of proportion to the palpation. Apart from mild leukocytosis and a lactate of 2.2 mmol/L, D-Dimer 2100 ng/ml. All other laboratory investigations were normal. After normal plain films of the abdomen and chest, the patient underwent a computed tomography (CT) scan of the abdomen with contrast.\nThe scan revealed extensive thrombosis of the portal, splenic, superior and inferior mesenteric veins. The mid-portion of the small bowel was suggestive of venous ischemia. No pneumatosis intestinalis was noted. An incidental finding of a totally occluded right pulmonary artery consistent with a pulmonary embolism was noted.\nThe patient received heparin therapy prior to a diagnostic laparoscopy. Intra-operatively a markedly dusky jejunal segment was identified along with turbid fluid in all quadrants. Conversion to open laparotomy ensued followed by resection of the diseased segment with temporary abdominal closure (). The patient was admitted to the ICU for resuscitation and anticoagulation. The patient was later taken to theatre for a side to side anastomosis. The patient was subsequently placed on extracorporeal membrane oxygenation (ECMO) and is currently under care in the intensive care unit (ICU).

A 38 year old previously healthy male presented to our ER complaining of a 2 day history of worsening left arm pain and mild shortness of breath. On examination a discolored left arm was noted and markedly reduced/absent pulses. The patient was afebrile and the only abnormal laboratory investigations was a D-Dimer of 1500 ng/ml. CT-angiography showed a totally occluded left axillary artery and partial occlusion of the brachial artery - likely embolic. Bilateral pulmonary embolism noted on subsequent CT scan.\nHeparin infusion was initiated and a surgical embolectomy performed successfully. The patient was admitted to the ICU for observation management. The patient recovered and was discharged after 2 weeks.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 38 year old male with no identifiable co-morbidities presented to the emergency department complaining of a 2-day history of progressively worsening abdominal pain, nausea, intractable vomiting and shortness of breath. Examination reveals tachycardia, respiratory distress, and abdominal pain out of proportion to the palpation. Apart from mild leukocytosis and a lactate of 2.2 mmol/L, D-Dimer 2100 ng/ml. All other laboratory investigations were normal. After normal plain films of the abdomen and chest, the patient underwent a computed tomography (CT) scan of the abdomen with contrast.\nThe scan revealed extensive thrombosis of the portal, splenic, superior and inferior mesenteric veins. The mid-portion of the small bowel was suggestive of venous ischemia. No pneumatosis intestinalis was noted. An incidental finding of a totally occluded right pulmonary artery consistent with a pulmonary embolism was noted.\nThe patient received heparin therapy prior to a diagnostic laparoscopy. Intra-operatively a markedly dusky jejunal segment was identified along with turbid fluid in all quadrants. Conversion to open laparotomy ensued followed by resection of the diseased segment with temporary abdominal closure (). The patient was admitted to the ICU for resuscitation and anticoagulation. The patient was later taken to theatre for a side to side anastomosis. The patient was subsequently placed on extracorporeal membrane oxygenation (ECMO) and is currently under care in the intensive care unit (ICU).

A 60 year old hypertensive male presented to our institution with significant respiratory distress. He was subsequently intubated in the ER due to deteriorating respiratory status and reduced level of consciousness. On day 8 of his ICU course, the left lower limb appeared dusky and mottled up to the mid-thigh (). The right distal forefoot displayed a well demarcated discoloration.\nCT angiography revealed; Infra-renal aortic left sided eccentric, non-calcified atheromatous plaque. Significant occlusion of the left common iliac artery extending to infra-popliteal arteries. A joint decision was made to avoid surgery given the poor prognosis associated with severe acute respiratory distress syndrome and high inotropic support. The patient expired the following morning.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 38 year old male with no identifiable co-morbidities presented to the emergency department complaining of a 2-day history of progressively worsening abdominal pain, nausea, intractable vomiting and shortness of breath. Examination reveals tachycardia, respiratory distress, and abdominal pain out of proportion to the palpation. Apart from mild leukocytosis and a lactate of 2.2 mmol/L, D-Dimer 2100 ng/ml. All other laboratory investigations were normal. After normal plain films of the abdomen and chest, the patient underwent a computed tomography (CT) scan of the abdomen with contrast.\nThe scan revealed extensive thrombosis of the portal, splenic, superior and inferior mesenteric veins. The mid-portion of the small bowel was suggestive of venous ischemia. No pneumatosis intestinalis was noted. An incidental finding of a totally occluded right pulmonary artery consistent with a pulmonary embolism was noted.\nThe patient received heparin therapy prior to a diagnostic laparoscopy. Intra-operatively a markedly dusky jejunal segment was identified along with turbid fluid in all quadrants. Conversion to open laparotomy ensued followed by resection of the diseased segment with temporary abdominal closure (). The patient was admitted to the ICU for resuscitation and anticoagulation. The patient was later taken to theatre for a side to side anastomosis. The patient was subsequently placed on extracorporeal membrane oxygenation (ECMO) and is currently under care in the intensive care unit (ICU).

A 58 year old previously healthy male who presented to us after being diagnosed with Covid-19 pneumonia. On arrival the patient was displaying signs of severe respiratory distress with exhaustion. He was immediately intubated and transferred to the ICU. During his stay he was on high ventilatory and inotropic support. On day 11, all distal extremities showed non salvageable ischemia with no palpable distal pulses (). Urgent CT angiography revealed extensive thrombosis affecting aortic bifurcation and bilateral iliac systems. Despite aggressive anticoagulation the patient subsequently expired secondary to refractory shock. The patient was anti-coagulated for the entire duration of his hospital stay ().

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 64-year-old male with a past medical history of type 2 diabetes mellitus and essential hypertension presented in the emergency department with a history of intermittent fever of 102 degrees Fahrenheit for the last five days along with numbness and discoloration in his right leg for the last three days and shortness of breath. On examination, his Glasgow coma scale (GCS) score was 15/15 and his mental status was normal on gross neurological examination. His oxygen saturation (SpO2) at room air was 85% (indicative of severe disease) and 94% SpO2 at 15 L oxygen via a non-breather mask (NRM).\nOn physical examination, his right leg had a blackish discoloration (Figure ).\nIt was cold, clammy, with an absent femoral pulse. Arterial Doppler ultrasound of the right lower limb showed no flow in the femoral, popliteal, anterior tibial, posterior tibial, and dorsalis pedis arteries although no plaque or echogenic thrombus was seen. A CT angiogram of the lower limb was performed, which showed no contrast opacification beyond the right common femoral artery (Figure ).\nA Vascular surgeon was consulted and a diagnosis of acute limb ischemia was made. It was classified as Rutherford stage III, which was three days old. The limb was declared as non-salvageable. Keeping in view the clinical picture and CT angiogram findings, the Vascular surgeon advised an above-knee amputation of the affected limb.\nThe patient's real-time SARS-CoV-2 polymerase chain reaction (PCR) test was positive. His arterial blood gases (ABGs) showed metabolic acidosis with respiratory compensation with a pH of 7.4, bicarbonate (HCO3-) of 17.9, and pCO2 of 25.9. His high-resolution computerized tomography (HRCT) of the chest gave a severity score of 31/40 for COVID-19 pneumonia (Figure ), indicative of severe disease.\nHis serum ferritin levels were 1,279 ng/mL (N=15-200 ng/mL), serum D-dimer 1,650 ng/mL (N≤250 ng/mL), serum LDH 861 U/L (N=135-225 U/L), serum CK 4,252 U/L (N= up to 192 U/L), INR=1, IL-6=14.8 pg/mL (N≤7.0 pg/mL). CBC showed WBC count of 29.0 x 109/L with neutrophil-lymphocyte ratio (NLR) of 22.25 (N=1-3). His HbA1c was 12.4 (N=4.5%-6.5%).\nThe patient's above-knee amputation was done under spinal anesthesia, and he was subsequently moved to the COVID-19 Intensive Care Unit, where he was started on injection meronem, dexamethasone, and remdesevir, as per local protocol. He was also given intravenous fluids, pain medication, and insulin according to a sliding scale. After 12 hours of surgery, he was given therapeutic anticoagulation with enoxaparin.\nAfter eight days, the patient's clinical state improved, with oxygen saturation increasing to 94% on room air. His inflammatory markers were within the normal range following 12 days of sickness. On day 15, he was discharged with instructions for chest physiotherapy and incentive spirometry, as well as wound care and pulmonology, vascular surgery, and rehabilitation clinic follow-up.

A 38 year old previously healthy male presented to our ER complaining of a 2 day history of worsening left arm pain and mild shortness of breath. On examination a discolored left arm was noted and markedly reduced/absent pulses. The patient was afebrile and the only abnormal laboratory investigations was a D-Dimer of 1500 ng/ml. CT-angiography showed a totally occluded left axillary artery and partial occlusion of the brachial artery - likely embolic. Bilateral pulmonary embolism noted on subsequent CT scan.\nHeparin infusion was initiated and a surgical embolectomy performed successfully. The patient was admitted to the ICU for observation management. The patient recovered and was discharged after 2 weeks.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 64-year-old male with a past medical history of type 2 diabetes mellitus and essential hypertension presented in the emergency department with a history of intermittent fever of 102 degrees Fahrenheit for the last five days along with numbness and discoloration in his right leg for the last three days and shortness of breath. On examination, his Glasgow coma scale (GCS) score was 15/15 and his mental status was normal on gross neurological examination. His oxygen saturation (SpO2) at room air was 85% (indicative of severe disease) and 94% SpO2 at 15 L oxygen via a non-breather mask (NRM).\nOn physical examination, his right leg had a blackish discoloration (Figure ).\nIt was cold, clammy, with an absent femoral pulse. Arterial Doppler ultrasound of the right lower limb showed no flow in the femoral, popliteal, anterior tibial, posterior tibial, and dorsalis pedis arteries although no plaque or echogenic thrombus was seen. A CT angiogram of the lower limb was performed, which showed no contrast opacification beyond the right common femoral artery (Figure ).\nA Vascular surgeon was consulted and a diagnosis of acute limb ischemia was made. It was classified as Rutherford stage III, which was three days old. The limb was declared as non-salvageable. Keeping in view the clinical picture and CT angiogram findings, the Vascular surgeon advised an above-knee amputation of the affected limb.\nThe patient's real-time SARS-CoV-2 polymerase chain reaction (PCR) test was positive. His arterial blood gases (ABGs) showed metabolic acidosis with respiratory compensation with a pH of 7.4, bicarbonate (HCO3-) of 17.9, and pCO2 of 25.9. His high-resolution computerized tomography (HRCT) of the chest gave a severity score of 31/40 for COVID-19 pneumonia (Figure ), indicative of severe disease.\nHis serum ferritin levels were 1,279 ng/mL (N=15-200 ng/mL), serum D-dimer 1,650 ng/mL (N≤250 ng/mL), serum LDH 861 U/L (N=135-225 U/L), serum CK 4,252 U/L (N= up to 192 U/L), INR=1, IL-6=14.8 pg/mL (N≤7.0 pg/mL). CBC showed WBC count of 29.0 x 109/L with neutrophil-lymphocyte ratio (NLR) of 22.25 (N=1-3). His HbA1c was 12.4 (N=4.5%-6.5%).\nThe patient's above-knee amputation was done under spinal anesthesia, and he was subsequently moved to the COVID-19 Intensive Care Unit, where he was started on injection meronem, dexamethasone, and remdesevir, as per local protocol. He was also given intravenous fluids, pain medication, and insulin according to a sliding scale. After 12 hours of surgery, he was given therapeutic anticoagulation with enoxaparin.\nAfter eight days, the patient's clinical state improved, with oxygen saturation increasing to 94% on room air. His inflammatory markers were within the normal range following 12 days of sickness. On day 15, he was discharged with instructions for chest physiotherapy and incentive spirometry, as well as wound care and pulmonology, vascular surgery, and rehabilitation clinic follow-up.

A 60 year old hypertensive male presented to our institution with significant respiratory distress. He was subsequently intubated in the ER due to deteriorating respiratory status and reduced level of consciousness. On day 8 of his ICU course, the left lower limb appeared dusky and mottled up to the mid-thigh (). The right distal forefoot displayed a well demarcated discoloration.\nCT angiography revealed; Infra-renal aortic left sided eccentric, non-calcified atheromatous plaque. Significant occlusion of the left common iliac artery extending to infra-popliteal arteries. A joint decision was made to avoid surgery given the poor prognosis associated with severe acute respiratory distress syndrome and high inotropic support. The patient expired the following morning.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 64-year-old male with a past medical history of type 2 diabetes mellitus and essential hypertension presented in the emergency department with a history of intermittent fever of 102 degrees Fahrenheit for the last five days along with numbness and discoloration in his right leg for the last three days and shortness of breath. On examination, his Glasgow coma scale (GCS) score was 15/15 and his mental status was normal on gross neurological examination. His oxygen saturation (SpO2) at room air was 85% (indicative of severe disease) and 94% SpO2 at 15 L oxygen via a non-breather mask (NRM).\nOn physical examination, his right leg had a blackish discoloration (Figure ).\nIt was cold, clammy, with an absent femoral pulse. Arterial Doppler ultrasound of the right lower limb showed no flow in the femoral, popliteal, anterior tibial, posterior tibial, and dorsalis pedis arteries although no plaque or echogenic thrombus was seen. A CT angiogram of the lower limb was performed, which showed no contrast opacification beyond the right common femoral artery (Figure ).\nA Vascular surgeon was consulted and a diagnosis of acute limb ischemia was made. It was classified as Rutherford stage III, which was three days old. The limb was declared as non-salvageable. Keeping in view the clinical picture and CT angiogram findings, the Vascular surgeon advised an above-knee amputation of the affected limb.\nThe patient's real-time SARS-CoV-2 polymerase chain reaction (PCR) test was positive. His arterial blood gases (ABGs) showed metabolic acidosis with respiratory compensation with a pH of 7.4, bicarbonate (HCO3-) of 17.9, and pCO2 of 25.9. His high-resolution computerized tomography (HRCT) of the chest gave a severity score of 31/40 for COVID-19 pneumonia (Figure ), indicative of severe disease.\nHis serum ferritin levels were 1,279 ng/mL (N=15-200 ng/mL), serum D-dimer 1,650 ng/mL (N≤250 ng/mL), serum LDH 861 U/L (N=135-225 U/L), serum CK 4,252 U/L (N= up to 192 U/L), INR=1, IL-6=14.8 pg/mL (N≤7.0 pg/mL). CBC showed WBC count of 29.0 x 109/L with neutrophil-lymphocyte ratio (NLR) of 22.25 (N=1-3). His HbA1c was 12.4 (N=4.5%-6.5%).\nThe patient's above-knee amputation was done under spinal anesthesia, and he was subsequently moved to the COVID-19 Intensive Care Unit, where he was started on injection meronem, dexamethasone, and remdesevir, as per local protocol. He was also given intravenous fluids, pain medication, and insulin according to a sliding scale. After 12 hours of surgery, he was given therapeutic anticoagulation with enoxaparin.\nAfter eight days, the patient's clinical state improved, with oxygen saturation increasing to 94% on room air. His inflammatory markers were within the normal range following 12 days of sickness. On day 15, he was discharged with instructions for chest physiotherapy and incentive spirometry, as well as wound care and pulmonology, vascular surgery, and rehabilitation clinic follow-up.

A 58 year old previously healthy male who presented to us after being diagnosed with Covid-19 pneumonia. On arrival the patient was displaying signs of severe respiratory distress with exhaustion. He was immediately intubated and transferred to the ICU. During his stay he was on high ventilatory and inotropic support. On day 11, all distal extremities showed non salvageable ischemia with no palpable distal pulses (). Urgent CT angiography revealed extensive thrombosis affecting aortic bifurcation and bilateral iliac systems. Despite aggressive anticoagulation the patient subsequently expired secondary to refractory shock. The patient was anti-coagulated for the entire duration of his hospital stay ().

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 38 year old previously healthy male presented to our ER complaining of a 2 day history of worsening left arm pain and mild shortness of breath. On examination a discolored left arm was noted and markedly reduced/absent pulses. The patient was afebrile and the only abnormal laboratory investigations was a D-Dimer of 1500 ng/ml. CT-angiography showed a totally occluded left axillary artery and partial occlusion of the brachial artery - likely embolic. Bilateral pulmonary embolism noted on subsequent CT scan.\nHeparin infusion was initiated and a surgical embolectomy performed successfully. The patient was admitted to the ICU for observation management. The patient recovered and was discharged after 2 weeks.

A 60 year old hypertensive male presented to our institution with significant respiratory distress. He was subsequently intubated in the ER due to deteriorating respiratory status and reduced level of consciousness. On day 8 of his ICU course, the left lower limb appeared dusky and mottled up to the mid-thigh (). The right distal forefoot displayed a well demarcated discoloration.\nCT angiography revealed; Infra-renal aortic left sided eccentric, non-calcified atheromatous plaque. Significant occlusion of the left common iliac artery extending to infra-popliteal arteries. A joint decision was made to avoid surgery given the poor prognosis associated with severe acute respiratory distress syndrome and high inotropic support. The patient expired the following morning.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 38 year old previously healthy male presented to our ER complaining of a 2 day history of worsening left arm pain and mild shortness of breath. On examination a discolored left arm was noted and markedly reduced/absent pulses. The patient was afebrile and the only abnormal laboratory investigations was a D-Dimer of 1500 ng/ml. CT-angiography showed a totally occluded left axillary artery and partial occlusion of the brachial artery - likely embolic. Bilateral pulmonary embolism noted on subsequent CT scan.\nHeparin infusion was initiated and a surgical embolectomy performed successfully. The patient was admitted to the ICU for observation management. The patient recovered and was discharged after 2 weeks.

A 58 year old previously healthy male who presented to us after being diagnosed with Covid-19 pneumonia. On arrival the patient was displaying signs of severe respiratory distress with exhaustion. He was immediately intubated and transferred to the ICU. During his stay he was on high ventilatory and inotropic support. On day 11, all distal extremities showed non salvageable ischemia with no palpable distal pulses (). Urgent CT angiography revealed extensive thrombosis affecting aortic bifurcation and bilateral iliac systems. Despite aggressive anticoagulation the patient subsequently expired secondary to refractory shock. The patient was anti-coagulated for the entire duration of his hospital stay ().

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

A 58 year old previously healthy male who presented to us after being diagnosed with Covid-19 pneumonia. On arrival the patient was displaying signs of severe respiratory distress with exhaustion. He was immediately intubated and transferred to the ICU. During his stay he was on high ventilatory and inotropic support. On day 11, all distal extremities showed non salvageable ischemia with no palpable distal pulses (). Urgent CT angiography revealed extensive thrombosis affecting aortic bifurcation and bilateral iliac systems. Despite aggressive anticoagulation the patient subsequently expired secondary to refractory shock. The patient was anti-coagulated for the entire duration of his hospital stay ().

A 60 year old hypertensive male presented to our institution with significant respiratory distress. He was subsequently intubated in the ER due to deteriorating respiratory status and reduced level of consciousness. On day 8 of his ICU course, the left lower limb appeared dusky and mottled up to the mid-thigh (). The right distal forefoot displayed a well demarcated discoloration.\nCT angiography revealed; Infra-renal aortic left sided eccentric, non-calcified atheromatous plaque. Significant occlusion of the left common iliac artery extending to infra-popliteal arteries. A joint decision was made to avoid surgery given the poor prognosis associated with severe acute respiratory distress syndrome and high inotropic support. The patient expired the following morning.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Thrombosis, Critical Care

Mrs. K, a 27-year-old pregnant woman at 27+4 weeks of gestation, presented to our obstetric emergency unit with tachypnea (RR 28×/min; saturation 92%) one day before admission. The patient also had a fever (103.1 °F) and cough 1 week before admission. Other than that, she also had chronic hypertension. A chest X-ray showed patchy consolidation that corresponded to bilateral pneumonia. A naso-oropharyngeal swab for SARS-CoV-2 was positive as tested by RT-PCR (RdRP Cq 35.15; E Gene Cq 32.10). The patient was taken care of in the High Care Unit (HCU) with oxygen therapy using 10 L per minute (Lpm) with a nonrebreathing mask (NRM), and O2 saturation maintained at 95–97%. She was diagnosed with acute respiratory distress and superimposed preeclampsia with severe features. The patient was treated with anti-hypertension (nifedipine 4 × 10 mg), MgSO4 for seizure prevention, and dexamethasone 2 × 6 mg for lung maturation for 2 days.\nOn hospital care day 2, tachypnea worsened (RR 32×/min), with a decreased O2 saturation to 90% while on oxygen therapy given at 10 Lpm with NRM. The patient had an emergency cesarean section, and a baby girl was born with a birthweight of 1150 g, birth length of 34 cm, and APGAR score (AS) 7/9. The baby was taken care of in the NICU isolation for COVID-19 as a naso-oropharyngeal swab for SARS-CoV-2 result was negative.\nFor postoperative observation, the patient was taken to HCU with no clinical improvement. On hospital care day 7 (HD 7), she was given Remdesivir protocol for 5 days. Tachypnea and saturation improved on HD 8 (RR 24×/min; O2 saturation 96% with NRM 6 Lpm). Both patient and baby were discharged on HD 12 after the SARS-CoV-2 swab came back negative.

Mrs. N, a 31-year-old pregnant woman at 40 weeks gestation, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%) and fever (101.3 °F) for one week before admission. The patient had a history of flu-like symptoms and anosmia for the previous 2 weeks. A chest X-ray showed no appearance of pneumonia. Oxygen therapy was given with a nasal cannula, 4 Lpm, and O2 saturation was 96%. SARS-CoV-2 (RdRP Cq 24.40; E Gene Cq 23.89) was confirmed using RT-PCR from a naso-oropharyngeal swab.\nWe immediately conducted a cesarean section due to a premature rupture of the membrane with oligohydramnios. The cesarean section was successful, and a born baby boy was born, 3465 g, 51 cm, AS 8/9. The neonate was taken care of in the perinatal isolation unit for COVID-19, and a naso-oropharyngeal swab for SARS-CoV-2 result came back negative.\nThe patient was taken to the isolation ward for COVID-19 for postoperative observation. The patient was given Remdesivir on HD 2 until HD 6. The patient’s symptoms improved during hospitalization with a negative swab result for SARS-CoV-2 on hospital care day 6. Both patient and baby were discharged with a stable condition on HD 7.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. K, a 27-year-old pregnant woman at 27+4 weeks of gestation, presented to our obstetric emergency unit with tachypnea (RR 28×/min; saturation 92%) one day before admission. The patient also had a fever (103.1 °F) and cough 1 week before admission. Other than that, she also had chronic hypertension. A chest X-ray showed patchy consolidation that corresponded to bilateral pneumonia. A naso-oropharyngeal swab for SARS-CoV-2 was positive as tested by RT-PCR (RdRP Cq 35.15; E Gene Cq 32.10). The patient was taken care of in the High Care Unit (HCU) with oxygen therapy using 10 L per minute (Lpm) with a nonrebreathing mask (NRM), and O2 saturation maintained at 95–97%. She was diagnosed with acute respiratory distress and superimposed preeclampsia with severe features. The patient was treated with anti-hypertension (nifedipine 4 × 10 mg), MgSO4 for seizure prevention, and dexamethasone 2 × 6 mg for lung maturation for 2 days.\nOn hospital care day 2, tachypnea worsened (RR 32×/min), with a decreased O2 saturation to 90% while on oxygen therapy given at 10 Lpm with NRM. The patient had an emergency cesarean section, and a baby girl was born with a birthweight of 1150 g, birth length of 34 cm, and APGAR score (AS) 7/9. The baby was taken care of in the NICU isolation for COVID-19 as a naso-oropharyngeal swab for SARS-CoV-2 result was negative.\nFor postoperative observation, the patient was taken to HCU with no clinical improvement. On hospital care day 7 (HD 7), she was given Remdesivir protocol for 5 days. Tachypnea and saturation improved on HD 8 (RR 24×/min; O2 saturation 96% with NRM 6 Lpm). Both patient and baby were discharged on HD 12 after the SARS-CoV-2 swab came back negative.

A 39-year-old woman, Gravida 3, Para 2 at 29 weeks gestation presented to the emergency department with complaints of fever, chills and dry cough since 3 days. Her past medical history was significant for Rheumatoid arthritis treated with Methotrexate for 5 years, Non-Hodgkin’s lymphoma treated with chemotherapy 10 years ago and is in remission, Sjogren’s syndrome (diagnosed 1 year ago) and Rheumatoid arthritis (relapsed 2 years ago), currently on Hydroxychloroquine. On admission, she was febrile with a temperature of 102.2 degrees Fahrenheit, tachycardic at 126 beats per minute, tachypneic at 24 breaths per minute and mildly hypoxic at 94% on room air. She was mildly hypertensive with a blood pressure of 141/76. Her oxygen saturation improved to 100% after oxygen supplementation with 2 liters via nasal cannula.\nInitial labs were significant for a leukocytosis of 14.75 x 103/µl with neutrophilia, a normal lymphocyte count, elevated C-reactive protein (CRP), lactate dehydrogenase and D-dimer. Procalcitonin was normal. Blood cultures were collected. A nasopharyngeal swab sample was taken and tested positive for COVID-19 by polymerase chain reaction. CT angiogram of the chest revealed extensive severe bilateral focal ground-glass infiltrates () without evidence of pulmonary embolism. Given the patient’s history of autoimmune conditions, current pregnancy, severe imaging findings and overall septic picture, she was admitted to the Intermediate Care Unit for close monitoring despite minimal oxygen requirements. Since the patient meets the criteria for the severe disease defined as requiring supplemental oxygen, as per our institution's policy, Infectious disease (ID) consultation was requested to evaluate if the patient meets the criteria for the use of Remdesivir set forth by the Emergency use authorization (EUA) released by the FDA []. Patient met the criteria and ID physician suggested to initiate Remdesivir after discussing the risks and benefits and obtaining the patient's consent since the teratogenic side effects of Remdesivir are not known. Patient has been provided information regarding the possible side effects including unknown teratogenicity and provided the copy of the patient information released by the Gilead sciences. Patient consented for the use of the Remdesivir. After following the standard of work flow for the use of Remdesivir at our institute which includes approval by hospital pharmacy as per the EUA guidelines for the Remdesivir issued by the FDA, she received 200 mg of IV Remdesivir on Day 1 followed by 100 mg daily for the next 4 days. Since the patient is symptomatic for less than 7 days at the time of admission, she did not meet the criteria to receive the steroid therapy as per the RECOVERY trial.\nShe successfully completed the course of Remdesivir without any side effects and showed steady improvement throughout the hospital stay. Fetal activity was monitored every 8 hours using the external fetal monitor, with no abnormalities detected. As per the obstetrician’s recommendations, supplemental oxygen was provided to maintain saturations >95%. Oxygen saturations were around 98−100% while on 2 L via NC and weaned down to room air with saturations >95% by the time of discharge on day six.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. K, a 27-year-old pregnant woman at 27+4 weeks of gestation, presented to our obstetric emergency unit with tachypnea (RR 28×/min; saturation 92%) one day before admission. The patient also had a fever (103.1 °F) and cough 1 week before admission. Other than that, she also had chronic hypertension. A chest X-ray showed patchy consolidation that corresponded to bilateral pneumonia. A naso-oropharyngeal swab for SARS-CoV-2 was positive as tested by RT-PCR (RdRP Cq 35.15; E Gene Cq 32.10). The patient was taken care of in the High Care Unit (HCU) with oxygen therapy using 10 L per minute (Lpm) with a nonrebreathing mask (NRM), and O2 saturation maintained at 95–97%. She was diagnosed with acute respiratory distress and superimposed preeclampsia with severe features. The patient was treated with anti-hypertension (nifedipine 4 × 10 mg), MgSO4 for seizure prevention, and dexamethasone 2 × 6 mg for lung maturation for 2 days.\nOn hospital care day 2, tachypnea worsened (RR 32×/min), with a decreased O2 saturation to 90% while on oxygen therapy given at 10 Lpm with NRM. The patient had an emergency cesarean section, and a baby girl was born with a birthweight of 1150 g, birth length of 34 cm, and APGAR score (AS) 7/9. The baby was taken care of in the NICU isolation for COVID-19 as a naso-oropharyngeal swab for SARS-CoV-2 result was negative.\nFor postoperative observation, the patient was taken to HCU with no clinical improvement. On hospital care day 7 (HD 7), she was given Remdesivir protocol for 5 days. Tachypnea and saturation improved on HD 8 (RR 24×/min; O2 saturation 96% with NRM 6 Lpm). Both patient and baby were discharged on HD 12 after the SARS-CoV-2 swab came back negative.

Mrs. M, a 28-year-old pregnant woman at 36 weeks gestation, was diagnosed with confirmed COVID-19 and was referred to our hospital due to worsening clinical symptoms. The patient had been treated in a previous hospital for 2 days with symptoms of cough and fever 4 days before admission. During hospitalization, the patient’s condition worsened as she displayed tachypnea (RR 32×/min, O2 saturation 92%) and fever (102.2 °F).\nA chest X-ray showed no abnormalities in both lungs. A naso-oropharyngeal swab for SARS-CoV-2 was positive (N gene Cq 39.54). Oxygen saturation was 95% using oxygen therapy at 3 Lpm with a nasal cannula. An emergency cesarean section was directly performed due to the worsening of the maternal condition and oligohydramnios seen from ultrasound examination. The cesarean section was performed with no complications. A baby boy was born with a birthweight of 2345 g, a birth length of 45 cm, and AS 7/8. The baby was taken to perinatal isolation for COVID-19 with a negative result for SARS-CoV-2 from a naso-oropharyngeal swab.\nThe patient was taken care of in HCU after surgery on day 1 postoperative (HD 1). Remdesivir was directly given with a dose of 200 mg IV on the 1st day and continued with 1 × 100 mg IV on day 2 until 5. The patient’s postoperative condition was stable, and the RT-PCR result for SARS-CoV-2 was negative on HD 4. Both patient and baby were discharged on HD 7 after Remdesivir therapy was completed.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. K, a 27-year-old pregnant woman at 27+4 weeks of gestation, presented to our obstetric emergency unit with tachypnea (RR 28×/min; saturation 92%) one day before admission. The patient also had a fever (103.1 °F) and cough 1 week before admission. Other than that, she also had chronic hypertension. A chest X-ray showed patchy consolidation that corresponded to bilateral pneumonia. A naso-oropharyngeal swab for SARS-CoV-2 was positive as tested by RT-PCR (RdRP Cq 35.15; E Gene Cq 32.10). The patient was taken care of in the High Care Unit (HCU) with oxygen therapy using 10 L per minute (Lpm) with a nonrebreathing mask (NRM), and O2 saturation maintained at 95–97%. She was diagnosed with acute respiratory distress and superimposed preeclampsia with severe features. The patient was treated with anti-hypertension (nifedipine 4 × 10 mg), MgSO4 for seizure prevention, and dexamethasone 2 × 6 mg for lung maturation for 2 days.\nOn hospital care day 2, tachypnea worsened (RR 32×/min), with a decreased O2 saturation to 90% while on oxygen therapy given at 10 Lpm with NRM. The patient had an emergency cesarean section, and a baby girl was born with a birthweight of 1150 g, birth length of 34 cm, and APGAR score (AS) 7/9. The baby was taken care of in the NICU isolation for COVID-19 as a naso-oropharyngeal swab for SARS-CoV-2 result was negative.\nFor postoperative observation, the patient was taken to HCU with no clinical improvement. On hospital care day 7 (HD 7), she was given Remdesivir protocol for 5 days. Tachypnea and saturation improved on HD 8 (RR 24×/min; O2 saturation 96% with NRM 6 Lpm). Both patient and baby were discharged on HD 12 after the SARS-CoV-2 swab came back negative.

Mrs. T, a 30-year-old at 32 weeks gestation with two histories of cesarean section, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%), cough, and fever (102.2 °F). The patient had complained of tachypnea for 7 days before admission. Her naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 26.09; E Gene Cq 26.10) without abnormalities in a chest X-ray.\nThe patient was treated in HCU and was given oxygen therapy 4 Lpm with a nasal cannula, and O2 saturation was maintained at 95%. Remdesivir was given on HD 1 and continued for 6 days (HD 6). During hospitalization, the fetal condition was observed using cardiotocography, and no abnormalities were seen. Clinical symptoms improved, and the patient was discharged on HD 7 with a negative result from a naso-oropharyngeal swab for SARS-CoV-2. The patient underwent a cesarean section at 39 weeks gestation due to a previous cesarean section. A baby girl was born, 2700 g, 49 cm, A/S 9/10. The baby was rooming with her mother after delivery.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. K, a 27-year-old pregnant woman at 27+4 weeks of gestation, presented to our obstetric emergency unit with tachypnea (RR 28×/min; saturation 92%) one day before admission. The patient also had a fever (103.1 °F) and cough 1 week before admission. Other than that, she also had chronic hypertension. A chest X-ray showed patchy consolidation that corresponded to bilateral pneumonia. A naso-oropharyngeal swab for SARS-CoV-2 was positive as tested by RT-PCR (RdRP Cq 35.15; E Gene Cq 32.10). The patient was taken care of in the High Care Unit (HCU) with oxygen therapy using 10 L per minute (Lpm) with a nonrebreathing mask (NRM), and O2 saturation maintained at 95–97%. She was diagnosed with acute respiratory distress and superimposed preeclampsia with severe features. The patient was treated with anti-hypertension (nifedipine 4 × 10 mg), MgSO4 for seizure prevention, and dexamethasone 2 × 6 mg for lung maturation for 2 days.\nOn hospital care day 2, tachypnea worsened (RR 32×/min), with a decreased O2 saturation to 90% while on oxygen therapy given at 10 Lpm with NRM. The patient had an emergency cesarean section, and a baby girl was born with a birthweight of 1150 g, birth length of 34 cm, and APGAR score (AS) 7/9. The baby was taken care of in the NICU isolation for COVID-19 as a naso-oropharyngeal swab for SARS-CoV-2 result was negative.\nFor postoperative observation, the patient was taken to HCU with no clinical improvement. On hospital care day 7 (HD 7), she was given Remdesivir protocol for 5 days. Tachypnea and saturation improved on HD 8 (RR 24×/min; O2 saturation 96% with NRM 6 Lpm). Both patient and baby were discharged on HD 12 after the SARS-CoV-2 swab came back negative.

Mrs. A, a 35-year-old at 27 weeks gestation, was referred to our institution with a fever (101.3 °F), flu-like syndrome, tachypnea (RR 28×/min; O2 saturation 94% room air), and anosmia. The patient had complained of symptoms for 4 days before admission. A chest X-ray was normal. A naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 15.21; E Gene Cq 15.58) without abnormalities in a chest X-ray.\nThe patient was taken care of in an isolation ward for COVID-19 and given oxygen therapy 4 Lpm with a nasal cannula (saturation 96–97%). Remdesivir was given on HD 1 until HD 6. Daily fetal monitoring was performed using a fetal doppler and fetal kick count chart. During hospitalization, clinical symptoms improved. The patient was discharged after 7 days of hospitalization with a repeated naso-oropharyngeal swab for SARS-CoV-2 result which came back negative. The patient underwent vaginal delivery at 37 weeks gestation. A baby boy was born, 3100 g, 51 cm, A/S 8/9. Both mother and baby were in good condition after delivery.\nRemdesivir Protocol:\nDay 1: 200 mg IV single dose\nDay 2–5: 100 mg IV/daily

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

A 39-year-old woman, Gravida 3, Para 2 at 29 weeks gestation presented to the emergency department with complaints of fever, chills and dry cough since 3 days. Her past medical history was significant for Rheumatoid arthritis treated with Methotrexate for 5 years, Non-Hodgkin’s lymphoma treated with chemotherapy 10 years ago and is in remission, Sjogren’s syndrome (diagnosed 1 year ago) and Rheumatoid arthritis (relapsed 2 years ago), currently on Hydroxychloroquine. On admission, she was febrile with a temperature of 102.2 degrees Fahrenheit, tachycardic at 126 beats per minute, tachypneic at 24 breaths per minute and mildly hypoxic at 94% on room air. She was mildly hypertensive with a blood pressure of 141/76. Her oxygen saturation improved to 100% after oxygen supplementation with 2 liters via nasal cannula.\nInitial labs were significant for a leukocytosis of 14.75 x 103/µl with neutrophilia, a normal lymphocyte count, elevated C-reactive protein (CRP), lactate dehydrogenase and D-dimer. Procalcitonin was normal. Blood cultures were collected. A nasopharyngeal swab sample was taken and tested positive for COVID-19 by polymerase chain reaction. CT angiogram of the chest revealed extensive severe bilateral focal ground-glass infiltrates () without evidence of pulmonary embolism. Given the patient’s history of autoimmune conditions, current pregnancy, severe imaging findings and overall septic picture, she was admitted to the Intermediate Care Unit for close monitoring despite minimal oxygen requirements. Since the patient meets the criteria for the severe disease defined as requiring supplemental oxygen, as per our institution's policy, Infectious disease (ID) consultation was requested to evaluate if the patient meets the criteria for the use of Remdesivir set forth by the Emergency use authorization (EUA) released by the FDA []. Patient met the criteria and ID physician suggested to initiate Remdesivir after discussing the risks and benefits and obtaining the patient's consent since the teratogenic side effects of Remdesivir are not known. Patient has been provided information regarding the possible side effects including unknown teratogenicity and provided the copy of the patient information released by the Gilead sciences. Patient consented for the use of the Remdesivir. After following the standard of work flow for the use of Remdesivir at our institute which includes approval by hospital pharmacy as per the EUA guidelines for the Remdesivir issued by the FDA, she received 200 mg of IV Remdesivir on Day 1 followed by 100 mg daily for the next 4 days. Since the patient is symptomatic for less than 7 days at the time of admission, she did not meet the criteria to receive the steroid therapy as per the RECOVERY trial.\nShe successfully completed the course of Remdesivir without any side effects and showed steady improvement throughout the hospital stay. Fetal activity was monitored every 8 hours using the external fetal monitor, with no abnormalities detected. As per the obstetrician’s recommendations, supplemental oxygen was provided to maintain saturations >95%. Oxygen saturations were around 98−100% while on 2 L via NC and weaned down to room air with saturations >95% by the time of discharge on day six.

Mrs. N, a 31-year-old pregnant woman at 40 weeks gestation, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%) and fever (101.3 °F) for one week before admission. The patient had a history of flu-like symptoms and anosmia for the previous 2 weeks. A chest X-ray showed no appearance of pneumonia. Oxygen therapy was given with a nasal cannula, 4 Lpm, and O2 saturation was 96%. SARS-CoV-2 (RdRP Cq 24.40; E Gene Cq 23.89) was confirmed using RT-PCR from a naso-oropharyngeal swab.\nWe immediately conducted a cesarean section due to a premature rupture of the membrane with oligohydramnios. The cesarean section was successful, and a born baby boy was born, 3465 g, 51 cm, AS 8/9. The neonate was taken care of in the perinatal isolation unit for COVID-19, and a naso-oropharyngeal swab for SARS-CoV-2 result came back negative.\nThe patient was taken to the isolation ward for COVID-19 for postoperative observation. The patient was given Remdesivir on HD 2 until HD 6. The patient’s symptoms improved during hospitalization with a negative swab result for SARS-CoV-2 on hospital care day 6. Both patient and baby were discharged with a stable condition on HD 7.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. N, a 31-year-old pregnant woman at 40 weeks gestation, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%) and fever (101.3 °F) for one week before admission. The patient had a history of flu-like symptoms and anosmia for the previous 2 weeks. A chest X-ray showed no appearance of pneumonia. Oxygen therapy was given with a nasal cannula, 4 Lpm, and O2 saturation was 96%. SARS-CoV-2 (RdRP Cq 24.40; E Gene Cq 23.89) was confirmed using RT-PCR from a naso-oropharyngeal swab.\nWe immediately conducted a cesarean section due to a premature rupture of the membrane with oligohydramnios. The cesarean section was successful, and a born baby boy was born, 3465 g, 51 cm, AS 8/9. The neonate was taken care of in the perinatal isolation unit for COVID-19, and a naso-oropharyngeal swab for SARS-CoV-2 result came back negative.\nThe patient was taken to the isolation ward for COVID-19 for postoperative observation. The patient was given Remdesivir on HD 2 until HD 6. The patient’s symptoms improved during hospitalization with a negative swab result for SARS-CoV-2 on hospital care day 6. Both patient and baby were discharged with a stable condition on HD 7.

Mrs. M, a 28-year-old pregnant woman at 36 weeks gestation, was diagnosed with confirmed COVID-19 and was referred to our hospital due to worsening clinical symptoms. The patient had been treated in a previous hospital for 2 days with symptoms of cough and fever 4 days before admission. During hospitalization, the patient’s condition worsened as she displayed tachypnea (RR 32×/min, O2 saturation 92%) and fever (102.2 °F).\nA chest X-ray showed no abnormalities in both lungs. A naso-oropharyngeal swab for SARS-CoV-2 was positive (N gene Cq 39.54). Oxygen saturation was 95% using oxygen therapy at 3 Lpm with a nasal cannula. An emergency cesarean section was directly performed due to the worsening of the maternal condition and oligohydramnios seen from ultrasound examination. The cesarean section was performed with no complications. A baby boy was born with a birthweight of 2345 g, a birth length of 45 cm, and AS 7/8. The baby was taken to perinatal isolation for COVID-19 with a negative result for SARS-CoV-2 from a naso-oropharyngeal swab.\nThe patient was taken care of in HCU after surgery on day 1 postoperative (HD 1). Remdesivir was directly given with a dose of 200 mg IV on the 1st day and continued with 1 × 100 mg IV on day 2 until 5. The patient’s postoperative condition was stable, and the RT-PCR result for SARS-CoV-2 was negative on HD 4. Both patient and baby were discharged on HD 7 after Remdesivir therapy was completed.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. N, a 31-year-old pregnant woman at 40 weeks gestation, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%) and fever (101.3 °F) for one week before admission. The patient had a history of flu-like symptoms and anosmia for the previous 2 weeks. A chest X-ray showed no appearance of pneumonia. Oxygen therapy was given with a nasal cannula, 4 Lpm, and O2 saturation was 96%. SARS-CoV-2 (RdRP Cq 24.40; E Gene Cq 23.89) was confirmed using RT-PCR from a naso-oropharyngeal swab.\nWe immediately conducted a cesarean section due to a premature rupture of the membrane with oligohydramnios. The cesarean section was successful, and a born baby boy was born, 3465 g, 51 cm, AS 8/9. The neonate was taken care of in the perinatal isolation unit for COVID-19, and a naso-oropharyngeal swab for SARS-CoV-2 result came back negative.\nThe patient was taken to the isolation ward for COVID-19 for postoperative observation. The patient was given Remdesivir on HD 2 until HD 6. The patient’s symptoms improved during hospitalization with a negative swab result for SARS-CoV-2 on hospital care day 6. Both patient and baby were discharged with a stable condition on HD 7.

Mrs. T, a 30-year-old at 32 weeks gestation with two histories of cesarean section, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%), cough, and fever (102.2 °F). The patient had complained of tachypnea for 7 days before admission. Her naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 26.09; E Gene Cq 26.10) without abnormalities in a chest X-ray.\nThe patient was treated in HCU and was given oxygen therapy 4 Lpm with a nasal cannula, and O2 saturation was maintained at 95%. Remdesivir was given on HD 1 and continued for 6 days (HD 6). During hospitalization, the fetal condition was observed using cardiotocography, and no abnormalities were seen. Clinical symptoms improved, and the patient was discharged on HD 7 with a negative result from a naso-oropharyngeal swab for SARS-CoV-2. The patient underwent a cesarean section at 39 weeks gestation due to a previous cesarean section. A baby girl was born, 2700 g, 49 cm, A/S 9/10. The baby was rooming with her mother after delivery.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. N, a 31-year-old pregnant woman at 40 weeks gestation, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%) and fever (101.3 °F) for one week before admission. The patient had a history of flu-like symptoms and anosmia for the previous 2 weeks. A chest X-ray showed no appearance of pneumonia. Oxygen therapy was given with a nasal cannula, 4 Lpm, and O2 saturation was 96%. SARS-CoV-2 (RdRP Cq 24.40; E Gene Cq 23.89) was confirmed using RT-PCR from a naso-oropharyngeal swab.\nWe immediately conducted a cesarean section due to a premature rupture of the membrane with oligohydramnios. The cesarean section was successful, and a born baby boy was born, 3465 g, 51 cm, AS 8/9. The neonate was taken care of in the perinatal isolation unit for COVID-19, and a naso-oropharyngeal swab for SARS-CoV-2 result came back negative.\nThe patient was taken to the isolation ward for COVID-19 for postoperative observation. The patient was given Remdesivir on HD 2 until HD 6. The patient’s symptoms improved during hospitalization with a negative swab result for SARS-CoV-2 on hospital care day 6. Both patient and baby were discharged with a stable condition on HD 7.

Mrs. A, a 35-year-old at 27 weeks gestation, was referred to our institution with a fever (101.3 °F), flu-like syndrome, tachypnea (RR 28×/min; O2 saturation 94% room air), and anosmia. The patient had complained of symptoms for 4 days before admission. A chest X-ray was normal. A naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 15.21; E Gene Cq 15.58) without abnormalities in a chest X-ray.\nThe patient was taken care of in an isolation ward for COVID-19 and given oxygen therapy 4 Lpm with a nasal cannula (saturation 96–97%). Remdesivir was given on HD 1 until HD 6. Daily fetal monitoring was performed using a fetal doppler and fetal kick count chart. During hospitalization, clinical symptoms improved. The patient was discharged after 7 days of hospitalization with a repeated naso-oropharyngeal swab for SARS-CoV-2 result which came back negative. The patient underwent vaginal delivery at 37 weeks gestation. A baby boy was born, 3100 g, 51 cm, A/S 8/9. Both mother and baby were in good condition after delivery.\nRemdesivir Protocol:\nDay 1: 200 mg IV single dose\nDay 2–5: 100 mg IV/daily

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

A 39-year-old woman, Gravida 3, Para 2 at 29 weeks gestation presented to the emergency department with complaints of fever, chills and dry cough since 3 days. Her past medical history was significant for Rheumatoid arthritis treated with Methotrexate for 5 years, Non-Hodgkin’s lymphoma treated with chemotherapy 10 years ago and is in remission, Sjogren’s syndrome (diagnosed 1 year ago) and Rheumatoid arthritis (relapsed 2 years ago), currently on Hydroxychloroquine. On admission, she was febrile with a temperature of 102.2 degrees Fahrenheit, tachycardic at 126 beats per minute, tachypneic at 24 breaths per minute and mildly hypoxic at 94% on room air. She was mildly hypertensive with a blood pressure of 141/76. Her oxygen saturation improved to 100% after oxygen supplementation with 2 liters via nasal cannula.\nInitial labs were significant for a leukocytosis of 14.75 x 103/µl with neutrophilia, a normal lymphocyte count, elevated C-reactive protein (CRP), lactate dehydrogenase and D-dimer. Procalcitonin was normal. Blood cultures were collected. A nasopharyngeal swab sample was taken and tested positive for COVID-19 by polymerase chain reaction. CT angiogram of the chest revealed extensive severe bilateral focal ground-glass infiltrates () without evidence of pulmonary embolism. Given the patient’s history of autoimmune conditions, current pregnancy, severe imaging findings and overall septic picture, she was admitted to the Intermediate Care Unit for close monitoring despite minimal oxygen requirements. Since the patient meets the criteria for the severe disease defined as requiring supplemental oxygen, as per our institution's policy, Infectious disease (ID) consultation was requested to evaluate if the patient meets the criteria for the use of Remdesivir set forth by the Emergency use authorization (EUA) released by the FDA []. Patient met the criteria and ID physician suggested to initiate Remdesivir after discussing the risks and benefits and obtaining the patient's consent since the teratogenic side effects of Remdesivir are not known. Patient has been provided information regarding the possible side effects including unknown teratogenicity and provided the copy of the patient information released by the Gilead sciences. Patient consented for the use of the Remdesivir. After following the standard of work flow for the use of Remdesivir at our institute which includes approval by hospital pharmacy as per the EUA guidelines for the Remdesivir issued by the FDA, she received 200 mg of IV Remdesivir on Day 1 followed by 100 mg daily for the next 4 days. Since the patient is symptomatic for less than 7 days at the time of admission, she did not meet the criteria to receive the steroid therapy as per the RECOVERY trial.\nShe successfully completed the course of Remdesivir without any side effects and showed steady improvement throughout the hospital stay. Fetal activity was monitored every 8 hours using the external fetal monitor, with no abnormalities detected. As per the obstetrician’s recommendations, supplemental oxygen was provided to maintain saturations >95%. Oxygen saturations were around 98−100% while on 2 L via NC and weaned down to room air with saturations >95% by the time of discharge on day six.

Mrs. M, a 28-year-old pregnant woman at 36 weeks gestation, was diagnosed with confirmed COVID-19 and was referred to our hospital due to worsening clinical symptoms. The patient had been treated in a previous hospital for 2 days with symptoms of cough and fever 4 days before admission. During hospitalization, the patient’s condition worsened as she displayed tachypnea (RR 32×/min, O2 saturation 92%) and fever (102.2 °F).\nA chest X-ray showed no abnormalities in both lungs. A naso-oropharyngeal swab for SARS-CoV-2 was positive (N gene Cq 39.54). Oxygen saturation was 95% using oxygen therapy at 3 Lpm with a nasal cannula. An emergency cesarean section was directly performed due to the worsening of the maternal condition and oligohydramnios seen from ultrasound examination. The cesarean section was performed with no complications. A baby boy was born with a birthweight of 2345 g, a birth length of 45 cm, and AS 7/8. The baby was taken to perinatal isolation for COVID-19 with a negative result for SARS-CoV-2 from a naso-oropharyngeal swab.\nThe patient was taken care of in HCU after surgery on day 1 postoperative (HD 1). Remdesivir was directly given with a dose of 200 mg IV on the 1st day and continued with 1 × 100 mg IV on day 2 until 5. The patient’s postoperative condition was stable, and the RT-PCR result for SARS-CoV-2 was negative on HD 4. Both patient and baby were discharged on HD 7 after Remdesivir therapy was completed.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

A 39-year-old woman, Gravida 3, Para 2 at 29 weeks gestation presented to the emergency department with complaints of fever, chills and dry cough since 3 days. Her past medical history was significant for Rheumatoid arthritis treated with Methotrexate for 5 years, Non-Hodgkin’s lymphoma treated with chemotherapy 10 years ago and is in remission, Sjogren’s syndrome (diagnosed 1 year ago) and Rheumatoid arthritis (relapsed 2 years ago), currently on Hydroxychloroquine. On admission, she was febrile with a temperature of 102.2 degrees Fahrenheit, tachycardic at 126 beats per minute, tachypneic at 24 breaths per minute and mildly hypoxic at 94% on room air. She was mildly hypertensive with a blood pressure of 141/76. Her oxygen saturation improved to 100% after oxygen supplementation with 2 liters via nasal cannula.\nInitial labs were significant for a leukocytosis of 14.75 x 103/µl with neutrophilia, a normal lymphocyte count, elevated C-reactive protein (CRP), lactate dehydrogenase and D-dimer. Procalcitonin was normal. Blood cultures were collected. A nasopharyngeal swab sample was taken and tested positive for COVID-19 by polymerase chain reaction. CT angiogram of the chest revealed extensive severe bilateral focal ground-glass infiltrates () without evidence of pulmonary embolism. Given the patient’s history of autoimmune conditions, current pregnancy, severe imaging findings and overall septic picture, she was admitted to the Intermediate Care Unit for close monitoring despite minimal oxygen requirements. Since the patient meets the criteria for the severe disease defined as requiring supplemental oxygen, as per our institution's policy, Infectious disease (ID) consultation was requested to evaluate if the patient meets the criteria for the use of Remdesivir set forth by the Emergency use authorization (EUA) released by the FDA []. Patient met the criteria and ID physician suggested to initiate Remdesivir after discussing the risks and benefits and obtaining the patient's consent since the teratogenic side effects of Remdesivir are not known. Patient has been provided information regarding the possible side effects including unknown teratogenicity and provided the copy of the patient information released by the Gilead sciences. Patient consented for the use of the Remdesivir. After following the standard of work flow for the use of Remdesivir at our institute which includes approval by hospital pharmacy as per the EUA guidelines for the Remdesivir issued by the FDA, she received 200 mg of IV Remdesivir on Day 1 followed by 100 mg daily for the next 4 days. Since the patient is symptomatic for less than 7 days at the time of admission, she did not meet the criteria to receive the steroid therapy as per the RECOVERY trial.\nShe successfully completed the course of Remdesivir without any side effects and showed steady improvement throughout the hospital stay. Fetal activity was monitored every 8 hours using the external fetal monitor, with no abnormalities detected. As per the obstetrician’s recommendations, supplemental oxygen was provided to maintain saturations >95%. Oxygen saturations were around 98−100% while on 2 L via NC and weaned down to room air with saturations >95% by the time of discharge on day six.

Mrs. T, a 30-year-old at 32 weeks gestation with two histories of cesarean section, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%), cough, and fever (102.2 °F). The patient had complained of tachypnea for 7 days before admission. Her naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 26.09; E Gene Cq 26.10) without abnormalities in a chest X-ray.\nThe patient was treated in HCU and was given oxygen therapy 4 Lpm with a nasal cannula, and O2 saturation was maintained at 95%. Remdesivir was given on HD 1 and continued for 6 days (HD 6). During hospitalization, the fetal condition was observed using cardiotocography, and no abnormalities were seen. Clinical symptoms improved, and the patient was discharged on HD 7 with a negative result from a naso-oropharyngeal swab for SARS-CoV-2. The patient underwent a cesarean section at 39 weeks gestation due to a previous cesarean section. A baby girl was born, 2700 g, 49 cm, A/S 9/10. The baby was rooming with her mother after delivery.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

A 39-year-old woman, Gravida 3, Para 2 at 29 weeks gestation presented to the emergency department with complaints of fever, chills and dry cough since 3 days. Her past medical history was significant for Rheumatoid arthritis treated with Methotrexate for 5 years, Non-Hodgkin’s lymphoma treated with chemotherapy 10 years ago and is in remission, Sjogren’s syndrome (diagnosed 1 year ago) and Rheumatoid arthritis (relapsed 2 years ago), currently on Hydroxychloroquine. On admission, she was febrile with a temperature of 102.2 degrees Fahrenheit, tachycardic at 126 beats per minute, tachypneic at 24 breaths per minute and mildly hypoxic at 94% on room air. She was mildly hypertensive with a blood pressure of 141/76. Her oxygen saturation improved to 100% after oxygen supplementation with 2 liters via nasal cannula.\nInitial labs were significant for a leukocytosis of 14.75 x 103/µl with neutrophilia, a normal lymphocyte count, elevated C-reactive protein (CRP), lactate dehydrogenase and D-dimer. Procalcitonin was normal. Blood cultures were collected. A nasopharyngeal swab sample was taken and tested positive for COVID-19 by polymerase chain reaction. CT angiogram of the chest revealed extensive severe bilateral focal ground-glass infiltrates () without evidence of pulmonary embolism. Given the patient’s history of autoimmune conditions, current pregnancy, severe imaging findings and overall septic picture, she was admitted to the Intermediate Care Unit for close monitoring despite minimal oxygen requirements. Since the patient meets the criteria for the severe disease defined as requiring supplemental oxygen, as per our institution's policy, Infectious disease (ID) consultation was requested to evaluate if the patient meets the criteria for the use of Remdesivir set forth by the Emergency use authorization (EUA) released by the FDA []. Patient met the criteria and ID physician suggested to initiate Remdesivir after discussing the risks and benefits and obtaining the patient's consent since the teratogenic side effects of Remdesivir are not known. Patient has been provided information regarding the possible side effects including unknown teratogenicity and provided the copy of the patient information released by the Gilead sciences. Patient consented for the use of the Remdesivir. After following the standard of work flow for the use of Remdesivir at our institute which includes approval by hospital pharmacy as per the EUA guidelines for the Remdesivir issued by the FDA, she received 200 mg of IV Remdesivir on Day 1 followed by 100 mg daily for the next 4 days. Since the patient is symptomatic for less than 7 days at the time of admission, she did not meet the criteria to receive the steroid therapy as per the RECOVERY trial.\nShe successfully completed the course of Remdesivir without any side effects and showed steady improvement throughout the hospital stay. Fetal activity was monitored every 8 hours using the external fetal monitor, with no abnormalities detected. As per the obstetrician’s recommendations, supplemental oxygen was provided to maintain saturations >95%. Oxygen saturations were around 98−100% while on 2 L via NC and weaned down to room air with saturations >95% by the time of discharge on day six.

Mrs. A, a 35-year-old at 27 weeks gestation, was referred to our institution with a fever (101.3 °F), flu-like syndrome, tachypnea (RR 28×/min; O2 saturation 94% room air), and anosmia. The patient had complained of symptoms for 4 days before admission. A chest X-ray was normal. A naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 15.21; E Gene Cq 15.58) without abnormalities in a chest X-ray.\nThe patient was taken care of in an isolation ward for COVID-19 and given oxygen therapy 4 Lpm with a nasal cannula (saturation 96–97%). Remdesivir was given on HD 1 until HD 6. Daily fetal monitoring was performed using a fetal doppler and fetal kick count chart. During hospitalization, clinical symptoms improved. The patient was discharged after 7 days of hospitalization with a repeated naso-oropharyngeal swab for SARS-CoV-2 result which came back negative. The patient underwent vaginal delivery at 37 weeks gestation. A baby boy was born, 3100 g, 51 cm, A/S 8/9. Both mother and baby were in good condition after delivery.\nRemdesivir Protocol:\nDay 1: 200 mg IV single dose\nDay 2–5: 100 mg IV/daily

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. T, a 30-year-old at 32 weeks gestation with two histories of cesarean section, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%), cough, and fever (102.2 °F). The patient had complained of tachypnea for 7 days before admission. Her naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 26.09; E Gene Cq 26.10) without abnormalities in a chest X-ray.\nThe patient was treated in HCU and was given oxygen therapy 4 Lpm with a nasal cannula, and O2 saturation was maintained at 95%. Remdesivir was given on HD 1 and continued for 6 days (HD 6). During hospitalization, the fetal condition was observed using cardiotocography, and no abnormalities were seen. Clinical symptoms improved, and the patient was discharged on HD 7 with a negative result from a naso-oropharyngeal swab for SARS-CoV-2. The patient underwent a cesarean section at 39 weeks gestation due to a previous cesarean section. A baby girl was born, 2700 g, 49 cm, A/S 9/10. The baby was rooming with her mother after delivery.

Mrs. M, a 28-year-old pregnant woman at 36 weeks gestation, was diagnosed with confirmed COVID-19 and was referred to our hospital due to worsening clinical symptoms. The patient had been treated in a previous hospital for 2 days with symptoms of cough and fever 4 days before admission. During hospitalization, the patient’s condition worsened as she displayed tachypnea (RR 32×/min, O2 saturation 92%) and fever (102.2 °F).\nA chest X-ray showed no abnormalities in both lungs. A naso-oropharyngeal swab for SARS-CoV-2 was positive (N gene Cq 39.54). Oxygen saturation was 95% using oxygen therapy at 3 Lpm with a nasal cannula. An emergency cesarean section was directly performed due to the worsening of the maternal condition and oligohydramnios seen from ultrasound examination. The cesarean section was performed with no complications. A baby boy was born with a birthweight of 2345 g, a birth length of 45 cm, and AS 7/8. The baby was taken to perinatal isolation for COVID-19 with a negative result for SARS-CoV-2 from a naso-oropharyngeal swab.\nThe patient was taken care of in HCU after surgery on day 1 postoperative (HD 1). Remdesivir was directly given with a dose of 200 mg IV on the 1st day and continued with 1 × 100 mg IV on day 2 until 5. The patient’s postoperative condition was stable, and the RT-PCR result for SARS-CoV-2 was negative on HD 4. Both patient and baby were discharged on HD 7 after Remdesivir therapy was completed.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. A, a 35-year-old at 27 weeks gestation, was referred to our institution with a fever (101.3 °F), flu-like syndrome, tachypnea (RR 28×/min; O2 saturation 94% room air), and anosmia. The patient had complained of symptoms for 4 days before admission. A chest X-ray was normal. A naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 15.21; E Gene Cq 15.58) without abnormalities in a chest X-ray.\nThe patient was taken care of in an isolation ward for COVID-19 and given oxygen therapy 4 Lpm with a nasal cannula (saturation 96–97%). Remdesivir was given on HD 1 until HD 6. Daily fetal monitoring was performed using a fetal doppler and fetal kick count chart. During hospitalization, clinical symptoms improved. The patient was discharged after 7 days of hospitalization with a repeated naso-oropharyngeal swab for SARS-CoV-2 result which came back negative. The patient underwent vaginal delivery at 37 weeks gestation. A baby boy was born, 3100 g, 51 cm, A/S 8/9. Both mother and baby were in good condition after delivery.\nRemdesivir Protocol:\nDay 1: 200 mg IV single dose\nDay 2–5: 100 mg IV/daily

Mrs. M, a 28-year-old pregnant woman at 36 weeks gestation, was diagnosed with confirmed COVID-19 and was referred to our hospital due to worsening clinical symptoms. The patient had been treated in a previous hospital for 2 days with symptoms of cough and fever 4 days before admission. During hospitalization, the patient’s condition worsened as she displayed tachypnea (RR 32×/min, O2 saturation 92%) and fever (102.2 °F).\nA chest X-ray showed no abnormalities in both lungs. A naso-oropharyngeal swab for SARS-CoV-2 was positive (N gene Cq 39.54). Oxygen saturation was 95% using oxygen therapy at 3 Lpm with a nasal cannula. An emergency cesarean section was directly performed due to the worsening of the maternal condition and oligohydramnios seen from ultrasound examination. The cesarean section was performed with no complications. A baby boy was born with a birthweight of 2345 g, a birth length of 45 cm, and AS 7/8. The baby was taken to perinatal isolation for COVID-19 with a negative result for SARS-CoV-2 from a naso-oropharyngeal swab.\nThe patient was taken care of in HCU after surgery on day 1 postoperative (HD 1). Remdesivir was directly given with a dose of 200 mg IV on the 1st day and continued with 1 × 100 mg IV on day 2 until 5. The patient’s postoperative condition was stable, and the RT-PCR result for SARS-CoV-2 was negative on HD 4. Both patient and baby were discharged on HD 7 after Remdesivir therapy was completed.

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

Mrs. T, a 30-year-old at 32 weeks gestation with two histories of cesarean section, presented to our obstetric emergency unit with tachypnea (RR 30×/min; O2 saturation 93%), cough, and fever (102.2 °F). The patient had complained of tachypnea for 7 days before admission. Her naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 26.09; E Gene Cq 26.10) without abnormalities in a chest X-ray.\nThe patient was treated in HCU and was given oxygen therapy 4 Lpm with a nasal cannula, and O2 saturation was maintained at 95%. Remdesivir was given on HD 1 and continued for 6 days (HD 6). During hospitalization, the fetal condition was observed using cardiotocography, and no abnormalities were seen. Clinical symptoms improved, and the patient was discharged on HD 7 with a negative result from a naso-oropharyngeal swab for SARS-CoV-2. The patient underwent a cesarean section at 39 weeks gestation due to a previous cesarean section. A baby girl was born, 2700 g, 49 cm, A/S 9/10. The baby was rooming with her mother after delivery.

Mrs. A, a 35-year-old at 27 weeks gestation, was referred to our institution with a fever (101.3 °F), flu-like syndrome, tachypnea (RR 28×/min; O2 saturation 94% room air), and anosmia. The patient had complained of symptoms for 4 days before admission. A chest X-ray was normal. A naso-oropharyngeal swab was positive for SARS-CoV-2 by real-time PCR (RdRP Cq 15.21; E Gene Cq 15.58) without abnormalities in a chest X-ray.\nThe patient was taken care of in an isolation ward for COVID-19 and given oxygen therapy 4 Lpm with a nasal cannula (saturation 96–97%). Remdesivir was given on HD 1 until HD 6. Daily fetal monitoring was performed using a fetal doppler and fetal kick count chart. During hospitalization, clinical symptoms improved. The patient was discharged after 7 days of hospitalization with a repeated naso-oropharyngeal swab for SARS-CoV-2 result which came back negative. The patient underwent vaginal delivery at 37 weeks gestation. A baby boy was born, 3100 g, 51 cm, A/S 8/9. Both mother and baby were in good condition after delivery.\nRemdesivir Protocol:\nDay 1: 200 mg IV single dose\nDay 2–5: 100 mg IV/daily

Write a detailed clinical case vignette based on the following key phrases: COVID-19, Pregnancy, Remdesivir

A 70-year-old male presented to our medical center with one episode of “black tarry stools” in the morning. Three weeks prior to this admission, the patient underwent esophagogastroduodenoscopy (EGD), which revealed a 6-mm, clean-based ulcer at the gastroesophageal junction without active bleeding. Colonoscopy, performed during the same visit, was significant for mild diverticulosis and small nonbleeding hemorrhoids. He had a medical history of chronic active alcohol abuse, prior gastrointestinal bleeding, hypertension, diabetes mellitus type 2, and non-small-cell lung cancer (T2N0M0; status post-lobectomy, 18 years ago). The patient had been consuming 3-4 drinks of liquor daily; however, he was non-smoker and drug-free. He was under therapy with oral iron sulfate, metformin, pantoprazole, enalapril, and multivitamins. Review of the systems was significant for fatigue, malaise, and confusion. His vitals included blood pressure 137/81 mm Hg, heart rate 108 beats per minute, temperature 36.9°C, respiratory rate 16 per minute and oxygen saturation 100% on room air. On physical examination, he was in no acute distress but appeared lethargic. The cardiopulmonary examination was inconclusive for abnormalities. The abdomen was soft and non-tender without organomegaly.\nHe underwent extensive diagnostic workup. The details of his laboratory studies are provided in Table .\nChest radiograph showed left-sided thoracotomy with chronically elevated left hemidiaphragm but no airspace opacity, effusion, or pneumothorax. He was started on intravenous proton-pump inhibitor therapy for upper gastrointestinal bleeding. Subsequently, EGD showed nodular, edematous and erythematous mucosa with petechial hemorrhages in the gastric fundus and body, with questionable prominence of underlying vasculature (Figure ).\nThe endoscopy was inconclusive for an active bleeding focus; duodenum appeared normal. He also received one unit of packed red blood cells. During the course of hospitalization, he continued to experience black-colored stools. His hemoglobin demonstrated a gradual downward trend, prompting the need for a second endoscopic evaluation. On day 7 of admission, repeat EGD revealed frank fresh blood along with blood clots in the proximal body of the stomach. The clots were irrigated, suctioned, and removed with Roth net. A pinpoint area under one of the removed clots was actively oozing, which mimicked a Dieulafoy’s lesion; primary hemostasis was achieved with a combination therapy using epinephrine injection, cautery, and hemoclip application (Figure ).\nOn day 10 of admission, laboratory studies showed an acute elevation of liver enzymes (alanine transaminase 1096 IU/L; aspartate aminotransferase 123 IU/L; alkaline phosphatase 47 IU/L; and total bilirubin 1.3 mg/dL). Drug-induced liver injury and obstructing lesion were considered plausible. Computed tomography (CT) with pancreatic imaging protocol revealed a large 4.2 x 2.9-cm pseudoaneurysm, likely arising from the gastroduodenal artery, located in the head of the pancreas, with evidence of moderate intrahepatic ductal dilatation and portal vein obstruction. Given the large size with compressive features of the surrounding structures, embolization of the pseudoaneurysm utilizing 11 coils with thrombin/Gelfoam injection was performed (Figure ).\nA two-day post-procedure abdominal ultrasound showed an increase in the size of the pseudoaneurysm, measuring 5.6 x 5.8 cm. Interventional radiology then repeated the embolotherapy with thrombin injection. In the next few days, he continued to report both melena and bright red blood per rectum, but his hemoglobin remained stable. On day 19 of admission, third EGD was performed, which was unremarkable for an active bleeding spot. His hemoglobin started to drop but another endoscopic evaluation was not recommended as last EGD was unremarkable. Therein, a bleeding scan showed an equivocal left-flank bleeding focus, not suggestive of a lower gastrointestinal collection, but possibly a small bowel focus with low-grade extravasation. Subsequently, his hemoglobin dropped to 6.3 g/dL, with no signs of overt gastrointestinal hemorrhage. On day 27 of admission, abdominal paracentesis ruled out hemoperitoneum and CTA abdomen showed possible hemorrhage in the left flank outside the gastrointestinal tract, possibly due to an infarcted spleen.\nAfter a discussion with surgery and gastroenterology teams, a repeat EGD with a side-viewing duodenoscope was planned. It initially demonstrated an extremely small blood-oozing spot from the ampulla of Vater. The blood extravasation increased shortly after first pinpointing the source. Over the next few seconds, the blood started to ooze at a rapid rate. In the next one minute, frank intermittent bleeding through the ampulla of Vater into the duodenum was identified (Figure ).\nThese findings were consistent with hemosuccus pancreaticus, likely due to the bleeding from the pseudoaneurysm of the gastroduodenal artery. After the precise etiology establishment, surgical intervention was considered due to prior failed attempts of embolization. However, there was a high risk of perioperative mortality given the patient’s comorbid conditions, poor clinical and performance status and complexity of the anatomical location of pseudoaneurysm. Therefore, a conservative approach was preferred by the patient and his family. On the other hand, he continued to experience intermittent hemorrhage requiring blood transfusions with episodes of hemodynamic instability. An urgent embolization of the pseudoaneurysm was planned. However, the patient and his family refused to undergo therapeutic procedures. The patient continued to worsen clinically over the next few days but he wished not to be resuscitated. He died in a couple of days following hemodynamic instability.

A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 70-year-old male presented to our medical center with one episode of “black tarry stools” in the morning. Three weeks prior to this admission, the patient underwent esophagogastroduodenoscopy (EGD), which revealed a 6-mm, clean-based ulcer at the gastroesophageal junction without active bleeding. Colonoscopy, performed during the same visit, was significant for mild diverticulosis and small nonbleeding hemorrhoids. He had a medical history of chronic active alcohol abuse, prior gastrointestinal bleeding, hypertension, diabetes mellitus type 2, and non-small-cell lung cancer (T2N0M0; status post-lobectomy, 18 years ago). The patient had been consuming 3-4 drinks of liquor daily; however, he was non-smoker and drug-free. He was under therapy with oral iron sulfate, metformin, pantoprazole, enalapril, and multivitamins. Review of the systems was significant for fatigue, malaise, and confusion. His vitals included blood pressure 137/81 mm Hg, heart rate 108 beats per minute, temperature 36.9°C, respiratory rate 16 per minute and oxygen saturation 100% on room air. On physical examination, he was in no acute distress but appeared lethargic. The cardiopulmonary examination was inconclusive for abnormalities. The abdomen was soft and non-tender without organomegaly.\nHe underwent extensive diagnostic workup. The details of his laboratory studies are provided in Table .\nChest radiograph showed left-sided thoracotomy with chronically elevated left hemidiaphragm but no airspace opacity, effusion, or pneumothorax. He was started on intravenous proton-pump inhibitor therapy for upper gastrointestinal bleeding. Subsequently, EGD showed nodular, edematous and erythematous mucosa with petechial hemorrhages in the gastric fundus and body, with questionable prominence of underlying vasculature (Figure ).\nThe endoscopy was inconclusive for an active bleeding focus; duodenum appeared normal. He also received one unit of packed red blood cells. During the course of hospitalization, he continued to experience black-colored stools. His hemoglobin demonstrated a gradual downward trend, prompting the need for a second endoscopic evaluation. On day 7 of admission, repeat EGD revealed frank fresh blood along with blood clots in the proximal body of the stomach. The clots were irrigated, suctioned, and removed with Roth net. A pinpoint area under one of the removed clots was actively oozing, which mimicked a Dieulafoy’s lesion; primary hemostasis was achieved with a combination therapy using epinephrine injection, cautery, and hemoclip application (Figure ).\nOn day 10 of admission, laboratory studies showed an acute elevation of liver enzymes (alanine transaminase 1096 IU/L; aspartate aminotransferase 123 IU/L; alkaline phosphatase 47 IU/L; and total bilirubin 1.3 mg/dL). Drug-induced liver injury and obstructing lesion were considered plausible. Computed tomography (CT) with pancreatic imaging protocol revealed a large 4.2 x 2.9-cm pseudoaneurysm, likely arising from the gastroduodenal artery, located in the head of the pancreas, with evidence of moderate intrahepatic ductal dilatation and portal vein obstruction. Given the large size with compressive features of the surrounding structures, embolization of the pseudoaneurysm utilizing 11 coils with thrombin/Gelfoam injection was performed (Figure ).\nA two-day post-procedure abdominal ultrasound showed an increase in the size of the pseudoaneurysm, measuring 5.6 x 5.8 cm. Interventional radiology then repeated the embolotherapy with thrombin injection. In the next few days, he continued to report both melena and bright red blood per rectum, but his hemoglobin remained stable. On day 19 of admission, third EGD was performed, which was unremarkable for an active bleeding spot. His hemoglobin started to drop but another endoscopic evaluation was not recommended as last EGD was unremarkable. Therein, a bleeding scan showed an equivocal left-flank bleeding focus, not suggestive of a lower gastrointestinal collection, but possibly a small bowel focus with low-grade extravasation. Subsequently, his hemoglobin dropped to 6.3 g/dL, with no signs of overt gastrointestinal hemorrhage. On day 27 of admission, abdominal paracentesis ruled out hemoperitoneum and CTA abdomen showed possible hemorrhage in the left flank outside the gastrointestinal tract, possibly due to an infarcted spleen.\nAfter a discussion with surgery and gastroenterology teams, a repeat EGD with a side-viewing duodenoscope was planned. It initially demonstrated an extremely small blood-oozing spot from the ampulla of Vater. The blood extravasation increased shortly after first pinpointing the source. Over the next few seconds, the blood started to ooze at a rapid rate. In the next one minute, frank intermittent bleeding through the ampulla of Vater into the duodenum was identified (Figure ).\nThese findings were consistent with hemosuccus pancreaticus, likely due to the bleeding from the pseudoaneurysm of the gastroduodenal artery. After the precise etiology establishment, surgical intervention was considered due to prior failed attempts of embolization. However, there was a high risk of perioperative mortality given the patient’s comorbid conditions, poor clinical and performance status and complexity of the anatomical location of pseudoaneurysm. Therefore, a conservative approach was preferred by the patient and his family. On the other hand, he continued to experience intermittent hemorrhage requiring blood transfusions with episodes of hemodynamic instability. An urgent embolization of the pseudoaneurysm was planned. However, the patient and his family refused to undergo therapeutic procedures. The patient continued to worsen clinically over the next few days but he wished not to be resuscitated. He died in a couple of days following hemodynamic instability.

A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 70-year-old male presented to our medical center with one episode of “black tarry stools” in the morning. Three weeks prior to this admission, the patient underwent esophagogastroduodenoscopy (EGD), which revealed a 6-mm, clean-based ulcer at the gastroesophageal junction without active bleeding. Colonoscopy, performed during the same visit, was significant for mild diverticulosis and small nonbleeding hemorrhoids. He had a medical history of chronic active alcohol abuse, prior gastrointestinal bleeding, hypertension, diabetes mellitus type 2, and non-small-cell lung cancer (T2N0M0; status post-lobectomy, 18 years ago). The patient had been consuming 3-4 drinks of liquor daily; however, he was non-smoker and drug-free. He was under therapy with oral iron sulfate, metformin, pantoprazole, enalapril, and multivitamins. Review of the systems was significant for fatigue, malaise, and confusion. His vitals included blood pressure 137/81 mm Hg, heart rate 108 beats per minute, temperature 36.9°C, respiratory rate 16 per minute and oxygen saturation 100% on room air. On physical examination, he was in no acute distress but appeared lethargic. The cardiopulmonary examination was inconclusive for abnormalities. The abdomen was soft and non-tender without organomegaly.\nHe underwent extensive diagnostic workup. The details of his laboratory studies are provided in Table .\nChest radiograph showed left-sided thoracotomy with chronically elevated left hemidiaphragm but no airspace opacity, effusion, or pneumothorax. He was started on intravenous proton-pump inhibitor therapy for upper gastrointestinal bleeding. Subsequently, EGD showed nodular, edematous and erythematous mucosa with petechial hemorrhages in the gastric fundus and body, with questionable prominence of underlying vasculature (Figure ).\nThe endoscopy was inconclusive for an active bleeding focus; duodenum appeared normal. He also received one unit of packed red blood cells. During the course of hospitalization, he continued to experience black-colored stools. His hemoglobin demonstrated a gradual downward trend, prompting the need for a second endoscopic evaluation. On day 7 of admission, repeat EGD revealed frank fresh blood along with blood clots in the proximal body of the stomach. The clots were irrigated, suctioned, and removed with Roth net. A pinpoint area under one of the removed clots was actively oozing, which mimicked a Dieulafoy’s lesion; primary hemostasis was achieved with a combination therapy using epinephrine injection, cautery, and hemoclip application (Figure ).\nOn day 10 of admission, laboratory studies showed an acute elevation of liver enzymes (alanine transaminase 1096 IU/L; aspartate aminotransferase 123 IU/L; alkaline phosphatase 47 IU/L; and total bilirubin 1.3 mg/dL). Drug-induced liver injury and obstructing lesion were considered plausible. Computed tomography (CT) with pancreatic imaging protocol revealed a large 4.2 x 2.9-cm pseudoaneurysm, likely arising from the gastroduodenal artery, located in the head of the pancreas, with evidence of moderate intrahepatic ductal dilatation and portal vein obstruction. Given the large size with compressive features of the surrounding structures, embolization of the pseudoaneurysm utilizing 11 coils with thrombin/Gelfoam injection was performed (Figure ).\nA two-day post-procedure abdominal ultrasound showed an increase in the size of the pseudoaneurysm, measuring 5.6 x 5.8 cm. Interventional radiology then repeated the embolotherapy with thrombin injection. In the next few days, he continued to report both melena and bright red blood per rectum, but his hemoglobin remained stable. On day 19 of admission, third EGD was performed, which was unremarkable for an active bleeding spot. His hemoglobin started to drop but another endoscopic evaluation was not recommended as last EGD was unremarkable. Therein, a bleeding scan showed an equivocal left-flank bleeding focus, not suggestive of a lower gastrointestinal collection, but possibly a small bowel focus with low-grade extravasation. Subsequently, his hemoglobin dropped to 6.3 g/dL, with no signs of overt gastrointestinal hemorrhage. On day 27 of admission, abdominal paracentesis ruled out hemoperitoneum and CTA abdomen showed possible hemorrhage in the left flank outside the gastrointestinal tract, possibly due to an infarcted spleen.\nAfter a discussion with surgery and gastroenterology teams, a repeat EGD with a side-viewing duodenoscope was planned. It initially demonstrated an extremely small blood-oozing spot from the ampulla of Vater. The blood extravasation increased shortly after first pinpointing the source. Over the next few seconds, the blood started to ooze at a rapid rate. In the next one minute, frank intermittent bleeding through the ampulla of Vater into the duodenum was identified (Figure ).\nThese findings were consistent with hemosuccus pancreaticus, likely due to the bleeding from the pseudoaneurysm of the gastroduodenal artery. After the precise etiology establishment, surgical intervention was considered due to prior failed attempts of embolization. However, there was a high risk of perioperative mortality given the patient’s comorbid conditions, poor clinical and performance status and complexity of the anatomical location of pseudoaneurysm. Therefore, a conservative approach was preferred by the patient and his family. On the other hand, he continued to experience intermittent hemorrhage requiring blood transfusions with episodes of hemodynamic instability. An urgent embolization of the pseudoaneurysm was planned. However, the patient and his family refused to undergo therapeutic procedures. The patient continued to worsen clinically over the next few days but he wished not to be resuscitated. He died in a couple of days following hemodynamic instability.

A 39-year-old man was admitted to the hospital due to hematemesis and melena for 2 wk, with a new episode lasting 1 d.\nTwo weeks before admission, the patient had hematemesis and melena without obvious known causes. He vomited light red fluids 4-5 times/d and passed tarry stools 3-4 times/d; these events were accompanied by epigastric pain, abdominal distension, and fatigue. He had no dizziness or syncope. He was hospitalized at a local hospital where examinations showed a hemoglobin (Hb) level of 86 g/L. Esophagogastroduodenoscopy (EGD) showed fresh blood in the descending part of the duodenum but did not show a clear bleeding site. The patient was treated with blood transfusion, acid blockers, and intravenous (IV) fluid and discharged from the hospital after no recurrence of hematemesis or melena was observed.\nOne day before admission to our hospital, the patient vomited bright red blood once and was admitted to the local hospital. Bedside EGD showed no obvious bleeding in the upper gastrointestinal tract. During his hospitalization, the patient had repeated hematemesis and hematochezia 4-5 times/d accompanied by left upper abdominal pain and fatigue. His minimum Hb level was 42 g/L. After treatment with blood transfusion, IV fluid, acid blockers, and hemostasis, he was transferred to our hospital for emergency admission.\nThe patient had a history of chronic pancreatitis. He denied chronic diseases such as hypertension, coronary heart disease, and diabetes, a history of abdominal surgery and trauma, and a history of food and drug allergy.\nThe patient denied a history of smoking and drinking and any history of diseases in family members.\nOn admission, the patient had a body temperature of 37.2 °C, a pulse of 102 beats/min, a respiratory rate of 19 times/min, a blood pressure of 117/91 mmHg, and an oxygen saturation of 98%. The patient had manifestations of anemia and pale conjunctiva. His abdomen was soft with upper abdominal tenderness. No rebound tenderness was noted. No abdominal mass was palpable. No other obvious abnormality was noted.\nThe complete blood count on admission was as follows: White blood cell count, 8.00 × 109/L; red blood cell count, 2.34 × 109/L; Hb, 66 g/L; hematocrit, 0.192; platelet count, 108 × 109/L; total amylase, 198 U/L; D-dimer, 6060 µg/L; hypersensitive C-reactive protein, 40.1 mg/L; procalcitonin, 0.12 ng/mL; and serum albumin, 24 g/L (Table ). Coagulation function, alanine aminotransferase, aspartate aminotransferase, total bilirubin, alkaline phosphatase, glutamyl transpeptidase, urinalysis results, stool analysis, tumor marker expression, troponin I, and electrocardiogram results were all within normal limits.\nA noncontrast-enhanced computed tomography (CT) scan of the abdomen and pelvis showed pancreatic swelling, uneven density, vague edges, multiple spots of calcifications, and hyperintense opacities in the pancreatic head and body, indicating chronic pancreatitis and pancreatic head hemorrhage.\nSubsequent contrast-enhanced CT of the abdomen showed isointense, rounded opacities with a diameter of approximately 41 mm in the pancreatic head that were enhanced with contrast in the arterial phase and were closely related to the gastroduodenal artery, indicating pseudoaneurysm (Figure ). Furthermore, digital subtraction angiography performed via the celiac trunk showed the formation of pseudoaneurysms at the proximal gastroduodenal artery; the remaining blood vessels were unremarkable (Figure , Video 1A).

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 70-year-old male presented to our medical center with one episode of “black tarry stools” in the morning. Three weeks prior to this admission, the patient underwent esophagogastroduodenoscopy (EGD), which revealed a 6-mm, clean-based ulcer at the gastroesophageal junction without active bleeding. Colonoscopy, performed during the same visit, was significant for mild diverticulosis and small nonbleeding hemorrhoids. He had a medical history of chronic active alcohol abuse, prior gastrointestinal bleeding, hypertension, diabetes mellitus type 2, and non-small-cell lung cancer (T2N0M0; status post-lobectomy, 18 years ago). The patient had been consuming 3-4 drinks of liquor daily; however, he was non-smoker and drug-free. He was under therapy with oral iron sulfate, metformin, pantoprazole, enalapril, and multivitamins. Review of the systems was significant for fatigue, malaise, and confusion. His vitals included blood pressure 137/81 mm Hg, heart rate 108 beats per minute, temperature 36.9°C, respiratory rate 16 per minute and oxygen saturation 100% on room air. On physical examination, he was in no acute distress but appeared lethargic. The cardiopulmonary examination was inconclusive for abnormalities. The abdomen was soft and non-tender without organomegaly.\nHe underwent extensive diagnostic workup. The details of his laboratory studies are provided in Table .\nChest radiograph showed left-sided thoracotomy with chronically elevated left hemidiaphragm but no airspace opacity, effusion, or pneumothorax. He was started on intravenous proton-pump inhibitor therapy for upper gastrointestinal bleeding. Subsequently, EGD showed nodular, edematous and erythematous mucosa with petechial hemorrhages in the gastric fundus and body, with questionable prominence of underlying vasculature (Figure ).\nThe endoscopy was inconclusive for an active bleeding focus; duodenum appeared normal. He also received one unit of packed red blood cells. During the course of hospitalization, he continued to experience black-colored stools. His hemoglobin demonstrated a gradual downward trend, prompting the need for a second endoscopic evaluation. On day 7 of admission, repeat EGD revealed frank fresh blood along with blood clots in the proximal body of the stomach. The clots were irrigated, suctioned, and removed with Roth net. A pinpoint area under one of the removed clots was actively oozing, which mimicked a Dieulafoy’s lesion; primary hemostasis was achieved with a combination therapy using epinephrine injection, cautery, and hemoclip application (Figure ).\nOn day 10 of admission, laboratory studies showed an acute elevation of liver enzymes (alanine transaminase 1096 IU/L; aspartate aminotransferase 123 IU/L; alkaline phosphatase 47 IU/L; and total bilirubin 1.3 mg/dL). Drug-induced liver injury and obstructing lesion were considered plausible. Computed tomography (CT) with pancreatic imaging protocol revealed a large 4.2 x 2.9-cm pseudoaneurysm, likely arising from the gastroduodenal artery, located in the head of the pancreas, with evidence of moderate intrahepatic ductal dilatation and portal vein obstruction. Given the large size with compressive features of the surrounding structures, embolization of the pseudoaneurysm utilizing 11 coils with thrombin/Gelfoam injection was performed (Figure ).\nA two-day post-procedure abdominal ultrasound showed an increase in the size of the pseudoaneurysm, measuring 5.6 x 5.8 cm. Interventional radiology then repeated the embolotherapy with thrombin injection. In the next few days, he continued to report both melena and bright red blood per rectum, but his hemoglobin remained stable. On day 19 of admission, third EGD was performed, which was unremarkable for an active bleeding spot. His hemoglobin started to drop but another endoscopic evaluation was not recommended as last EGD was unremarkable. Therein, a bleeding scan showed an equivocal left-flank bleeding focus, not suggestive of a lower gastrointestinal collection, but possibly a small bowel focus with low-grade extravasation. Subsequently, his hemoglobin dropped to 6.3 g/dL, with no signs of overt gastrointestinal hemorrhage. On day 27 of admission, abdominal paracentesis ruled out hemoperitoneum and CTA abdomen showed possible hemorrhage in the left flank outside the gastrointestinal tract, possibly due to an infarcted spleen.\nAfter a discussion with surgery and gastroenterology teams, a repeat EGD with a side-viewing duodenoscope was planned. It initially demonstrated an extremely small blood-oozing spot from the ampulla of Vater. The blood extravasation increased shortly after first pinpointing the source. Over the next few seconds, the blood started to ooze at a rapid rate. In the next one minute, frank intermittent bleeding through the ampulla of Vater into the duodenum was identified (Figure ).\nThese findings were consistent with hemosuccus pancreaticus, likely due to the bleeding from the pseudoaneurysm of the gastroduodenal artery. After the precise etiology establishment, surgical intervention was considered due to prior failed attempts of embolization. However, there was a high risk of perioperative mortality given the patient’s comorbid conditions, poor clinical and performance status and complexity of the anatomical location of pseudoaneurysm. Therefore, a conservative approach was preferred by the patient and his family. On the other hand, he continued to experience intermittent hemorrhage requiring blood transfusions with episodes of hemodynamic instability. An urgent embolization of the pseudoaneurysm was planned. However, the patient and his family refused to undergo therapeutic procedures. The patient continued to worsen clinically over the next few days but he wished not to be resuscitated. He died in a couple of days following hemodynamic instability.

A 47-year-old male, nonsmoker with no significant medical history initially presented with sudden onset right-sided chest pain, fever, and shortness of breath. After a hemorrhagic pleural tap and chest x-ray demonstrating large retro cardiac soft tissue density, gross right pleural effusion, and right lower lobe lung collapse the patient was referred to our center with a working diagnosis of thoracic malignancy and large lung carcinoma with hemorrhagic pleural effusion.\nThe patient was admitted to our center for further workup. Immediately after, the patient experienced severe respiratory distress; oxygen saturation (SpO2) was 74% on two liters of oxygen. The patient was transferred to the intensive care unit (ICU) with pulse: 102 beats per minute and regular, blood pressure: 95/79 mm Hg, respiratory rate: 22/minute, temperature: 97°F, and SpO2: 100% on high-flow oxygen. Glasgow Coma Scale (GCS) was 15/15, and on examination of the chest, there was decreased air entry on the right side. A right-sided chest drain was placed; 1300 ml of hemorrhagic fluid was drained by the end of the day. Total leukocyte count (TLC) then was 21710/mm^3. A blood and sputum culture was obtained. The sputum sample demonstrated Klebsiella pneumonia, which was managed accordingly, normalizing the counts on the days to come. Whole blood was transfused during the ICU stay as required. After three days the patient was shifted to the general ward with the drain holding 50 ml of blood and stable vital signs.\nCECT chest performed on the fifth day of admission demonstrated a large lesion involving the subcarinal region with intensely enhancing focus adjacent to right bronchus intermedius likely pseudoaneurysm with associated hematoma, collapse of basal right-lower lobe, and collection in the right pleural space (Figure ). The plan for the trucut biopsy of the lung was deferred, and a bronchial angiogram with embolization for bronchial artery pseudoaneurysm was planned. The right common femoral artery was accessed with a 5 French gauge (Fr) vascular sheath, a diagnostic angiographic catheter (Shepherd catheter 5 Fr, Cook Medical, USA) aided in cannulating the right bronchial artery. A selective angiogram revealed a pseudoaneurysm with patent distal flow (Figure ). After the introduction of the 2.1 Fr microcatheter (Artec microcatheter, Japan) the distal normal arterial lumen was reached and coiled with a 2 mm x 2 mm pushable coil (Cook Medical, USA). Similarly, a 2 mm x 2 mm pushable coil was used to trap the front door/proximal part of the right bronchial artery. Post coil embolization, angiogram after 15 minutes showed reduced flow to the sac; however, complete thrombosis was not seen (Figure ). Another permanent embolizing agent Glue mixed with lipiodol (1:7 ratio) was used to achieve complete embolization endpoint. The final angiogram revealed complete thrombosis of the pseudoaneurysm sac and the right bronchial artery (Figure ). No immediate complications were noted. Hemostasis was achieved at the groin by manual compression. After a few days, the chest tube was removed due to a minimal drain.\nFollow-up CT angiography showed coils in the subcarinal region without obvious abnormal enhancement suggestive of adequate embolization and a slight decrease in the size of hematoma at the subcarinal region. The patient was hemodynamically stable and symptomatically better, thus was discharged after one week of hospital stay. The patient was re-evaluated after three weeks by a CECT chest, which showed a significant interval decrease in the lesion at the subcarinal region, subsegmental collapse of a basal segment of the right lower lung, and a significant decrease in the pleural collection (Figure ).

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 70-year-old male presented to our medical center with one episode of “black tarry stools” in the morning. Three weeks prior to this admission, the patient underwent esophagogastroduodenoscopy (EGD), which revealed a 6-mm, clean-based ulcer at the gastroesophageal junction without active bleeding. Colonoscopy, performed during the same visit, was significant for mild diverticulosis and small nonbleeding hemorrhoids. He had a medical history of chronic active alcohol abuse, prior gastrointestinal bleeding, hypertension, diabetes mellitus type 2, and non-small-cell lung cancer (T2N0M0; status post-lobectomy, 18 years ago). The patient had been consuming 3-4 drinks of liquor daily; however, he was non-smoker and drug-free. He was under therapy with oral iron sulfate, metformin, pantoprazole, enalapril, and multivitamins. Review of the systems was significant for fatigue, malaise, and confusion. His vitals included blood pressure 137/81 mm Hg, heart rate 108 beats per minute, temperature 36.9°C, respiratory rate 16 per minute and oxygen saturation 100% on room air. On physical examination, he was in no acute distress but appeared lethargic. The cardiopulmonary examination was inconclusive for abnormalities. The abdomen was soft and non-tender without organomegaly.\nHe underwent extensive diagnostic workup. The details of his laboratory studies are provided in Table .\nChest radiograph showed left-sided thoracotomy with chronically elevated left hemidiaphragm but no airspace opacity, effusion, or pneumothorax. He was started on intravenous proton-pump inhibitor therapy for upper gastrointestinal bleeding. Subsequently, EGD showed nodular, edematous and erythematous mucosa with petechial hemorrhages in the gastric fundus and body, with questionable prominence of underlying vasculature (Figure ).\nThe endoscopy was inconclusive for an active bleeding focus; duodenum appeared normal. He also received one unit of packed red blood cells. During the course of hospitalization, he continued to experience black-colored stools. His hemoglobin demonstrated a gradual downward trend, prompting the need for a second endoscopic evaluation. On day 7 of admission, repeat EGD revealed frank fresh blood along with blood clots in the proximal body of the stomach. The clots were irrigated, suctioned, and removed with Roth net. A pinpoint area under one of the removed clots was actively oozing, which mimicked a Dieulafoy’s lesion; primary hemostasis was achieved with a combination therapy using epinephrine injection, cautery, and hemoclip application (Figure ).\nOn day 10 of admission, laboratory studies showed an acute elevation of liver enzymes (alanine transaminase 1096 IU/L; aspartate aminotransferase 123 IU/L; alkaline phosphatase 47 IU/L; and total bilirubin 1.3 mg/dL). Drug-induced liver injury and obstructing lesion were considered plausible. Computed tomography (CT) with pancreatic imaging protocol revealed a large 4.2 x 2.9-cm pseudoaneurysm, likely arising from the gastroduodenal artery, located in the head of the pancreas, with evidence of moderate intrahepatic ductal dilatation and portal vein obstruction. Given the large size with compressive features of the surrounding structures, embolization of the pseudoaneurysm utilizing 11 coils with thrombin/Gelfoam injection was performed (Figure ).\nA two-day post-procedure abdominal ultrasound showed an increase in the size of the pseudoaneurysm, measuring 5.6 x 5.8 cm. Interventional radiology then repeated the embolotherapy with thrombin injection. In the next few days, he continued to report both melena and bright red blood per rectum, but his hemoglobin remained stable. On day 19 of admission, third EGD was performed, which was unremarkable for an active bleeding spot. His hemoglobin started to drop but another endoscopic evaluation was not recommended as last EGD was unremarkable. Therein, a bleeding scan showed an equivocal left-flank bleeding focus, not suggestive of a lower gastrointestinal collection, but possibly a small bowel focus with low-grade extravasation. Subsequently, his hemoglobin dropped to 6.3 g/dL, with no signs of overt gastrointestinal hemorrhage. On day 27 of admission, abdominal paracentesis ruled out hemoperitoneum and CTA abdomen showed possible hemorrhage in the left flank outside the gastrointestinal tract, possibly due to an infarcted spleen.\nAfter a discussion with surgery and gastroenterology teams, a repeat EGD with a side-viewing duodenoscope was planned. It initially demonstrated an extremely small blood-oozing spot from the ampulla of Vater. The blood extravasation increased shortly after first pinpointing the source. Over the next few seconds, the blood started to ooze at a rapid rate. In the next one minute, frank intermittent bleeding through the ampulla of Vater into the duodenum was identified (Figure ).\nThese findings were consistent with hemosuccus pancreaticus, likely due to the bleeding from the pseudoaneurysm of the gastroduodenal artery. After the precise etiology establishment, surgical intervention was considered due to prior failed attempts of embolization. However, there was a high risk of perioperative mortality given the patient’s comorbid conditions, poor clinical and performance status and complexity of the anatomical location of pseudoaneurysm. Therefore, a conservative approach was preferred by the patient and his family. On the other hand, he continued to experience intermittent hemorrhage requiring blood transfusions with episodes of hemodynamic instability. An urgent embolization of the pseudoaneurysm was planned. However, the patient and his family refused to undergo therapeutic procedures. The patient continued to worsen clinically over the next few days but he wished not to be resuscitated. He died in a couple of days following hemodynamic instability.

A 55-year-old male diagnosed case of ethanol-related chronic pancreatitis presented with frequent episodes of melena associated with paroxysms of abdominal pain. He was given blood transfusions elsewhere for severe anemia. As patient had persistent GI bleeding with repeated drop in hemoglobin, he was referred for further evaluation and management. On clinical examination, he had profuse sweating, hypotension, tachycardia, severe pallor and mild tenderness in the epigastrium. His laboratory investigations revealed hemoglobin of 7.1 g% and hematocrit of 22%, mild renal failure and increased serum triglycerides. Contrast-enhanced computed tomography of the abdomen showed evidence of chronic calcifying pancreatitis (). Esophagogastroduodenoscopy with a standard scope and colonoscopy were normal. Repeat esophagogastroduodenoscopy with a standard scope after an episode of melena showed active bleeding from the ampulla (). Angiographic study could not localize the site of bleeding. Endoscopic ultrasound showed chronic pancreatitis with a heterogeneous inflammatory lesion in the body of the pancreas (). As the bleeding source could not be localized and the patient had ongoing melena and drop in hemoglobin, emergency exploratory laparotomy was performed after initial hemodynamic stabilization. Pancreas was seen adherent to splenic vessels and hilum. There was evidence of splenic vein rupturing into the main pancreatic duct. Distal pancreatectomy with splenectomy was performed. The patient had an uneventful recovery postoperatively. Postoperative histology demonstrated chronic calcifying pancreatitis (), lymphnodes with reactive hyperplasia and congested spleen (). He was discharged in a hemodynamically stable condition and there was no further recurrence of GI bleeding after 6 months of follow up.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 70-year-old male presented to our medical center with one episode of “black tarry stools” in the morning. Three weeks prior to this admission, the patient underwent esophagogastroduodenoscopy (EGD), which revealed a 6-mm, clean-based ulcer at the gastroesophageal junction without active bleeding. Colonoscopy, performed during the same visit, was significant for mild diverticulosis and small nonbleeding hemorrhoids. He had a medical history of chronic active alcohol abuse, prior gastrointestinal bleeding, hypertension, diabetes mellitus type 2, and non-small-cell lung cancer (T2N0M0; status post-lobectomy, 18 years ago). The patient had been consuming 3-4 drinks of liquor daily; however, he was non-smoker and drug-free. He was under therapy with oral iron sulfate, metformin, pantoprazole, enalapril, and multivitamins. Review of the systems was significant for fatigue, malaise, and confusion. His vitals included blood pressure 137/81 mm Hg, heart rate 108 beats per minute, temperature 36.9°C, respiratory rate 16 per minute and oxygen saturation 100% on room air. On physical examination, he was in no acute distress but appeared lethargic. The cardiopulmonary examination was inconclusive for abnormalities. The abdomen was soft and non-tender without organomegaly.\nHe underwent extensive diagnostic workup. The details of his laboratory studies are provided in Table .\nChest radiograph showed left-sided thoracotomy with chronically elevated left hemidiaphragm but no airspace opacity, effusion, or pneumothorax. He was started on intravenous proton-pump inhibitor therapy for upper gastrointestinal bleeding. Subsequently, EGD showed nodular, edematous and erythematous mucosa with petechial hemorrhages in the gastric fundus and body, with questionable prominence of underlying vasculature (Figure ).\nThe endoscopy was inconclusive for an active bleeding focus; duodenum appeared normal. He also received one unit of packed red blood cells. During the course of hospitalization, he continued to experience black-colored stools. His hemoglobin demonstrated a gradual downward trend, prompting the need for a second endoscopic evaluation. On day 7 of admission, repeat EGD revealed frank fresh blood along with blood clots in the proximal body of the stomach. The clots were irrigated, suctioned, and removed with Roth net. A pinpoint area under one of the removed clots was actively oozing, which mimicked a Dieulafoy’s lesion; primary hemostasis was achieved with a combination therapy using epinephrine injection, cautery, and hemoclip application (Figure ).\nOn day 10 of admission, laboratory studies showed an acute elevation of liver enzymes (alanine transaminase 1096 IU/L; aspartate aminotransferase 123 IU/L; alkaline phosphatase 47 IU/L; and total bilirubin 1.3 mg/dL). Drug-induced liver injury and obstructing lesion were considered plausible. Computed tomography (CT) with pancreatic imaging protocol revealed a large 4.2 x 2.9-cm pseudoaneurysm, likely arising from the gastroduodenal artery, located in the head of the pancreas, with evidence of moderate intrahepatic ductal dilatation and portal vein obstruction. Given the large size with compressive features of the surrounding structures, embolization of the pseudoaneurysm utilizing 11 coils with thrombin/Gelfoam injection was performed (Figure ).\nA two-day post-procedure abdominal ultrasound showed an increase in the size of the pseudoaneurysm, measuring 5.6 x 5.8 cm. Interventional radiology then repeated the embolotherapy with thrombin injection. In the next few days, he continued to report both melena and bright red blood per rectum, but his hemoglobin remained stable. On day 19 of admission, third EGD was performed, which was unremarkable for an active bleeding spot. His hemoglobin started to drop but another endoscopic evaluation was not recommended as last EGD was unremarkable. Therein, a bleeding scan showed an equivocal left-flank bleeding focus, not suggestive of a lower gastrointestinal collection, but possibly a small bowel focus with low-grade extravasation. Subsequently, his hemoglobin dropped to 6.3 g/dL, with no signs of overt gastrointestinal hemorrhage. On day 27 of admission, abdominal paracentesis ruled out hemoperitoneum and CTA abdomen showed possible hemorrhage in the left flank outside the gastrointestinal tract, possibly due to an infarcted spleen.\nAfter a discussion with surgery and gastroenterology teams, a repeat EGD with a side-viewing duodenoscope was planned. It initially demonstrated an extremely small blood-oozing spot from the ampulla of Vater. The blood extravasation increased shortly after first pinpointing the source. Over the next few seconds, the blood started to ooze at a rapid rate. In the next one minute, frank intermittent bleeding through the ampulla of Vater into the duodenum was identified (Figure ).\nThese findings were consistent with hemosuccus pancreaticus, likely due to the bleeding from the pseudoaneurysm of the gastroduodenal artery. After the precise etiology establishment, surgical intervention was considered due to prior failed attempts of embolization. However, there was a high risk of perioperative mortality given the patient’s comorbid conditions, poor clinical and performance status and complexity of the anatomical location of pseudoaneurysm. Therefore, a conservative approach was preferred by the patient and his family. On the other hand, he continued to experience intermittent hemorrhage requiring blood transfusions with episodes of hemodynamic instability. An urgent embolization of the pseudoaneurysm was planned. However, the patient and his family refused to undergo therapeutic procedures. The patient continued to worsen clinically over the next few days but he wished not to be resuscitated. He died in a couple of days following hemodynamic instability.

A 67-year-old Caucasian man was admitted with diffuse abdominal pain, vomiting, diarrhea, and 4 kg weight loss within a couple of weeks. He had a history of alcohol abuse but further medical history was negative. There was no significant abdominal tenderness, no abdominal palpable mass or flank-knocking tenderness. Laboratory studies showed mild anemia with a hemoglobin level of 10.0 g/dL. An abdominal ultrasound (US) scan showed a partially inverted flow in the portal vein with a small cirrhotic liver, ascites, and a small spleen. Abdominal computed tomography (CT) revealed a large pseudoaneurysm between the SMA and coeliac trunk with a diameter of 77 × 53 × 59 mm. Just below this pseudoaneurysm lay the pancreas with calcifications due to chronic pancreatitis. CT angiography revealed an arterioportal fistula between the pseudoaneurysm and portal vein. Due to this pseudoaneurysm, there was compression of the superior mesenteric vein. Ascites around the liver and spleen were seen, probably due to portal hypertension. There was an increase of the pseudoaneurysm diameter compared to the abdominal CT scan made 5 days earlier, with a maximal diameter of 81 mm (Fig. ). Digital angiography revealed a pseudoaneurysm arising from the proximal superior mesenteric artery with fistulization to the portal vein. The pseudoaneurysm was filled via a large defect in the top of the superior mesenteric artery (Fig. ).\nFrom a technical point of view, covered stenting of the SMA was preferred over embolization of the pseudoaneurysm. A 6 French LIMA sheath was placed in the superior mesenteric artery using a femoral approach. Next, a balloon-expandable covered stent (Bentley Begraft® diameter 8 mm, length 37 mm; Bentley, Hechingen, Germany) was deployed in the SMA. Control angiography showed refilling of the pseudoaneurysm via the common hepatic artery (CHA) through the right gastric and gastroduodenal arteries (Fig. ). Since there was no filling of the CHA from the coeliac trunk, it is probable that the CHA originated from the SMA as a normal variant and was separated from its origin, possibly due to the pancreatitis (Fig. ). After catheterization of the CHA via the left and then the right gastric artery, selective embolization was performed with a 2.7 Fr Progreat® microcatheter (Terumo Medical Corp., Somerset, NY, USA) using multiple Hilal microcoils (3, 4, and 5 mm wide and 3 and 6 cm long; Cook Medical, Bloomington, IN, USA), covering the origin of the GDA (Fig. ). The residual perfusion of the liver is only supplied by the right gastric artery from the left gastric artery.\nPostoperatively, the patient was given clopidogrel therapy for 6 weeks and lifelong acetylsalicylic acid.\nHe was discharged on the eighth postoperative day. Follow-up after 6 months revealed no recurrent abdominal symptoms. The pseudoaneurysm was no longer detectable on control CT angiography (Fig. ).

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 70-year-old male presented to our medical center with one episode of “black tarry stools” in the morning. Three weeks prior to this admission, the patient underwent esophagogastroduodenoscopy (EGD), which revealed a 6-mm, clean-based ulcer at the gastroesophageal junction without active bleeding. Colonoscopy, performed during the same visit, was significant for mild diverticulosis and small nonbleeding hemorrhoids. He had a medical history of chronic active alcohol abuse, prior gastrointestinal bleeding, hypertension, diabetes mellitus type 2, and non-small-cell lung cancer (T2N0M0; status post-lobectomy, 18 years ago). The patient had been consuming 3-4 drinks of liquor daily; however, he was non-smoker and drug-free. He was under therapy with oral iron sulfate, metformin, pantoprazole, enalapril, and multivitamins. Review of the systems was significant for fatigue, malaise, and confusion. His vitals included blood pressure 137/81 mm Hg, heart rate 108 beats per minute, temperature 36.9°C, respiratory rate 16 per minute and oxygen saturation 100% on room air. On physical examination, he was in no acute distress but appeared lethargic. The cardiopulmonary examination was inconclusive for abnormalities. The abdomen was soft and non-tender without organomegaly.\nHe underwent extensive diagnostic workup. The details of his laboratory studies are provided in Table .\nChest radiograph showed left-sided thoracotomy with chronically elevated left hemidiaphragm but no airspace opacity, effusion, or pneumothorax. He was started on intravenous proton-pump inhibitor therapy for upper gastrointestinal bleeding. Subsequently, EGD showed nodular, edematous and erythematous mucosa with petechial hemorrhages in the gastric fundus and body, with questionable prominence of underlying vasculature (Figure ).\nThe endoscopy was inconclusive for an active bleeding focus; duodenum appeared normal. He also received one unit of packed red blood cells. During the course of hospitalization, he continued to experience black-colored stools. His hemoglobin demonstrated a gradual downward trend, prompting the need for a second endoscopic evaluation. On day 7 of admission, repeat EGD revealed frank fresh blood along with blood clots in the proximal body of the stomach. The clots were irrigated, suctioned, and removed with Roth net. A pinpoint area under one of the removed clots was actively oozing, which mimicked a Dieulafoy’s lesion; primary hemostasis was achieved with a combination therapy using epinephrine injection, cautery, and hemoclip application (Figure ).\nOn day 10 of admission, laboratory studies showed an acute elevation of liver enzymes (alanine transaminase 1096 IU/L; aspartate aminotransferase 123 IU/L; alkaline phosphatase 47 IU/L; and total bilirubin 1.3 mg/dL). Drug-induced liver injury and obstructing lesion were considered plausible. Computed tomography (CT) with pancreatic imaging protocol revealed a large 4.2 x 2.9-cm pseudoaneurysm, likely arising from the gastroduodenal artery, located in the head of the pancreas, with evidence of moderate intrahepatic ductal dilatation and portal vein obstruction. Given the large size with compressive features of the surrounding structures, embolization of the pseudoaneurysm utilizing 11 coils with thrombin/Gelfoam injection was performed (Figure ).\nA two-day post-procedure abdominal ultrasound showed an increase in the size of the pseudoaneurysm, measuring 5.6 x 5.8 cm. Interventional radiology then repeated the embolotherapy with thrombin injection. In the next few days, he continued to report both melena and bright red blood per rectum, but his hemoglobin remained stable. On day 19 of admission, third EGD was performed, which was unremarkable for an active bleeding spot. His hemoglobin started to drop but another endoscopic evaluation was not recommended as last EGD was unremarkable. Therein, a bleeding scan showed an equivocal left-flank bleeding focus, not suggestive of a lower gastrointestinal collection, but possibly a small bowel focus with low-grade extravasation. Subsequently, his hemoglobin dropped to 6.3 g/dL, with no signs of overt gastrointestinal hemorrhage. On day 27 of admission, abdominal paracentesis ruled out hemoperitoneum and CTA abdomen showed possible hemorrhage in the left flank outside the gastrointestinal tract, possibly due to an infarcted spleen.\nAfter a discussion with surgery and gastroenterology teams, a repeat EGD with a side-viewing duodenoscope was planned. It initially demonstrated an extremely small blood-oozing spot from the ampulla of Vater. The blood extravasation increased shortly after first pinpointing the source. Over the next few seconds, the blood started to ooze at a rapid rate. In the next one minute, frank intermittent bleeding through the ampulla of Vater into the duodenum was identified (Figure ).\nThese findings were consistent with hemosuccus pancreaticus, likely due to the bleeding from the pseudoaneurysm of the gastroduodenal artery. After the precise etiology establishment, surgical intervention was considered due to prior failed attempts of embolization. However, there was a high risk of perioperative mortality given the patient’s comorbid conditions, poor clinical and performance status and complexity of the anatomical location of pseudoaneurysm. Therefore, a conservative approach was preferred by the patient and his family. On the other hand, he continued to experience intermittent hemorrhage requiring blood transfusions with episodes of hemodynamic instability. An urgent embolization of the pseudoaneurysm was planned. However, the patient and his family refused to undergo therapeutic procedures. The patient continued to worsen clinically over the next few days but he wished not to be resuscitated. He died in a couple of days following hemodynamic instability.

A 38-year-old male complaining of recurrent episodes of melena for the past 2 weeks was admitted to the emergency department of our hospital. Two days before the hospital visit, the patient had complained of the presence of blood in vomiting and had a history of recurrent complaints of upper abdominal pain often radiating to the back. His previous medical history revealed that he had suffered from chronic pancreatitis for 3 years before present admission, possibly due to alcohol abuse. He was resuscitated with the blood and intravenous fluid for melena during present admission. Ultrasonography (USG) whole abdomen revealed a moderately enlarged liver (18.5 cm × 12.3 cm) with heterogeneous echotexture, with a prominent portal vein, of size 1.3 cm; hepatic and splenic hilar collaterals were suggestive of portal hypertension. The presence of mild ascites was documented. Transabdominal USG showed echogenic pancreas with multiple, small, hyperechoic, nonshadowing foci in the pancreas suggestive of fibrotic changes. There was evidence of irregular dilated main pancreatic duct with pancreatic and intraductal calculi. These features were consistent with chronic pancreatitis. The findings were suggestive of alcoholic liver disease with portal hypertension and chronic obstructive pancreatitis. After resuscitation, upper GI endoscopy was performed on two different occasions that showed bleeding from the second part of the duodenum with an abnormal tortuous vessel at the ampulla of Vater. This was diagnosed as hemosuccus pancreaticus, which might have caused the bleeding []. Serendipitously during the endoscopy, a worm was also found penetrating the mucosa of the duodenum. The worm was retrieved and referred to the laboratory for identification. It was a single intact live worm (size 12.3 mm × 0.3 mm) reddish pink, with head bent in the same direction of the body curvature with a spine at the posterior end []. The buccal capsule had six teeth (four hook-like on ventral surface and two knob-like on dorsal surface) []. The live worm was seen to lay eggs while examining under the microscope []. Three consecutive stool samples of the patients were examined. The stool sample was dark-colored, semi-solid in consistency without any parasitic elements. Wet mount examination of stool revealed nonbile-stained ova (60– 65 μm in length, 40– 45 μm in width) with transparent hyaline shell membrane containing blastomeres. The above morphological features of the worm and micrometry of the ova were consistent with Ancylostoma duodenale. For further confirmation and to exclude the probability of mixed infection with Strongyloides stercoralis, the modified Harada– Mori nematode larval culture method[] was performed, and larva of hookworm was retrieved after 1 week of incubation at ambient room temperature. However, duodenal biopsy could not be done to rule out this possibility.\nThe patient was a chronic alcoholic and had deranged liver functions. Other laboratory test revealed low hemoglobin (5.6 g/dL), elevated total leukocyte count (12,300/μl) with increased eosinophils (neutrophils - 54%, lymphocytes – 24%, eosinophils – 16%, and monocytes – 6%), hyperbilirubinemia (total serum bilirubin 12.5 mg% and conjugated bilirubin 11.7 mg%), alanine transaminase/aspartate transaminase (87.7/90 IU), serum alkaline phosphatase (827 IU/L), hypoalbuminemia (2.3 g%), and raised serum globulin (3.9 g%) with reversal of albumin:globulin ratio. Blood and urine cultures were bacteriologically sterile. Peripheral blood smear examination showed microcytic, hypochromic anemia, with the absence of any hemoparasites. The patient was planned for contrast-enhanced computed tomography (CECT) abdomen, but the course of illness was rapidly fatal, and he succumbed to the illness within 48 h of admission, hindering further investigative course. The cause of death was unexplained shock secondary to upper GI bleeding precipitated by chronic, alcoholic liver disease with chronic pancreatitis and portal hypertension.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.

A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.

A 39-year-old man was admitted to the hospital due to hematemesis and melena for 2 wk, with a new episode lasting 1 d.\nTwo weeks before admission, the patient had hematemesis and melena without obvious known causes. He vomited light red fluids 4-5 times/d and passed tarry stools 3-4 times/d; these events were accompanied by epigastric pain, abdominal distension, and fatigue. He had no dizziness or syncope. He was hospitalized at a local hospital where examinations showed a hemoglobin (Hb) level of 86 g/L. Esophagogastroduodenoscopy (EGD) showed fresh blood in the descending part of the duodenum but did not show a clear bleeding site. The patient was treated with blood transfusion, acid blockers, and intravenous (IV) fluid and discharged from the hospital after no recurrence of hematemesis or melena was observed.\nOne day before admission to our hospital, the patient vomited bright red blood once and was admitted to the local hospital. Bedside EGD showed no obvious bleeding in the upper gastrointestinal tract. During his hospitalization, the patient had repeated hematemesis and hematochezia 4-5 times/d accompanied by left upper abdominal pain and fatigue. His minimum Hb level was 42 g/L. After treatment with blood transfusion, IV fluid, acid blockers, and hemostasis, he was transferred to our hospital for emergency admission.\nThe patient had a history of chronic pancreatitis. He denied chronic diseases such as hypertension, coronary heart disease, and diabetes, a history of abdominal surgery and trauma, and a history of food and drug allergy.\nThe patient denied a history of smoking and drinking and any history of diseases in family members.\nOn admission, the patient had a body temperature of 37.2 °C, a pulse of 102 beats/min, a respiratory rate of 19 times/min, a blood pressure of 117/91 mmHg, and an oxygen saturation of 98%. The patient had manifestations of anemia and pale conjunctiva. His abdomen was soft with upper abdominal tenderness. No rebound tenderness was noted. No abdominal mass was palpable. No other obvious abnormality was noted.\nThe complete blood count on admission was as follows: White blood cell count, 8.00 × 109/L; red blood cell count, 2.34 × 109/L; Hb, 66 g/L; hematocrit, 0.192; platelet count, 108 × 109/L; total amylase, 198 U/L; D-dimer, 6060 µg/L; hypersensitive C-reactive protein, 40.1 mg/L; procalcitonin, 0.12 ng/mL; and serum albumin, 24 g/L (Table ). Coagulation function, alanine aminotransferase, aspartate aminotransferase, total bilirubin, alkaline phosphatase, glutamyl transpeptidase, urinalysis results, stool analysis, tumor marker expression, troponin I, and electrocardiogram results were all within normal limits.\nA noncontrast-enhanced computed tomography (CT) scan of the abdomen and pelvis showed pancreatic swelling, uneven density, vague edges, multiple spots of calcifications, and hyperintense opacities in the pancreatic head and body, indicating chronic pancreatitis and pancreatic head hemorrhage.\nSubsequent contrast-enhanced CT of the abdomen showed isointense, rounded opacities with a diameter of approximately 41 mm in the pancreatic head that were enhanced with contrast in the arterial phase and were closely related to the gastroduodenal artery, indicating pseudoaneurysm (Figure ). Furthermore, digital subtraction angiography performed via the celiac trunk showed the formation of pseudoaneurysms at the proximal gastroduodenal artery; the remaining blood vessels were unremarkable (Figure , Video 1A).

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.

A 47-year-old male, nonsmoker with no significant medical history initially presented with sudden onset right-sided chest pain, fever, and shortness of breath. After a hemorrhagic pleural tap and chest x-ray demonstrating large retro cardiac soft tissue density, gross right pleural effusion, and right lower lobe lung collapse the patient was referred to our center with a working diagnosis of thoracic malignancy and large lung carcinoma with hemorrhagic pleural effusion.\nThe patient was admitted to our center for further workup. Immediately after, the patient experienced severe respiratory distress; oxygen saturation (SpO2) was 74% on two liters of oxygen. The patient was transferred to the intensive care unit (ICU) with pulse: 102 beats per minute and regular, blood pressure: 95/79 mm Hg, respiratory rate: 22/minute, temperature: 97°F, and SpO2: 100% on high-flow oxygen. Glasgow Coma Scale (GCS) was 15/15, and on examination of the chest, there was decreased air entry on the right side. A right-sided chest drain was placed; 1300 ml of hemorrhagic fluid was drained by the end of the day. Total leukocyte count (TLC) then was 21710/mm^3. A blood and sputum culture was obtained. The sputum sample demonstrated Klebsiella pneumonia, which was managed accordingly, normalizing the counts on the days to come. Whole blood was transfused during the ICU stay as required. After three days the patient was shifted to the general ward with the drain holding 50 ml of blood and stable vital signs.\nCECT chest performed on the fifth day of admission demonstrated a large lesion involving the subcarinal region with intensely enhancing focus adjacent to right bronchus intermedius likely pseudoaneurysm with associated hematoma, collapse of basal right-lower lobe, and collection in the right pleural space (Figure ). The plan for the trucut biopsy of the lung was deferred, and a bronchial angiogram with embolization for bronchial artery pseudoaneurysm was planned. The right common femoral artery was accessed with a 5 French gauge (Fr) vascular sheath, a diagnostic angiographic catheter (Shepherd catheter 5 Fr, Cook Medical, USA) aided in cannulating the right bronchial artery. A selective angiogram revealed a pseudoaneurysm with patent distal flow (Figure ). After the introduction of the 2.1 Fr microcatheter (Artec microcatheter, Japan) the distal normal arterial lumen was reached and coiled with a 2 mm x 2 mm pushable coil (Cook Medical, USA). Similarly, a 2 mm x 2 mm pushable coil was used to trap the front door/proximal part of the right bronchial artery. Post coil embolization, angiogram after 15 minutes showed reduced flow to the sac; however, complete thrombosis was not seen (Figure ). Another permanent embolizing agent Glue mixed with lipiodol (1:7 ratio) was used to achieve complete embolization endpoint. The final angiogram revealed complete thrombosis of the pseudoaneurysm sac and the right bronchial artery (Figure ). No immediate complications were noted. Hemostasis was achieved at the groin by manual compression. After a few days, the chest tube was removed due to a minimal drain.\nFollow-up CT angiography showed coils in the subcarinal region without obvious abnormal enhancement suggestive of adequate embolization and a slight decrease in the size of hematoma at the subcarinal region. The patient was hemodynamically stable and symptomatically better, thus was discharged after one week of hospital stay. The patient was re-evaluated after three weeks by a CECT chest, which showed a significant interval decrease in the lesion at the subcarinal region, subsegmental collapse of a basal segment of the right lower lung, and a significant decrease in the pleural collection (Figure ).

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.

A 55-year-old male diagnosed case of ethanol-related chronic pancreatitis presented with frequent episodes of melena associated with paroxysms of abdominal pain. He was given blood transfusions elsewhere for severe anemia. As patient had persistent GI bleeding with repeated drop in hemoglobin, he was referred for further evaluation and management. On clinical examination, he had profuse sweating, hypotension, tachycardia, severe pallor and mild tenderness in the epigastrium. His laboratory investigations revealed hemoglobin of 7.1 g% and hematocrit of 22%, mild renal failure and increased serum triglycerides. Contrast-enhanced computed tomography of the abdomen showed evidence of chronic calcifying pancreatitis (). Esophagogastroduodenoscopy with a standard scope and colonoscopy were normal. Repeat esophagogastroduodenoscopy with a standard scope after an episode of melena showed active bleeding from the ampulla (). Angiographic study could not localize the site of bleeding. Endoscopic ultrasound showed chronic pancreatitis with a heterogeneous inflammatory lesion in the body of the pancreas (). As the bleeding source could not be localized and the patient had ongoing melena and drop in hemoglobin, emergency exploratory laparotomy was performed after initial hemodynamic stabilization. Pancreas was seen adherent to splenic vessels and hilum. There was evidence of splenic vein rupturing into the main pancreatic duct. Distal pancreatectomy with splenectomy was performed. The patient had an uneventful recovery postoperatively. Postoperative histology demonstrated chronic calcifying pancreatitis (), lymphnodes with reactive hyperplasia and congested spleen (). He was discharged in a hemodynamically stable condition and there was no further recurrence of GI bleeding after 6 months of follow up.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 67-year-old Caucasian man was admitted with diffuse abdominal pain, vomiting, diarrhea, and 4 kg weight loss within a couple of weeks. He had a history of alcohol abuse but further medical history was negative. There was no significant abdominal tenderness, no abdominal palpable mass or flank-knocking tenderness. Laboratory studies showed mild anemia with a hemoglobin level of 10.0 g/dL. An abdominal ultrasound (US) scan showed a partially inverted flow in the portal vein with a small cirrhotic liver, ascites, and a small spleen. Abdominal computed tomography (CT) revealed a large pseudoaneurysm between the SMA and coeliac trunk with a diameter of 77 × 53 × 59 mm. Just below this pseudoaneurysm lay the pancreas with calcifications due to chronic pancreatitis. CT angiography revealed an arterioportal fistula between the pseudoaneurysm and portal vein. Due to this pseudoaneurysm, there was compression of the superior mesenteric vein. Ascites around the liver and spleen were seen, probably due to portal hypertension. There was an increase of the pseudoaneurysm diameter compared to the abdominal CT scan made 5 days earlier, with a maximal diameter of 81 mm (Fig. ). Digital angiography revealed a pseudoaneurysm arising from the proximal superior mesenteric artery with fistulization to the portal vein. The pseudoaneurysm was filled via a large defect in the top of the superior mesenteric artery (Fig. ).\nFrom a technical point of view, covered stenting of the SMA was preferred over embolization of the pseudoaneurysm. A 6 French LIMA sheath was placed in the superior mesenteric artery using a femoral approach. Next, a balloon-expandable covered stent (Bentley Begraft® diameter 8 mm, length 37 mm; Bentley, Hechingen, Germany) was deployed in the SMA. Control angiography showed refilling of the pseudoaneurysm via the common hepatic artery (CHA) through the right gastric and gastroduodenal arteries (Fig. ). Since there was no filling of the CHA from the coeliac trunk, it is probable that the CHA originated from the SMA as a normal variant and was separated from its origin, possibly due to the pancreatitis (Fig. ). After catheterization of the CHA via the left and then the right gastric artery, selective embolization was performed with a 2.7 Fr Progreat® microcatheter (Terumo Medical Corp., Somerset, NY, USA) using multiple Hilal microcoils (3, 4, and 5 mm wide and 3 and 6 cm long; Cook Medical, Bloomington, IN, USA), covering the origin of the GDA (Fig. ). The residual perfusion of the liver is only supplied by the right gastric artery from the left gastric artery.\nPostoperatively, the patient was given clopidogrel therapy for 6 weeks and lifelong acetylsalicylic acid.\nHe was discharged on the eighth postoperative day. Follow-up after 6 months revealed no recurrent abdominal symptoms. The pseudoaneurysm was no longer detectable on control CT angiography (Fig. ).

A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.

A 38-year-old male complaining of recurrent episodes of melena for the past 2 weeks was admitted to the emergency department of our hospital. Two days before the hospital visit, the patient had complained of the presence of blood in vomiting and had a history of recurrent complaints of upper abdominal pain often radiating to the back. His previous medical history revealed that he had suffered from chronic pancreatitis for 3 years before present admission, possibly due to alcohol abuse. He was resuscitated with the blood and intravenous fluid for melena during present admission. Ultrasonography (USG) whole abdomen revealed a moderately enlarged liver (18.5 cm × 12.3 cm) with heterogeneous echotexture, with a prominent portal vein, of size 1.3 cm; hepatic and splenic hilar collaterals were suggestive of portal hypertension. The presence of mild ascites was documented. Transabdominal USG showed echogenic pancreas with multiple, small, hyperechoic, nonshadowing foci in the pancreas suggestive of fibrotic changes. There was evidence of irregular dilated main pancreatic duct with pancreatic and intraductal calculi. These features were consistent with chronic pancreatitis. The findings were suggestive of alcoholic liver disease with portal hypertension and chronic obstructive pancreatitis. After resuscitation, upper GI endoscopy was performed on two different occasions that showed bleeding from the second part of the duodenum with an abnormal tortuous vessel at the ampulla of Vater. This was diagnosed as hemosuccus pancreaticus, which might have caused the bleeding []. Serendipitously during the endoscopy, a worm was also found penetrating the mucosa of the duodenum. The worm was retrieved and referred to the laboratory for identification. It was a single intact live worm (size 12.3 mm × 0.3 mm) reddish pink, with head bent in the same direction of the body curvature with a spine at the posterior end []. The buccal capsule had six teeth (four hook-like on ventral surface and two knob-like on dorsal surface) []. The live worm was seen to lay eggs while examining under the microscope []. Three consecutive stool samples of the patients were examined. The stool sample was dark-colored, semi-solid in consistency without any parasitic elements. Wet mount examination of stool revealed nonbile-stained ova (60– 65 μm in length, 40– 45 μm in width) with transparent hyaline shell membrane containing blastomeres. The above morphological features of the worm and micrometry of the ova were consistent with Ancylostoma duodenale. For further confirmation and to exclude the probability of mixed infection with Strongyloides stercoralis, the modified Harada– Mori nematode larval culture method[] was performed, and larva of hookworm was retrieved after 1 week of incubation at ambient room temperature. However, duodenal biopsy could not be done to rule out this possibility.\nThe patient was a chronic alcoholic and had deranged liver functions. Other laboratory test revealed low hemoglobin (5.6 g/dL), elevated total leukocyte count (12,300/μl) with increased eosinophils (neutrophils - 54%, lymphocytes – 24%, eosinophils – 16%, and monocytes – 6%), hyperbilirubinemia (total serum bilirubin 12.5 mg% and conjugated bilirubin 11.7 mg%), alanine transaminase/aspartate transaminase (87.7/90 IU), serum alkaline phosphatase (827 IU/L), hypoalbuminemia (2.3 g%), and raised serum globulin (3.9 g%) with reversal of albumin:globulin ratio. Blood and urine cultures were bacteriologically sterile. Peripheral blood smear examination showed microcytic, hypochromic anemia, with the absence of any hemoparasites. The patient was planned for contrast-enhanced computed tomography (CECT) abdomen, but the course of illness was rapidly fatal, and he succumbed to the illness within 48 h of admission, hindering further investigative course. The cause of death was unexplained shock secondary to upper GI bleeding precipitated by chronic, alcoholic liver disease with chronic pancreatitis and portal hypertension.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 39-year-old man was admitted to the hospital due to hematemesis and melena for 2 wk, with a new episode lasting 1 d.\nTwo weeks before admission, the patient had hematemesis and melena without obvious known causes. He vomited light red fluids 4-5 times/d and passed tarry stools 3-4 times/d; these events were accompanied by epigastric pain, abdominal distension, and fatigue. He had no dizziness or syncope. He was hospitalized at a local hospital where examinations showed a hemoglobin (Hb) level of 86 g/L. Esophagogastroduodenoscopy (EGD) showed fresh blood in the descending part of the duodenum but did not show a clear bleeding site. The patient was treated with blood transfusion, acid blockers, and intravenous (IV) fluid and discharged from the hospital after no recurrence of hematemesis or melena was observed.\nOne day before admission to our hospital, the patient vomited bright red blood once and was admitted to the local hospital. Bedside EGD showed no obvious bleeding in the upper gastrointestinal tract. During his hospitalization, the patient had repeated hematemesis and hematochezia 4-5 times/d accompanied by left upper abdominal pain and fatigue. His minimum Hb level was 42 g/L. After treatment with blood transfusion, IV fluid, acid blockers, and hemostasis, he was transferred to our hospital for emergency admission.\nThe patient had a history of chronic pancreatitis. He denied chronic diseases such as hypertension, coronary heart disease, and diabetes, a history of abdominal surgery and trauma, and a history of food and drug allergy.\nThe patient denied a history of smoking and drinking and any history of diseases in family members.\nOn admission, the patient had a body temperature of 37.2 °C, a pulse of 102 beats/min, a respiratory rate of 19 times/min, a blood pressure of 117/91 mmHg, and an oxygen saturation of 98%. The patient had manifestations of anemia and pale conjunctiva. His abdomen was soft with upper abdominal tenderness. No rebound tenderness was noted. No abdominal mass was palpable. No other obvious abnormality was noted.\nThe complete blood count on admission was as follows: White blood cell count, 8.00 × 109/L; red blood cell count, 2.34 × 109/L; Hb, 66 g/L; hematocrit, 0.192; platelet count, 108 × 109/L; total amylase, 198 U/L; D-dimer, 6060 µg/L; hypersensitive C-reactive protein, 40.1 mg/L; procalcitonin, 0.12 ng/mL; and serum albumin, 24 g/L (Table ). Coagulation function, alanine aminotransferase, aspartate aminotransferase, total bilirubin, alkaline phosphatase, glutamyl transpeptidase, urinalysis results, stool analysis, tumor marker expression, troponin I, and electrocardiogram results were all within normal limits.\nA noncontrast-enhanced computed tomography (CT) scan of the abdomen and pelvis showed pancreatic swelling, uneven density, vague edges, multiple spots of calcifications, and hyperintense opacities in the pancreatic head and body, indicating chronic pancreatitis and pancreatic head hemorrhage.\nSubsequent contrast-enhanced CT of the abdomen showed isointense, rounded opacities with a diameter of approximately 41 mm in the pancreatic head that were enhanced with contrast in the arterial phase and were closely related to the gastroduodenal artery, indicating pseudoaneurysm (Figure ). Furthermore, digital subtraction angiography performed via the celiac trunk showed the formation of pseudoaneurysms at the proximal gastroduodenal artery; the remaining blood vessels were unremarkable (Figure , Video 1A).

A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 47-year-old male, nonsmoker with no significant medical history initially presented with sudden onset right-sided chest pain, fever, and shortness of breath. After a hemorrhagic pleural tap and chest x-ray demonstrating large retro cardiac soft tissue density, gross right pleural effusion, and right lower lobe lung collapse the patient was referred to our center with a working diagnosis of thoracic malignancy and large lung carcinoma with hemorrhagic pleural effusion.\nThe patient was admitted to our center for further workup. Immediately after, the patient experienced severe respiratory distress; oxygen saturation (SpO2) was 74% on two liters of oxygen. The patient was transferred to the intensive care unit (ICU) with pulse: 102 beats per minute and regular, blood pressure: 95/79 mm Hg, respiratory rate: 22/minute, temperature: 97°F, and SpO2: 100% on high-flow oxygen. Glasgow Coma Scale (GCS) was 15/15, and on examination of the chest, there was decreased air entry on the right side. A right-sided chest drain was placed; 1300 ml of hemorrhagic fluid was drained by the end of the day. Total leukocyte count (TLC) then was 21710/mm^3. A blood and sputum culture was obtained. The sputum sample demonstrated Klebsiella pneumonia, which was managed accordingly, normalizing the counts on the days to come. Whole blood was transfused during the ICU stay as required. After three days the patient was shifted to the general ward with the drain holding 50 ml of blood and stable vital signs.\nCECT chest performed on the fifth day of admission demonstrated a large lesion involving the subcarinal region with intensely enhancing focus adjacent to right bronchus intermedius likely pseudoaneurysm with associated hematoma, collapse of basal right-lower lobe, and collection in the right pleural space (Figure ). The plan for the trucut biopsy of the lung was deferred, and a bronchial angiogram with embolization for bronchial artery pseudoaneurysm was planned. The right common femoral artery was accessed with a 5 French gauge (Fr) vascular sheath, a diagnostic angiographic catheter (Shepherd catheter 5 Fr, Cook Medical, USA) aided in cannulating the right bronchial artery. A selective angiogram revealed a pseudoaneurysm with patent distal flow (Figure ). After the introduction of the 2.1 Fr microcatheter (Artec microcatheter, Japan) the distal normal arterial lumen was reached and coiled with a 2 mm x 2 mm pushable coil (Cook Medical, USA). Similarly, a 2 mm x 2 mm pushable coil was used to trap the front door/proximal part of the right bronchial artery. Post coil embolization, angiogram after 15 minutes showed reduced flow to the sac; however, complete thrombosis was not seen (Figure ). Another permanent embolizing agent Glue mixed with lipiodol (1:7 ratio) was used to achieve complete embolization endpoint. The final angiogram revealed complete thrombosis of the pseudoaneurysm sac and the right bronchial artery (Figure ). No immediate complications were noted. Hemostasis was achieved at the groin by manual compression. After a few days, the chest tube was removed due to a minimal drain.\nFollow-up CT angiography showed coils in the subcarinal region without obvious abnormal enhancement suggestive of adequate embolization and a slight decrease in the size of hematoma at the subcarinal region. The patient was hemodynamically stable and symptomatically better, thus was discharged after one week of hospital stay. The patient was re-evaluated after three weeks by a CECT chest, which showed a significant interval decrease in the lesion at the subcarinal region, subsegmental collapse of a basal segment of the right lower lung, and a significant decrease in the pleural collection (Figure ).

A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.

A 55-year-old male diagnosed case of ethanol-related chronic pancreatitis presented with frequent episodes of melena associated with paroxysms of abdominal pain. He was given blood transfusions elsewhere for severe anemia. As patient had persistent GI bleeding with repeated drop in hemoglobin, he was referred for further evaluation and management. On clinical examination, he had profuse sweating, hypotension, tachycardia, severe pallor and mild tenderness in the epigastrium. His laboratory investigations revealed hemoglobin of 7.1 g% and hematocrit of 22%, mild renal failure and increased serum triglycerides. Contrast-enhanced computed tomography of the abdomen showed evidence of chronic calcifying pancreatitis (). Esophagogastroduodenoscopy with a standard scope and colonoscopy were normal. Repeat esophagogastroduodenoscopy with a standard scope after an episode of melena showed active bleeding from the ampulla (). Angiographic study could not localize the site of bleeding. Endoscopic ultrasound showed chronic pancreatitis with a heterogeneous inflammatory lesion in the body of the pancreas (). As the bleeding source could not be localized and the patient had ongoing melena and drop in hemoglobin, emergency exploratory laparotomy was performed after initial hemodynamic stabilization. Pancreas was seen adherent to splenic vessels and hilum. There was evidence of splenic vein rupturing into the main pancreatic duct. Distal pancreatectomy with splenectomy was performed. The patient had an uneventful recovery postoperatively. Postoperative histology demonstrated chronic calcifying pancreatitis (), lymphnodes with reactive hyperplasia and congested spleen (). He was discharged in a hemodynamically stable condition and there was no further recurrence of GI bleeding after 6 months of follow up.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 67-year-old Caucasian man was admitted with diffuse abdominal pain, vomiting, diarrhea, and 4 kg weight loss within a couple of weeks. He had a history of alcohol abuse but further medical history was negative. There was no significant abdominal tenderness, no abdominal palpable mass or flank-knocking tenderness. Laboratory studies showed mild anemia with a hemoglobin level of 10.0 g/dL. An abdominal ultrasound (US) scan showed a partially inverted flow in the portal vein with a small cirrhotic liver, ascites, and a small spleen. Abdominal computed tomography (CT) revealed a large pseudoaneurysm between the SMA and coeliac trunk with a diameter of 77 × 53 × 59 mm. Just below this pseudoaneurysm lay the pancreas with calcifications due to chronic pancreatitis. CT angiography revealed an arterioportal fistula between the pseudoaneurysm and portal vein. Due to this pseudoaneurysm, there was compression of the superior mesenteric vein. Ascites around the liver and spleen were seen, probably due to portal hypertension. There was an increase of the pseudoaneurysm diameter compared to the abdominal CT scan made 5 days earlier, with a maximal diameter of 81 mm (Fig. ). Digital angiography revealed a pseudoaneurysm arising from the proximal superior mesenteric artery with fistulization to the portal vein. The pseudoaneurysm was filled via a large defect in the top of the superior mesenteric artery (Fig. ).\nFrom a technical point of view, covered stenting of the SMA was preferred over embolization of the pseudoaneurysm. A 6 French LIMA sheath was placed in the superior mesenteric artery using a femoral approach. Next, a balloon-expandable covered stent (Bentley Begraft® diameter 8 mm, length 37 mm; Bentley, Hechingen, Germany) was deployed in the SMA. Control angiography showed refilling of the pseudoaneurysm via the common hepatic artery (CHA) through the right gastric and gastroduodenal arteries (Fig. ). Since there was no filling of the CHA from the coeliac trunk, it is probable that the CHA originated from the SMA as a normal variant and was separated from its origin, possibly due to the pancreatitis (Fig. ). After catheterization of the CHA via the left and then the right gastric artery, selective embolization was performed with a 2.7 Fr Progreat® microcatheter (Terumo Medical Corp., Somerset, NY, USA) using multiple Hilal microcoils (3, 4, and 5 mm wide and 3 and 6 cm long; Cook Medical, Bloomington, IN, USA), covering the origin of the GDA (Fig. ). The residual perfusion of the liver is only supplied by the right gastric artery from the left gastric artery.\nPostoperatively, the patient was given clopidogrel therapy for 6 weeks and lifelong acetylsalicylic acid.\nHe was discharged on the eighth postoperative day. Follow-up after 6 months revealed no recurrent abdominal symptoms. The pseudoaneurysm was no longer detectable on control CT angiography (Fig. ).

A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.

A 38-year-old male complaining of recurrent episodes of melena for the past 2 weeks was admitted to the emergency department of our hospital. Two days before the hospital visit, the patient had complained of the presence of blood in vomiting and had a history of recurrent complaints of upper abdominal pain often radiating to the back. His previous medical history revealed that he had suffered from chronic pancreatitis for 3 years before present admission, possibly due to alcohol abuse. He was resuscitated with the blood and intravenous fluid for melena during present admission. Ultrasonography (USG) whole abdomen revealed a moderately enlarged liver (18.5 cm × 12.3 cm) with heterogeneous echotexture, with a prominent portal vein, of size 1.3 cm; hepatic and splenic hilar collaterals were suggestive of portal hypertension. The presence of mild ascites was documented. Transabdominal USG showed echogenic pancreas with multiple, small, hyperechoic, nonshadowing foci in the pancreas suggestive of fibrotic changes. There was evidence of irregular dilated main pancreatic duct with pancreatic and intraductal calculi. These features were consistent with chronic pancreatitis. The findings were suggestive of alcoholic liver disease with portal hypertension and chronic obstructive pancreatitis. After resuscitation, upper GI endoscopy was performed on two different occasions that showed bleeding from the second part of the duodenum with an abnormal tortuous vessel at the ampulla of Vater. This was diagnosed as hemosuccus pancreaticus, which might have caused the bleeding []. Serendipitously during the endoscopy, a worm was also found penetrating the mucosa of the duodenum. The worm was retrieved and referred to the laboratory for identification. It was a single intact live worm (size 12.3 mm × 0.3 mm) reddish pink, with head bent in the same direction of the body curvature with a spine at the posterior end []. The buccal capsule had six teeth (four hook-like on ventral surface and two knob-like on dorsal surface) []. The live worm was seen to lay eggs while examining under the microscope []. Three consecutive stool samples of the patients were examined. The stool sample was dark-colored, semi-solid in consistency without any parasitic elements. Wet mount examination of stool revealed nonbile-stained ova (60– 65 μm in length, 40– 45 μm in width) with transparent hyaline shell membrane containing blastomeres. The above morphological features of the worm and micrometry of the ova were consistent with Ancylostoma duodenale. For further confirmation and to exclude the probability of mixed infection with Strongyloides stercoralis, the modified Harada– Mori nematode larval culture method[] was performed, and larva of hookworm was retrieved after 1 week of incubation at ambient room temperature. However, duodenal biopsy could not be done to rule out this possibility.\nThe patient was a chronic alcoholic and had deranged liver functions. Other laboratory test revealed low hemoglobin (5.6 g/dL), elevated total leukocyte count (12,300/μl) with increased eosinophils (neutrophils - 54%, lymphocytes – 24%, eosinophils – 16%, and monocytes – 6%), hyperbilirubinemia (total serum bilirubin 12.5 mg% and conjugated bilirubin 11.7 mg%), alanine transaminase/aspartate transaminase (87.7/90 IU), serum alkaline phosphatase (827 IU/L), hypoalbuminemia (2.3 g%), and raised serum globulin (3.9 g%) with reversal of albumin:globulin ratio. Blood and urine cultures were bacteriologically sterile. Peripheral blood smear examination showed microcytic, hypochromic anemia, with the absence of any hemoparasites. The patient was planned for contrast-enhanced computed tomography (CECT) abdomen, but the course of illness was rapidly fatal, and he succumbed to the illness within 48 h of admission, hindering further investigative course. The cause of death was unexplained shock secondary to upper GI bleeding precipitated by chronic, alcoholic liver disease with chronic pancreatitis and portal hypertension.

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis

A 39-year-old man was admitted to the hospital due to hematemesis and melena for 2 wk, with a new episode lasting 1 d.\nTwo weeks before admission, the patient had hematemesis and melena without obvious known causes. He vomited light red fluids 4-5 times/d and passed tarry stools 3-4 times/d; these events were accompanied by epigastric pain, abdominal distension, and fatigue. He had no dizziness or syncope. He was hospitalized at a local hospital where examinations showed a hemoglobin (Hb) level of 86 g/L. Esophagogastroduodenoscopy (EGD) showed fresh blood in the descending part of the duodenum but did not show a clear bleeding site. The patient was treated with blood transfusion, acid blockers, and intravenous (IV) fluid and discharged from the hospital after no recurrence of hematemesis or melena was observed.\nOne day before admission to our hospital, the patient vomited bright red blood once and was admitted to the local hospital. Bedside EGD showed no obvious bleeding in the upper gastrointestinal tract. During his hospitalization, the patient had repeated hematemesis and hematochezia 4-5 times/d accompanied by left upper abdominal pain and fatigue. His minimum Hb level was 42 g/L. After treatment with blood transfusion, IV fluid, acid blockers, and hemostasis, he was transferred to our hospital for emergency admission.\nThe patient had a history of chronic pancreatitis. He denied chronic diseases such as hypertension, coronary heart disease, and diabetes, a history of abdominal surgery and trauma, and a history of food and drug allergy.\nThe patient denied a history of smoking and drinking and any history of diseases in family members.\nOn admission, the patient had a body temperature of 37.2 °C, a pulse of 102 beats/min, a respiratory rate of 19 times/min, a blood pressure of 117/91 mmHg, and an oxygen saturation of 98%. The patient had manifestations of anemia and pale conjunctiva. His abdomen was soft with upper abdominal tenderness. No rebound tenderness was noted. No abdominal mass was palpable. No other obvious abnormality was noted.\nThe complete blood count on admission was as follows: White blood cell count, 8.00 × 109/L; red blood cell count, 2.34 × 109/L; Hb, 66 g/L; hematocrit, 0.192; platelet count, 108 × 109/L; total amylase, 198 U/L; D-dimer, 6060 µg/L; hypersensitive C-reactive protein, 40.1 mg/L; procalcitonin, 0.12 ng/mL; and serum albumin, 24 g/L (Table ). Coagulation function, alanine aminotransferase, aspartate aminotransferase, total bilirubin, alkaline phosphatase, glutamyl transpeptidase, urinalysis results, stool analysis, tumor marker expression, troponin I, and electrocardiogram results were all within normal limits.\nA noncontrast-enhanced computed tomography (CT) scan of the abdomen and pelvis showed pancreatic swelling, uneven density, vague edges, multiple spots of calcifications, and hyperintense opacities in the pancreatic head and body, indicating chronic pancreatitis and pancreatic head hemorrhage.\nSubsequent contrast-enhanced CT of the abdomen showed isointense, rounded opacities with a diameter of approximately 41 mm in the pancreatic head that were enhanced with contrast in the arterial phase and were closely related to the gastroduodenal artery, indicating pseudoaneurysm (Figure ). Furthermore, digital subtraction angiography performed via the celiac trunk showed the formation of pseudoaneurysms at the proximal gastroduodenal artery; the remaining blood vessels were unremarkable (Figure , Video 1A).

A 47-year-old male, nonsmoker with no significant medical history initially presented with sudden onset right-sided chest pain, fever, and shortness of breath. After a hemorrhagic pleural tap and chest x-ray demonstrating large retro cardiac soft tissue density, gross right pleural effusion, and right lower lobe lung collapse the patient was referred to our center with a working diagnosis of thoracic malignancy and large lung carcinoma with hemorrhagic pleural effusion.\nThe patient was admitted to our center for further workup. Immediately after, the patient experienced severe respiratory distress; oxygen saturation (SpO2) was 74% on two liters of oxygen. The patient was transferred to the intensive care unit (ICU) with pulse: 102 beats per minute and regular, blood pressure: 95/79 mm Hg, respiratory rate: 22/minute, temperature: 97°F, and SpO2: 100% on high-flow oxygen. Glasgow Coma Scale (GCS) was 15/15, and on examination of the chest, there was decreased air entry on the right side. A right-sided chest drain was placed; 1300 ml of hemorrhagic fluid was drained by the end of the day. Total leukocyte count (TLC) then was 21710/mm^3. A blood and sputum culture was obtained. The sputum sample demonstrated Klebsiella pneumonia, which was managed accordingly, normalizing the counts on the days to come. Whole blood was transfused during the ICU stay as required. After three days the patient was shifted to the general ward with the drain holding 50 ml of blood and stable vital signs.\nCECT chest performed on the fifth day of admission demonstrated a large lesion involving the subcarinal region with intensely enhancing focus adjacent to right bronchus intermedius likely pseudoaneurysm with associated hematoma, collapse of basal right-lower lobe, and collection in the right pleural space (Figure ). The plan for the trucut biopsy of the lung was deferred, and a bronchial angiogram with embolization for bronchial artery pseudoaneurysm was planned. The right common femoral artery was accessed with a 5 French gauge (Fr) vascular sheath, a diagnostic angiographic catheter (Shepherd catheter 5 Fr, Cook Medical, USA) aided in cannulating the right bronchial artery. A selective angiogram revealed a pseudoaneurysm with patent distal flow (Figure ). After the introduction of the 2.1 Fr microcatheter (Artec microcatheter, Japan) the distal normal arterial lumen was reached and coiled with a 2 mm x 2 mm pushable coil (Cook Medical, USA). Similarly, a 2 mm x 2 mm pushable coil was used to trap the front door/proximal part of the right bronchial artery. Post coil embolization, angiogram after 15 minutes showed reduced flow to the sac; however, complete thrombosis was not seen (Figure ). Another permanent embolizing agent Glue mixed with lipiodol (1:7 ratio) was used to achieve complete embolization endpoint. The final angiogram revealed complete thrombosis of the pseudoaneurysm sac and the right bronchial artery (Figure ). No immediate complications were noted. Hemostasis was achieved at the groin by manual compression. After a few days, the chest tube was removed due to a minimal drain.\nFollow-up CT angiography showed coils in the subcarinal region without obvious abnormal enhancement suggestive of adequate embolization and a slight decrease in the size of hematoma at the subcarinal region. The patient was hemodynamically stable and symptomatically better, thus was discharged after one week of hospital stay. The patient was re-evaluated after three weeks by a CECT chest, which showed a significant interval decrease in the lesion at the subcarinal region, subsegmental collapse of a basal segment of the right lower lung, and a significant decrease in the pleural collection (Figure ).

Write a detailed clinical case vignette based on the following key phrases: Gastrointestinal bleeding, Pseudoaneurysm, Chronic pancreatitis