Good Clinical Prognosis Research Articles

Two new mutations of the CLMP gene identified in a newborn presenting congenital short-bowel syndrome

Congenital short-bowel syndrome (CSBS) is a rare neonatal pathology associated with poor prognosis and high mortality rate. We describe a newborn presenting CSBS intestinal malrotation and chronic intestinal pseudo-obstruction syndrome (CIPS), compound heterozygous for two previously unreported heterozygous mutations in Coxsackie and adenovirus receptor-like membrane protein (CLMP) gene, one in intron 1 (c.28+1G>C), the other on exon 4 (c502C>T, p.R168X). Both mutations are predicted to be pathogenic, leading to impaired splicing and the appearance of a premature stop codon, respectively. Our case is remarkable in that it concerns two heterozygous truncating mutations associated with a good clinical prognosis with a favorable cerebral and gastrointestinal outcome and a substantial enteral input at 8 months of age, despite a small intestine measuring only 35cm.

Does ability to walk reflect general functionality in inflammatory neuropathies?

The "ability to walk" is considered a benchmark for good clinical recovery and prognosis, particularly in patients with Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). However, it has never been determined whether being "able to walk" represents general functionality. The purpose of this study was to examine whether the ability to walk outside independently reflects general functional improvement in patients with GBS, CIDP, and gammopathy-related neuropathy (MGUSP). A total of 137 patients with newly diagnosed (or relapsing) GBS (55), CIDP (59), and MGUSP (23) were serially examined (1-year). Predefined arbitrary cut-offs (so-called patients' Functional-Acceptable-Clinical-Thresholds [FACTs]) were taken at the 50th, 75th, and 90th percentile of the Inflammatory-Rasch-built-Overall-Disability-Scale (I-RODS(©) ). We determined the proportion of patients able to walk outside independently that reached the postulated cut-offs. A mean total of 85%, 39%, and 12% of all patients able to walk reached 50th, 75th, and 90th percentile thresholds, respectively. These findings were not neuropathy type related. Our findings show that assessing only one construct of functionality (e.g., walking ability) does not reflect the full scope of daily/social functional deficits perceived by patients. The ability to walk shows a patient is doing better, but not necessarily doing well. The I-RODS(©) bypasses these limitations.

Traumatic pseudocyst due to blunt trauma: Case report

Damage to lung parenchyma due to blunt thoracic trauma often appears as contusion or hematoma. Cavitary lung lesions or pseudocyst formation due to trauma is a rare phenomenon. In the literature traumatic pseudocysts are also known as pseudocystic hematomas, traumatic lung cavity and traumatic pneumotocel. Traumatic pseudocysts usually have good clinical prognosis, recover spontaneously with supportive treatment and do not require surgery. In this article, we present the case of 52 year old male who was brought to the emergency department after a fall from height and was diagnosed with lung contusions and traumatic cyst.

Abstract 13596: The Prognostic Impact of Spontaneous Coronary Artery Dissection in Younger Female Patients with Acute Myocardial Infarction; Report from Angina Pectoris-Myocardial Infarction Multicenter Investigations in Japan

Introduction: Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial infarction (AMI). It is postulated that the patients with SCAD have good clinical prognosis because they have few coronary risk factors (CRF). However, a recent report studying the US patients with SCAD aged 18~78 years suggested that the rate of recurrence was higher than we expected. In the present study, we therefore have focused on prognostic impact of SCAD on younger female populations. Methods: A total of 16,233 AMI patients registered by 10 institutes from 1991 to 2012 were retrospectively studied. The definition of SCAD was based on the presence of medial dissection or intramural hematoma that was recognized by angiography before any catheter intervention. Results: There were 27 patients diagnosed as SCAD (male/female 1/26, age 45±9 [SD] years). The overall prevalence of SCAD was 0.17% of AMI patients. SCAD developed after physical or emotional stress in 11 patients (40.7%). The left anterior descending artery was involved in 17 patients (62.9%), among whom 4 patients had multi-vessel SCAD (14.8%). Recurrences of SCAD were shown in 9 patients (33.3%). In 4 of 9, recurrence was seen in previously unaffected coronary arteries. In young population of AMI patients (age <50), we compared clinical parameters of SCAD (n=21) with those of Non-SCAD groups (atherosclerotic, n=35). In SCAD group, the number of CRF was significantly lower than in Non-SCAD groups (SCAD, 1.0+/-0.8 vs Non-SCAD, 2.2+/-1.1, P<0.0001). In Kaplan-Meier analysis, younger female AMI patients with SCAD showed significantly higher rate of cardiac event (death, AMI and heart failure) in comparison with those without SCAD (SCAD, 11/21 vs Non-SCAD, 4/34; P=0.0002) during a median follow-up of 1557 (1-8172) days. Conclusions: The present multicenter study demonstrated that younger female AMI patients with SCAD, characterized as minimum accumulation of CRF, seem to be prone to cardiac events.

Is the incidence of aliphatic amine-induced occupational rhinitis and asthma underestimated?

Amines, some of which are known to cause asthma, are frequently present in the work environment, but are rarely identified as being responsible for occupational rhinitis (OR) or asthma (OA). However, amine-induced OR/OA may be underreported. To discuss this hypothesis, we report a series of patients with positive amine-specific nasal provocation test (NPT). Review of the medical charts of 37 patients with OR (alone or associated with asthma), submitted to a NPT with an aliphatic or alicyclic amine (except for EDTA) present in a product used at work. Most patients worked in the healthcare sector or for a cleaning company. Amines were mostly present in cleaning products. Seven patients had a positive NPT. NPTs were positive for the following amines: bis(aminopropyl)laurylamine, C12-C18 alkyldimethylamine oxides, bis(2-hydroxyethyl)tallowamine oxides, 3-dimethylaminopropylamine, 2,2'-dimethyl-4,4'-methylene-bis(cyclohexylamine), lauryldimethylamine oxide. NPTs were negative for the following amines: monoethanolamine, diethanolamine, triethanolamine, isopropanolamine, triethylamine, triethylenetetramine, aminopropyltriethoxysilane, alkylpropylenediamineguanidine acetate. The frequency of amine-induced OR/OA may be underestimated, particularly when cleaning products are incriminated. Comprehensive investigation of all cases is mandatory to ensure an efficient prevention policy and consequently a good clinical and socio-occupational prognosis of occupational respiratory disease.

Accurate Assessment of Aortic Stenosis

Aortic valve (AV) stenosis is one of the most common valvular diseases and is the third most common cardiovascular disease in developed countries. It occurs in ≈2.8% of patients ≥75 years of age and can occur because of degenerative calcification and congenital valvular defects such as bicuspid AVs or rheumatic disease.1–3 Calcific aortic stenosis (AS) is associated with increased leaflet stiffness and a narrowed AV orifice, resulting in increased pressure gradients across the valve. The presence of a bicuspid AV significantly increases the risk of AS.4 The natural history of AS is a prolonged asymptomatic period, with progressive reduction of the AV orifice area due to sclerosis initially, culminating in calcific AS. This is accompanied by a corresponding increase in the transaortic pressure gradient (Δ P ) and myocardial pressure overload. Through the preload reserve, the left ventricle (LV) compensates for the increased workload until the sarcomeres stretch to their maximum diastolic length. Once the preload reserve is exhausted, increases in afterload are accompanied by a reduction in stroke volume (SV), resulting in afterload mismatch. Ultimately, this causes LV hypertrophy, associated with an enlargement of cardiac myocytes and increased LV wall thickness.5 Initial diagnosis of AS typically occurs during routine physical examination with the presence of a heart murmur, click, or other abnormal sounds, but undiagnosed patients may experience the onset of severe symptoms such as angina, syncope, and heart failure. Without intervention, patient mortality typically occurs within 5 years of the onset of symptoms.6–11 Multiple studies and reviews have focused on the clinical aspects of this disease, including disease progression, markers of disease severity, treatment guidelines, and outcomes.1–3,6,12–16 Very few reviews have focused on the hemodynamic principles underlying AS and on comparing data obtained across different …

One-Year Prospective Study of 7-mm-Long Implants in the Mandible: Installation Technique and Crown/Implant Ratio of 1.5 or Less

This study prospectively evaluated the clinical prognoses of short implants (7-mm long) in the mandible. We investigated the clinical prognosis of short implants in 20 patients (46 implants) according to the installation technique (submerged or nonsubmerged), installation depth (5.5-mm depth, 7-mm depth), and crown/implant ratio. We investigated the marginal bone loss and peri-implant soft-tissue index 12 months after the final prosthetic delivery. Twelve months after prosthetic delivery, no statistically significant differences were observed in bone loss in relation to the type of installation technique, installation depth, or crown/implant ratio. The plaque index and pocket depth indexes were not influenced by the installation technique, installation depth, or crown/implant ratio. We observed marginal bone loss of 3.3 mm in 1 implant from the nonsubmerged group. The total 1-year success rate was 97.83%. Based on this 1-year success rate, short implants had a good clinical prognosis, regardless of the installation technique, installation depth, or crown/implant ratio.

Brain abscess: Current management

Brain abscess (BA) is defined as a focal infection within the brain parenchyma, which starts as a localized area of cerebritis, which is subsequently converted into a collection of pus within a well-vascularized capsule. BA must be differentiated from parameningeal infections, including epidural abscess and subdural empyema. The BA is a challenge for the neurosurgeon because it is needed good clinical, pharmacological, and surgical skills for providing good clinical outcomes and prognosis to BA patients. Considered an infrequent brain infection, BA could be a devastator entity that easily left the patient into dead. The aim of this work is to review the current concepts regarding epidemiology, pathophysiology, etiology, clinical presentation, diagnosis, and management of BA.

Baseline Factors Predictive of Visual Prognosis in Acute Postoperative Bacterial Endophthalmitis in Patients Undergoing Cataract Surgery

Although rare, postoperative endophthalmitis in patients undergoing cataract surgery can lead to anatomical or functional loss of the eye. Therapeutic strategies such as antibiotic prophylaxis and microbiological diagnosis are more effective with a target patient population. New prospective data are needed to identify prognostic factors. To identify baseline factors of visual prognosis in patients with acute bacterial endophthalmitis after cataract surgery. Prospective study of consecutive patients undergoing cataract surgery, enrolled from March 1, 2004, through December 31, 2005. We analyzed outcomes to determine the effect on the final visual outcome, defined as poor (visual acuity [VA] worse than 20/100) or good (VA 20/40 or better) using univariate and multivariate analysis. Four academic hospitals. Ninety-nine consecutive patients with cataract. Corneal phacoemulsification. Factors related to the cataract surgery (complications), initial clinical presentation, and microbiological diagnosis and the final VA. The significant baseline factors (at presentation) for good visual outcome (45% of the series) were the winter season, absence of complications during cataract surgery, initial VA, microbiological investigations revealing no microorganism or a coagulase-negative Staphylococcus species (CNSP), and fundus visibility. Quantitative factors associated with a good clinical prognosis were shorter duration of cataract surgery, younger age, and a hypopyon no greater than 1.5 mm. Significant factors associated with poor visual outcome were infection of the right eye, initial VA, corneal edema, a hypopyon larger than 1.5 mm, detection of bacterial species other than a CNSP, and the absence of fundus visibility. Multiple logistic regression analysis showed that high bacterial virulence was the only independent factor (odds ratio, 14.0 [95% CI, 2.7-71.0]; P = .001) for poor visual outcome. On the other hand, low bacterial virulence (odds ratio, 0.2 [95% CI, 0.03-0.6]; P = .01) and the absence of complications during cataract surgery (0.1 [0.01-0.4]; P = .003) were independent factors for good VA. Most clinical outcome factors in acute postoperative endophthalmitis can be identified at presentation. The bacterial virulence level is the main factor predictive of the final visual prognosis.

KÖK REZORPSİYONU OLAN BİR OLGUNUN ENDODONTİK VE CERRAHİ KOMBİNE TEDAVİSİ : OLGU SUNUMU

This report presents a case treated both endodontically and surgically of a mandibular left canine tooth with two seperate inflammatory resorptive defects, one perforating the apical one-third. Following obturation with hybrid tecnique, mucoperiostal flap was performed and MTA was applied into the perforated resorptive cavity. At 1-year follow-up, the tooth was free of symptoms and complete healing was observed around the root in radiographic examination . At 2-year follow-up,the tooth was asymptomatic in clinically and radiologically. For postoperatif results of the treatment, sealing of perforation site with material such as MTA which has biocompatibility and good sealing properties may result in good clinical prognosis.

A Retrospectively Diagnosed Case of IgG4-Related Tubulointerstitial Nephritis Showing Good Renal Outcome and Pathological Progress

A 74-year-old man was hospitalized for diabetic nephropathy evaluation and assessment of the effect of treatment on his tubulointerstitial nephritis (TIN). When he was 62 years old, he developed polyarthralgia and had superficial lymph node swelling, mildly increased serum creatinine concentration, hypergammaglobulinemia, hypocomplementemia, high serum IL-2R level, and positive titer of antinuclear antibody. Several tissues were biopsied. Mild chronic sialadenitis and reactive lymphadenitis were identified. Renal specimen showed mild glomerular ischemia, extensive storiform fibrosis, and abundant infiltrating monocytes and plasma cells. He was treated with oral prednisolone and cyclophosphamide. After the treatment, most of his clinical parameters quickly returned to within the reference range. However, he developed diabetes mellitus soon after steroid therapy. At the time of rebiopsy, a high level of serum IgG4 was detected. The second renal biopsy showed diabetic nephropathy without any tubulointerstitial damage. The first biopsied tissues were retrospectively investigated. Large numbers of IgG4-positive plasma cells were detected in the kidneys and lymph nodes. A retrospective diagnosis of IgG4-related TIN with lymph node involvement was made. In conclusion, this paper describes a retrospectively diagnosed case of IgG4-related TIN with lymph node involvement, showing good clinical and pathological prognosis.

Transcription Factors Sp1 and p73 Control the Expression of the Proapoptotic Protein NOXA in the Response of Testicular Embryonal Carcinoma Cells to Cisplatin

Testicular germ cell tumors (TGCTs) are highly responsive to and curable by cisplatin-based chemotherapy even in advanced stages. We have studied the molecular mechanisms involved in the induction of apoptosis in response to cisplatin, and found that proapoptotic Noxa is transcriptionally up-regulated following cisplatin exposure, even in the absence of p53, in NTERA2 cisplatin-sensitive cells but not in 1411HP-resistant cells. Blockade of Noxa reduced the apoptotic response of embryonal carcinoma (EC) NTERA2 cells to cisplatin. A detailed analysis of the Noxa promoter revealed that p73 and Sp1-like factors, Sp1 and KLF6, played key roles in the transcriptional control of this gene. Overexpression of TAp73 induced Noxa whereas the dominant negative isoform ΔNp73, reduced the levels of Noxa after cisplatin exposure in NTERA2 and 2102EP. Interestingly, down-regulation of Sp1 increased Noxa expression in response to cisplatin. However, blockade of KLF6 decreased cisplatin-induced up-regulation of Noxa in EC cell lines. In addition, tissue microarray analyses of TGCTs revealed that expression of Noxa correlates with good clinical prognosis in patients with embryonal carcinoma. Thus, our data show the transcriptional network that regulates Noxa in EC cells, which is key for their apoptotic response to cisplatin-based chemotherapy, and propose Noxa as a predictive factor of therapeutic response.

Granular cell tumor of brachial plexus mimicking nerve sheath tumor: a case report.

Primary tumors of the brachial plexus region are rare and granular cell tumors arising from the brachial plexus region is an extremely rare disease. We present a case of granular cell tumor arising from of the brachial plexus which appeared to be a usual presentation of nerve sheath tumor before the pathological confirmation. We report a granular cell tumor of the brachial plexus with literature review. Total resection is important for good clinical outcome and prognosis in the treatment of granular cell tumor.

Primary Brain Tumors in the Elderly Population

Elderly cancer patients are an important challenge in oncology, and clinical data from younger populations cannot be automatically considered applicable to unselected elderly patients with brain tumors, who tend to have more comorbidities and tolerate chemotherapy and radiotherapy less well than their younger counterparts. Most data available on elderly cancer patients are from retrospective studies that do not include age-specific enrollment criteria and are biased by intrinsic selection criteria governing enrollment. Most clinicians are unwilling to enroll elderly patients because of ageism and a fear of toxicity and poor outcome. Specifically designed trials based on genetic features and clinical factors are required to clearly establish the standard of care required for elderly patients with brain tumors, especially those with glioblastoma. Currently, surgery followed by radiotherapy is widely used for elderly glioblastoma patients, but temozolomide is the chemotherapeutic approach of choice for those with a relatively good clinical condition and prognosis. However, the schedule to follow and the best dosage have yet to be satisfactorily established.

Long term outcome in children affected by absence epilepsy with onset before the age of three years

ObjectiveThe goal of this study was to define the long-term outcome of absence epilepsy presenting before the age of 3years. MethodsWe retrospectively studied the medical records of 40 children from eight neuropediatric centers in Italy with respect to the personal and family histories of epilepsy or febrile seizures, time of follow-up, cognitive functions, treatment, and outcome. ResultsForty patients were enrolled in this study. They all fulfilled the criteria for absence epilepsy with 3-Hz spike–wave complexes on the EEG, normal neurological examination, and no other seizures types. Seizure onset occurred between 24.1 and 36.0months. There was a family history of epilepsy in 28%, and of febrile seizures in 13%. Thirty-three patients were treated with valproic acid (VPA), mostly used in monotherapy (26 patients) or in association with ethosuximide. At final follow-up, 33 patients were seizure free and 29 had normal EEGs. Thirty-four patients had a normal intelligence quotient (IQ), whereas 6 had a decreased IQ, mainly associated with poor control of seizures. ConclusionIn our series, absence seizures presenting before the age of 3 appeared to have quite a good long-term clinical prognosis; the neuropsychological outcome was comparable to that of childhood epilepsy presenting after 3years of age.

Transarterial injection of H101 in combination with chemoembolization overcomes recurrent hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) has become the standard treatment modality for unresectable hepatocellular carcinoma (HCC). Nonetheless, the clinical outcomes in patients with unresectable HCC are often unsatisfactory, especially in those with recurrent HCC. H101, an E1B gene deleted adenovirus, is known to have a significant antitumor activity. In addition, local injection of H101 can enhance the effect of antitumor therapies (chemotherapy and radiotherapy). Transarterial H101 gene injection in combination with TACE may help to control refractory and recurrent HCC. In this study, we report a 55-year-old patient with recurrent HCC which was treated with transarterial injection of H101 in combination with TACE, leading to a good clinical prognosis of the patient.

Intraarterial Thrombolysis and Stent Placement for Acute Basilar Artery Occlusion

To study retrospectively the prognostic factors for acute basilar artery occlusion treated with intraarterial thrombolysis and stent placement. Within 3-48 hours of disease onset, 52 patients with basilar artery occlusion were treated with emergency intraarterial thrombolysis with recombinant tissue plasminogen activator (rtPA) or urokinase (UK) or intraarterial thrombolysis combined with stent placement. Sixteen patients simultaneously received stent placement for the partial recanalization of basilar artery occlusion after intraarterial thrombolysis. The National Institutes of Health Stroke Scale (NIHSS) scores and the modified Rankin Scale (mRS) scores of the patients were estimated. A favorable clinical outcome occurred in 22 patients (42.3%), and 20 patients (38.5%) died. The survival rate was 61.5% (32 patients). Successful recanalization of basilar artery occlusion was achieved in 24 patients (46.2%), and partial recanalization was achieved in 16 patients (30.7%). The rate of recanalization was 76.9%. NIHSS scores less than 14, treatment time window less than 24 hours, and a good recanalization were markedly correlated with good clinical prognosis. NIHSS scores less than 14 and treatment time window less than 24 hours were significantly correlated with recanalization. NIHSS scores less than 14 and good recanalization could act as independent predictors for clinical prognosis. NIHSS scores less than 14 on admission and successful recanalization can predict favorable outcome for patients with basilar artery occlusion. This study shows that intraarterial thrombolysis and stent placement may be a useful treatment for acute basilar artery occlusion.

Normotensos com resposta pressórica exagerada ao exercício possuem tônus vagal cardíaco aumentado

FUNDAMENTO: Valores exagerados da pressão arterial sistólica (PAS) durante um teste cardiopulmonar de exercício máximo (TCPE) são classicamente considerados como inapropriados e associados a um maior risco para desenvolvimento de doenças cardiovasculares. Sabe-se que o sistema nervoso autônomo modula a PA no exercício. Contudo, não está claramente estabelecido o comportamento do tônus vagal cardíaco (TVC) em indivíduos saudáveis com uma resposta pressórica exagerada no TCPE. OBJETIVO: Analisar o comportamento do TVC em homens adultos saudáveis que apresentam uma resposta pressórica exagerada no TCPE. MÉTODOS: De 2.505 casos avaliados entre 2002-2009, foram identificados criteriosamente 154 casos de homens, entre 20-50 anos de idade, saudáveis e normotensos. A avaliação incluía exame clínico, medidas antropométricas, testes de exercício de 4 segundos (tônus vagal cardíaco) e TCPE realizado em cicloergômetro, com medidas de pressão arterial a cada minuto pelo método auscultatório. Baseado no valor máximo de PAS obtido no TCPE, a amostra foi dividida em tercis, comparando-se o TVC, a carga máxima e o VO2 máximo. RESULTADOS: Os valores de TVC diferiram entre os indivíduos que se apresentavam nos tercis inferior e superior para a resposta da PAS ao TCPE, respectivamente, 1,57 ± 0,03 e 1,65 ± 0,04 (média ± erro padrão da média) (p = 0,014). Os dois tercis também diferiam quanto ao VO2 máximo (40,7 ± 1,3 vs 46,4 ± 1,3 ml/kg-1.min-1; p = 0,013) e a carga máxima (206 ± 6,3 vs 275 ± 8,7 watts; p < 0,001). CONCLUSÃO: Uma resposta pressórica exagerada durante o TCPE em homens adultos saudáveis é acompanhada de indicadores de bom prognóstico clínico, incluindo níveis mais altos de condição aeróbica e de tônus vagal cardíaco.

Clinical outcome and imaging follow-up in acute stroke patients with normal perfusion CT and normal CT angiography

Acute stroke multimodal CT imaging (MMCT: non-enhanced CT, CT angiography, and CT perfusion (CTP)) may show normal results despite persistent clinical stroke. We prospectively evaluated the sensitivity/specificity of MMCT infarct detection and the clinical outcome in patients with normal MMCT findings. From April 2007 to April 2008, all patients with acute hemispheric stroke within 6 h of symptom onset who underwent complete MMCT and MRI follow-up imaging were included. MMCT analysis included occlusion type, early infarct hypodensities (EIH), mean transit time (MTT), and cerebral blood volume (CBV) maps according to Alberta Stroke Program Early CT Score (ASPECTS). Clinical assessment included symptom onset to CT scan (≤3 h/>3 h), the National Institute of Health Stroke Scale score (admission/discharge), and the modified Rankin scale (mRS) 90 days after stroke onset. One hundred seven were included (mean age, 68.4 years; ≤3 h, n = 84; >3 h, n = 23; intravenous thrombolysis (IVT), n = 51; ≤3 h, n = 40; >3 h, n = 11). In patients with normal MMCT on admission (n = 54), follow-up MRT detected brain infarctions in 23 patients (lacunar strokes, n = 16; infratentorial strokes, n = 4; territorial infarction, n = 3). Sensitivity/specificity/positive predictive value/negative predictive value of any infarct detection was 69.5%/99.8%/99.9%/57.2% and of a any territorial infarct detection was 93.9%/99.9%/99.9%/93.6%, respectively. In univariate regression analysis (time to CT scan, ≤3 h/>3 h; IVT: yes/no; ASPECTS EIH/CBV/MTT, 10/<10), only the evidence of normal CTP (ASPECTS MTT = 10) had a statistically significant impact (p = 0.02) on a good outcome (mRS 0.1). MMCT sensitivity in acute lacunar or infratentorial stroke was poor. But, we found a high specifity and a fairly good sensitivity in territorial infarct detection. In acute stroke patients with normal MMCT findings on admission, a good clinical prognosis can be expected.

Capsular retraction: an uncommon imaging finding in hepatic inflammatory pseudotumour

Capsular retraction is an infrequent but characteristic feature of malignant liver lesions such as hepatic metastases and intrahepatic cholangiocarcinoma. Rarely, this finding may be observed in association with benign lesions, such as atypical haemangiomas. Capsular retraction has not previously been reported in association with hepatic inflammatory pseudotumour (IPT). Hepatic IPT is an uncommon benign hepatic lesion with a good clinical prognosis. In this report, we discuss the case of a 48-year-old woman with capsular retraction secondary to multifocal hepatic inflammatory IPTs.