Iatrogenic Manipulation Research Articles

Extensive Spinal Epidural Hematoma as the Cause of Postpartum Headache and Neck Pain After Epidural Anesthesia: a Case-Based Report

Spinal epidural hematomas (SEH) are a rare hemorrhagic event occurring after trauma, epidural anesthesia, or operative inventions. However, in 40–50% of cases, they occur spontaneously. Spontaneous spinal epidural hematomas (SSEH) are rare in occurrence with an estimated incidence of 1 case per million annually. Pregnancy is an independent risk factor. Sudden neck or back pain, often in combination with a rapid onset of neurological symptoms, is the most common presentation of SEH (1). A 36-year-old Caucasian female with rheumatoid arthritis (RA) presented to the emergency department approximately 48 h after an uncomplicated vaginal delivery. She sought medical attention due to constant headaches and neck pain that started during active labor. An MRI of the spine revealed an extensive SEH spreading from C1 to L5. The patient was without neurological symptoms or deficits and was successfully treated conservatively without any sequelae. Even though the definitive cause of this case of SEH will remain unknown, several possible synergistic mechanisms have been identified. These include female gender, full-term pregnancy, physical activity with increased intraabdominal pressure (i.e., Valsalva maneuver), systemic administration of platelet aggregation inhibitor (PAI), and iatrogenic manipulation such as spinal epidural anesthesia. Even though autoimmune and inflammatory disorders have been described in the literature to be rare sources of hemorrhage in the spinal canal, it is unclear whether the patient’s RA should be regarded as an individual risk factor.Key FactsSpinal epidural hematomas are a rare hemorrhagic event characterized by an accumulation of blood between the vertebrae and the dura of the spinal canal, and can be a clinical challenge to diagnose due to the insidious presentation, with symptoms ranging from asymptomatic to non-specific head or neck pain, or neurological deficits.The etiology of spontaneous spinal epidural hematomas remains largely unknown, although there are many predisposing factors, including vascular malformation, anticoagulation therapy, trauma, iatrogenic manipulations, and hypertension.The differential diagnosis to spinal epidural hematomas are several, e.g., meningitis, migraine, subarachnoid or intracranial hemorrhage, pituitary apoplexy, venous sinus thrombosis, and thrombosis, and radiological examination is key to diagnose and map the distribution of the hemorrhage.

Lumbar Giant Disk Herniations Treated With a Unilateral Approach for Bilateral Decompression.

Disk herniations that obstruct the spinal canal by more than 50% are named "giant disk herniations" (GDHs). GDHs are challenging to treat from a surgical perspective because of their size and the risk of iatrogenic manipulation during resection resulting in additional neurological compromise. As a result, the appropriateness of minimally invasive tubular approaches for the treatment of lumbar GDHs remains controversial. To report our experience in treating lumbar GDHs using tubular minimally invasive surgery. A total number of 228 disk herniations were evaluated for the criteria of GDH. In addition, the presence of neurological deficits such as cauda equina syndrome, pain as measured by a visual analog scale, operating time, complications, estimated intraoperative blood loss, and number of surgical revisions were assessed. The standard tubular diskectomy technique was modified to include unilateral laminectomy for bilateral decompression before the diskectomy to create a sufficient working space for removal of the disk fragments. Twenty-three (10%) patients met the criteria for GDH. Clinically significant motor weakness was present in 21 patients (91.3%) before surgery, and 3 patients (13%) presented with cauda equina syndrome. The average mean visual analog scale (±SD) for the preoperative pain score was 8.3 and decreased to 2.4 at follow-up after surgery. All cases of cauda equina syndrome resolved postoperatively. Unilateral tubular minimally invasive surgery diskectomy seems to be a safe and effective treatment alternative for lumbar GDHs, combined with the "over-the-top" decompression, which provides bilateral decompression and working space.

A new approach to the treatment of nontuberculous mycobacterium skin infections caused by iatrogenic manipulation: Photodynamic therapy combined with antibiotics: A pilot study

BackgroundRecently, the number of nontuberculous mycobacterium (NTM) infections caused by iatrogenic procedures, especially rapid NTM skin infections, has been increasing. Due to the nonspecific clinical manifestations and nonstandard treatment guidelines, these infections are often misdiagnosed and challenging to treat. MethodsIn this study, eight patients had NTM skin infections caused by iatrogenic procedures, and were diagnosed by bacterial culture and flight mass spectrometry tests. They were treated with 5-aminolevulinic acid-photodynamic therapy (ALA-PDT) combined with antibiotic therapy. ResultsAll eight patients enrolled in the study were cured with 100% efficacy after receiving combination therapy with ALA-PDT and antibiotics for 3–6 months. All patients experienced redness and pain during treatment but no other discomfort and were satisfified with the results of their treatments. ConclusionLocal ALA-PDT combined with antibiotics is a safe and effective method of treating NTM skin infections.

Adjacent segment degeneration following spinal fusion of vertebral fractures in paraplegic patients

The effects of adjacent segment degeneration (ASD) after spinal fusion of vertebral fractures have previously not been demonstrated in patients with trauma-related paraplegia. The aim of this study was to evaluate the role of ASD in patients with paraplegia caused by vertebral fractures and to observe whether there is adifference between unilateral or combined spinal fusion in long-term results regarding the degeneration of cranial or caudal adjacent spinal segments. Atotal of 111 paraplegic patients with an average age of 45years who underwent spinal fusion of vertebral fractures were observed in aretrospective longitudinal study with afollow-up period of 4years. Conventional X‑ray images and magnetic resonance imaging (MRI) scans were used to assess the ASD in the adjacent free vertebral segments cranial and caudal to the spinal fusion using the following elements: ventral spondylophytes, intervertebral space, intervertebral disc signal in MRI, posterior spondylophytes, facet joint arthrosis, bone bridging and ossification of the anterior longitudinal ligament. Additionally, the classification by the American Spinal Injury Association (ASIA) impairment scale and spinal cord independence measure version3 score were surveyed. The 4‑year incidence of radiographically detectable ASD was 3-12 % in this study. The majority of ASDs were observed in the cranial segments adjacent to the interbody fusion. The dorsoventral spinal fusion showed the least effects on the adjacent segments. In conclusion, aconcept of prompt surgery using short dorsoventral segment fusion carried out by an interdisciplinary paralysis center is recommended. The role of natural degeneration processes and whether they are influenced by iatrogenic manipulation through the vertebral stabilization is unclear. For this reason it is important to further investigate strategies for ASD reduction in the future to ensure the best possible treatment success including the lowest degree of additional impairments for this special patient group.

ESOPHAGOPERICARDIAL FISTULA: A CHALLENGING CASE OF SYNCOPE

Esophagopericardial fistula (EPF) is a rare condition with extremely high in-hospital mortality. Most presentations are in the setting of iatrogenic manipulation during endoscopies, atrial fibrillation catheter ablation, foreign body perforations or locally invasive malignancies. Syncope is an

Course of pelvic lift during total hip arthroplasty.

The position of the cup makes a major contribution to the success of total hip arthroplasty (THA). In conventional implantation of the prosthesis without navigation, the surgeon relies on the spatial position of the pelvis. However, iatrogenic manipulation of the pelvis during different surgical steps constantly changes the position of the pelvis during the operation. The position of the pelvis is substantial for the correct placement of the cup. The objective of this study was to investigate and visualize the course of this pelvic lift and correlate it to certain surgical steps. Pelvic lift was measured in 67 patients during implantation of a THA. This was done by measuring acceleration using the SensorLog app on a smartphone. It was placed on the patient's contralateral anterior superior iliac spine and recorded the movement of the pelvis throughout the whole surgical procedure. The position of the pelvis was allocated to each of eight relevant surgical steps during the operation. These surgical steps were normed over the time axis and transferred to a diagram. We found an average pelvic lift displacement of up to 14.9° upon placement in the figure-of-four position. This lift is particularly critical when exposing the acetabulum, as the true cup position can be unconsciously influenced. Average values of between 5.6° and 6.9° were found here. When implanting a THA in supine position, the pelvis is not fixed on the operating table. Rather, the side to be operated on is lifted to a greater or lesser degree, depending on the surgical step to be performed. The retractor traction immediately before cup implantation should be minimized. Nevertheless, it should be taken into account that anteversion of the cup implant in relation to the table plane is systematically higher than in relation to the pelvic entry plane.

Abstract PR047

Background & Objectives: Intraoperative hemodynamic instability (IHI) is a well-known complication of carotid endarterectomy (CEA). It is a common perioperative finding depends on the timing and type of surgery, iatrogenic manipulation of the baroreceptors and is influenced by the anesthetic management. Carotid artery stenting (CAS) is an alternative to CEA and may be associated with hypotension and bradycardia due to predominantly parasympathetic activity during placement of the stent. This study aims to compare the incidence of IHI between CAS and CEA. Materials & Methods: The medical records of 80 patients underwent CAS and 101 patients underwent CEA under cervical plexus block during a 10 month period at our institution, were retrospectively reviewed. The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) was used to classify CAS and CEA patients into 3 groups: low (I), medium (II) and high risk group (III), separately. IHI was defined as an increase/decrease in systolic and diastolic blood pressure or heart rate for ≥20% from basal value, for 2 minutes. In accordance to VSG-CRI, the incidence of IHI in low, medium and high risk group was compared among patients underwent CAS and CEA. Results: In line with VSG-CRI, patients underwent CEA were divided into three groups: group I consisted of 59 patients (56.2%), group II of 25 (23.8%) and group III of 21 (20%). Also, patients underwent CAS were divided into three groups, group I: 40 patients (50 %), group II: 30 (37.5%) and group III: 10 (12.5%). In low risk group, the incidence of bradycardia was significantly higher in the patients underwent CAS compared to the CEA patients (p=0.01). There was significantly higher incidence of IHI in the patients underwent CEA compared to the CAS patients in medium risk group (II) (p=0.03). In this group, diastolic blood pressure values immediately after cervical block application, were significantly higher in the patients underwent CEA compared to the CAS patients (p=0.009). Conclusion: According to VSG-CRI, in our study IHI and bradycardia were occured more often after CEA in medium and low risk group, respectively. This findings could suggest that the alteration of baroreceptor function is related more to the underlying carotid atherosclerotic disease that affects baroreceptor, than to the stenting procedure.

External pancreatic fistula treated by endoscopic ultrasound-guided drainage with a novel lumen-apposing metal stent mounted on a cautery-tipped delivery system

One of the most common causes of external pancreatic fistula is the iatrogenic manipulation of a complex pancreatic fluid collection concomitantly associated with a disconnected pancreatic duct [1,2]. This situation can lead to the development of a high output (up to 400mL/d) external pancreatic fistula that is difficult to manage and sometimes requires surgery [3]. In 2012, a 40-year-old woman underwent laparoscopic cholecystectomy with a hepaticojejunal Roux-en-Y anastomosis for a congenital Todani’s type IV common bile duct cyst. Postoperative pancreatitis resulted in the development of a complex pancreatic fluid collection in the pancreatic head, which was drained percutaneously. Subsequently, an external pancreatic fistula formedwith an output of 200mL/d. In 2014, the patient was referred to us for further evaluation. Endoscopic retrograde cholangiopancreatography (ERCP) showed a normal main pancreatic duct that lacked a clear communication with the collection (● Fig.1). The injection of contrast through the percutaneous catheter showed the presence of a 4-cm fluid collection (● Fig.2). Endoscopic ultrasound (EUS)-guided drainage with the placement of plastic stentswas planned. At EUS, the collection was accessed from the duodenal bulbwith a 19-gauge needle, after which a 0.035-inch guidewire was placed. The needle was then exchanged for an 8.5-Fr cystotome, but the collection no longer appeared adjacent to the duodenal wall, probably because it had been pushed away by the guidewire, and major vesselswere interposed (● Video1). Based on our previous experience, we decided to replace the cystotome with a novel cautery-tipped stent delivery system that allows the single-step EUS-guided placement of a lumen-apposing fully covered metal stent (Hot AXIOS System; Xlumena, Mountain View, California, USA) [4]. The lesionwas directly punctured and entered with the system, and an 8×8-mm lumenapposing fully covered metal stent was delivered under complete EUS guidance (● Fig.3,● Video 1). The output significantly dropped the following day, allowing removal of the external catheter 2 days after the procedure. The patient was discharged and remains well 3 months later, without any symptoms.

Frontal branch of the superficial temporal artery: anatomical study and clinical implications regarding injectable treatments.

The frontal branch of the superficial temporal artery (Fbr) is vulnerable to damage triggered by iatrogenic manipulation by both dermal filler and BoNT-A injection. The purpose of this study was to elucidate the branching pattern of Fbr and to determine its location and course on the lateral border of the frontal belly of the occipitofrontalis muscle (FB). Sixty-four hemifaces from 38 Korean cadavers (26 males and 12 females; mean age 71.9 years) were dissected, and the location and course of the Fbr were identified with reference to the lateral border of the FB. The ramification of the frontal branch from the superficial temporal artery (STA) occurred 36.9 ± 14.24 mm (mean ± SD) superior and 17.2 ± 8.2 mm anterior to the posterior-most point of the tragus [i.e., tragion (Tg)]. The Fbr was observed as a single branch in 96.9% of cases and reached its destination at a single point in 71.9%. It reached the Fbr 14.8 ± 7.7 mm superior to the uppermost point of the eyebrow and 15.8 ± 9.1 mm from the lateral epicanthus. The Fbr bifurcated into superior and inferior branches before reaching the FB in 25.0% of cases. In two cases (3%), the Fbr ramified from the STA within 1 mm of the Tg. The diameter of the superior division of Fbr was 1.6 ± 0.5 mm at the lateral border of the FB and 1.8 ± 0.6 mm at other locations. Physicians performing injection treatments such as botulinum toxin type A and dermal filler injection to the posterior frontal area should be aware of the various distributions of the Fbr.

Molecular Characterization of ILT3-Triggered Pathways in Suppression of T Cell Immunity

Introduction: ILT3 is an inhibitory receptor expressed on antigen presenting cells which inhibits T cell activation and effector function, while mediating the differentiation of CD8 T suppressor cells (Ts) and induction of anergy. We have demonstrated that recombinant ILT3Fc induces tolerance to pancreatic islet allografts in a humanized mouse model, however the molecular mechanisms of CD8 Ts generation and function remain poorly understood. Methods: We have analyzed the transcriptional profile of CD8 T cells primed in the presence or absence of ILT3Fc and identified over 2500 genes in 23 different gene ontology categories significantly up- or down-regulated by ILT3Fc treatment. To further analyze the relevance of individual molecular changes, we used siRNA technology to determine their impact on the acquisition of Ts function. Results: An interesting aspect of this study was the sheer magnitude of the changes induced by a single molecule, ILT3Fc. We demonstrated that this is accomplished through the transcriptional suppression of several microRNA species which in turn regulate hundreds of target genes. ILT3Fc-induced Ts displayed a significant up regulation of zinc finger proteins, most of which act as transcriptional repressors. Among these BCL6 was shown to play a critical role in the differentiation of ILT3Fc-induced Ts. A striking feature of ILT3-treated T cells is their inability to secrete pro-inflammatory cytokines in response to stimuli. The up regulation of BCL6, a known transcriptional repressor of IFNg, IL2 and IL5, is partly responsible for this phenotype, but alone it cannot explain the wide ranging cytokine and chemokine suppression observed in ILT3Fc treated cells. Other factors, such as SOCS1 and the suppression of the TCR signaling pathways, are involved. The down regulation of several cell cycle proteins and the up regulation of cyclin inhibitors underlie the ability of ILT3Fc to induce cell cycle arrest and T cell anergy. Several members of the WNT and transforming growth factor-beta pathways were consistently up regulated, although their exact involvement in the differentiation is CD8 Ts has not been yet elucidated. Conclusion: ILT3Fc treatment during T cell priming results in a vast number of transcriptional changes influencing the ultimate effector fate of these T cells. This data furthers our understanding of T suppressor cell induction and reveals several pathways which may be amenable to iatrogenic manipulation to induce immunological tolerance in transplantation.

Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video)

An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality. To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS. A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs. Tertiary-care pancreatic referral center. Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN. Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods. EPF resolution and morbidity. Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths. Small, selected group of patients without a comparative group. The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs.

Esophageal Toxicity From High-Dose, Single-Fraction Paraspinal Stereotactic Radiosurgery

To report the esophageal toxicity from single-fraction paraspinal stereotactic radiosurgery (SRS) and identify dosimetric and clinical risk factors for toxicity. A total of 204 spinal metastases abutting the esophagus (182 patients) were treated with high-dose single-fraction SRS during 2003-2010. Toxicity was scored using the National Cancer Institute Common Toxicity Criteria for Adverse Events, version 4.0. Dose-volume histograms were combined to generate a comprehensive atlas of complication incidence that identifies risk factors for toxicity. Correlation of dose-volume factors with esophageal toxicity was assessed using Fisher's exact test and logistic regression. Clinical factors were correlated with toxicity. The median dose to the planning treatment volume was 24 Gy. Median follow-up was 12 months (range, 3-81). There were 31 (15%) acute and 24 (12%) late esophageal toxicities. The rate of grade ≥3 acute or late toxicity was 6.8% (14 patients). Fisher's exact test resulted in significant median splits for grade ≥3 toxicity at V12 = 3.78 cm(3) (relative risk [RR] 3.7, P=.05), V15 = 1.87 cm(3) (RR 13, P=.0013), V20 = 0.11 cm(3) (RR 6, P=0.01), and V22 = 0.0 cm(3) (RR 13, P=.0013). The median split for D2.5 cm(3) (14.02 Gy) was also a significant predictor of toxicity (RR 6; P=.01). A highly significant logistic regression model was generated on the basis of D2.5 cm(3). One hundred percent (n = 7) of grade ≥4 toxicities were associated with radiation recall reactions after doxorubicin or gemcitabine chemotherapy or iatrogenic manipulation of the irradiated esophagus. High-dose, single-fraction paraspinal SRS has a low rate of grade ≥3 esophageal toxicity. Severe esophageal toxicity is minimized with careful attention to esophageal doses during treatment planning. Iatrogenic manipulation of the irradiated esophagus and systemic agents classically associated with radiation recall reactions are associated with development of grade ≥4 toxicity.

Clinical practice in radioembolization of hepatic malignancies: A survey among interventional centers in Europe

A survey was conducted to give an overview about the practice of radioembolization in malignant liver tumors by European centers. A questionnaire of 23 questions about the interventional center, preinterventional patient evaluation, the radioembolization procedure and aftercare were sent to 45 European centers. The response rate was 62.2% (28/45). The centers performed 1000 (median = 26) radioembolizations in 2009 and 1292 (median = 40) in 2010. Most centers perform preinterventional evaluation and radioembolization on an inpatient basis. An arterioportal shunt not amendable to preinterventional embolization is considered a contraindication. During preinterventional angiography, the gastroduodenal artery is embolized by 71%, the right gastric artery by 59%, and the cystic artery by 41%. In case of bilobar disease, yttrium-90 microspheres are infused into the common hepatic artery (14%) or separately into left and right hepatic artery (86%). 33% prefer a time interval between right and left liver lobe radioembolization to prevent radiation induced liver disease. 43% of the respondents do not prescribe prophylactic medication after radioembolization. In case of iatrogenic manipulation to the biliary duct system most centers perform radioembolization with prophylactic antibiotics. Despite standardization of the procedure, there are some differences in how radioembolization of liver tumors is performed in Europe.

A Rare Case of Upper Ureter Rupture: Ureteral Perforation Caused by Urinary Retention

Perforation of the ureter is a rare condition that causes a series of problems including retroperitoneal urinoma, urosepsis, abscess formation, infection, and subsequent renal impairment. There are causative factors that induce ureteric rupture, including malignancy, urinary calculi, idiopathic retroperitoneal fibrosis, recent iatrogenic manipulation, external trauma, degenerative kidney conditions, urography with external compression, and spontaneous causes. We report a rare case of ureteric rupture caused by urinary retention. The patient was treated with temporary percutaneous drainage and antibiotics. The present case illustrates that urinary retention can induce not only bladder rupture, but also ureteric rupture. It is thus of paramount importance to effectively manage patients with voiding problems.

Chronic Maxillary Sinusitis Associated with an Unusual Foreign Body: A Case Report

Foreign bodies in maxillary sinuses are unusual clinical conditions, and they can cause chronic sinusitis by mucosal irritation. Most cases of foreign bodies in maxillary sinus are related to iatrogenic dental manipulation and only a few cases with non-dental origin are reported. Oroantral fistulas secondary to dental procedures are the most common way of insertion. Treatment is surgical removal of the foreign body either endoscopically or with a combined approach, with Caldwell-Luc procedure if endoscopic approach is inadequate for visualisation. In this case, we present a 24-year-old male patient with unilateral chronic maxillary sinusitis due to a wooden toothpick in left maxillary sinus. The patient had a history of upper second premolar tooth extraction. CT scan revealed sinus opacification with presence of a foreign body in left maxillary sinus extending from the floor of the sinus to the orbital base. The foreign body, a wooden toothpick, was removed with Caldwell-Luc procedure since it was impossible to remove the toothpick endoscopically. There was no obvious oroantral fistula in the time of surgery, but the position of the toothpick made us to think that it was inserted through a previously healed fistula, willingly or accidentally.

Antikoagulation in der Dermatologie

The coagulation system protects the body from uncontrolled blood loss by means of highly regulated processes. In case of an injury the coagulation system instantly switches from controlled blood flow to acute coagulation and thrombus formation with the goal of stopping the blood loss. Minor changes in this well-maintained equilibrium of coagulation and blood flow tip the balance towards uncontrolled blood loss or even fatal thromboembolic events. Iatrogenic manipulation of this highly regulated system is possible with a variety of therapeutic agents. We review the basics of coagulation physiology and then discuss dermatologically relevant aspects of thrombosis prevention, as well as the use of anticoagulants to treat dermatologic diseases.

Right ventricular rupture due to recurrent mediastinal infection with a closed chest

Right ventricular (RV) rupture in cases of mediastinitis following cardiac surgery is a rare and dangerous complication. Bleeding from the right ventricle occurs mainly after sternal reopening, due to either iatrogenic manipulation (wire removal, lesions due to wiring maneuvers) or mechanical shearing forces, producing direct injury. We present a case of RV wall perforation due to infection in a recurrent postoperative mediastinitis with a closed chest. The current literature on treatment of postoperative mediastinitis is also reviewed.

Capecitabine-related intracranial hypotension syndrome mimicking dural metastasis in a breast cancer patient: Case report and review of the literature

Spontaneous intracranial hypotension (SICH) is an entity, which is secondary to iatrogenic manipulation and breaching of dura. Postural headache in patients should be suspected, cranial magnetic resonance imaging (MRI) is essential for precise diagnosis. Hallmark of MRI is regular shape of pachymeningeal gadolinium enhancement and subdural effusion. It may mimic central nervous system (CNS) metastasis. Prevention of such cases from receiving cranial radiotherapy by misinterpretation of the gadolinium enhancement as CNS metastasis is an important issue. Capecitabine is an antineoplastic agent, of which metabolites can cross blood-brain barrier in CNS via epithelial tissue. It may cause decrease in CSF production. SICH might be the clinical reflection of this decrease in CSF production. Review of the English literature revealed limited data because of the very little experience with oncologic patients suffering from intracranial hypotension. We report a case of spontaneous intracranial hypotension during capecitabine treatment. Patient was completely well following drug discontinuation and supportive treatment.

Cutaneous Cholesterol Embolization

Cutaneous cholesterol embolization syndrome occurs as a result of cholesterol embolization from atherosclerotic plaques lining the walls of arteries and arterioles. It can occur sporadically but is more commonly associated with iatrogenic manipulation via invasive vascular procedures or therapies (anticoagulation or thrombolytics) The three most common organ systems afflicted by cholesterol emboli include the kidneys, gastrointestinal system, and skin. We present two patients with cutaneous cholesterol embolization A 74-year-old with no prior disease or trauma was referred to the hospital with the acute chest pain. After 24-48 he developed livedo reticularis, followed by necrotic areas like bilaterally on hips and in the lumbar region. The second patient, 69-year-old man with a history of hyperglycemia, hyperlipidaemia, and hypertension was referred with weight loss, bilateral livedo reticularis, severe pain of lower extremities and impaired renal function. The toes first became cyanotic and than skin necrosis developed. Skin biopsy revealed presence of cholesterol clefts in the lumina of small arteries and arterioles. In both patients the necrotic skin and subcutaneous tissue had been debrided. Daily dressing was applied and tissue defects underwent secondary healing. The diagnosis of cholesterol embolization relies on clinical and histologic examination. Both, diagnosis and treatment needs a multidisciplinary approach, especially in cases of multi-organ involvement.

The inflammatory component of Kaposi sarcoma

Kaposi sarcoma (KS) is intimately linked to several aspects of the host immune system. KS development is linked to immunodeficiency in several clinical–epidemiological settings. The development of KS at local inflammatory sites has also been documented. Inflammatory cells are almost always present within KS lesions. Depending upon the inflammatory milieu, KS lesions may progress or regress. Not surprisingly, iatrogenic manipulation of host immunity with drugs may provoke KS growth and/or flare. Given the close association between KS and the immune system, the etiologic agent Kaposi Sarcoma Herpesvirus has developed a variety of mechanisms to evade the host immune system, all of which have cleverly evolved to promote oncogenesis and viral persistence.