Infraclavicular Region Research Articles

Accuracy and Feasibility of Real-time Continuous Glucose Monitoring in Critically Ill Patients After Abdominal Surgery and Solid Organ Transplantation.

Glycemia management in critical care is posing a challenge in frequent measuring and adequate insulin dose adjustment. In recent years, continuous glucose measurement has gained accuracy and reliability in outpatient and inpatient settings. The aim of this study was to assess the feasibility and accuracy of real-time continuous glucose monitoring (CGM) in ICU patients after major abdominal surgery. We included patients undergoing pancreatic surgery and solid organ transplantation (liver, pancreas, islets of Langerhans, kidney) requiring an ICU stay after surgery. We used a Dexcom G6 sensor, placed in the infraclavicular region, for real-time CGM. Arterial blood glucose measured by the amperometric principle (ABL 800; Radiometer, Copenhagen, Denmark) served as a reference value and for calibration. Blood glucose was also routinely monitored by a StatStrip bedside glucose meter. Sensor accuracy was assessed by mean absolute relative difference (MARD), bias, modified Bland-Altman plot, and surveillance error grid for paired samples of glucose values from CGM and acid-base analyzer (ABL). We analyzed data from 61 patients and obtained 1,546 paired glucose values from CGM and ABL. Active sensor use was 95.1%. MARD was 9.4%, relative bias was 1.4%, and 92.8% of values fell in zone A, 6.1% fell in zone B, and 1.2% fell in zone C of the surveillance error grid. Median time in range was 78%, with minimum (<1%) time spent in hypoglycemia. StatStrip glucose meter MARD compared with ABL was 5.8%. Our study shows clinically applicable accuracy and reliability of Dexcom G6 CGM in postoperative ICU patients and a feasible alternative sensor placement site.

A Distant Fasciocutaneous Chest Wall Skin Flap for Necrotic Finger Post Reimplantation: A Case Report

The hand is often compromised by scars or potentially necrotic wounds. Complete loss of index finger will result in impairment of 20% of hand and 11% of whole-person. One of the most influential factors in consideration of tissue loss are defect size, site, depth, and orientation. In our case study, a 16-year-old male presented with sensations of tingling and pain in his finger subsequent to an accidental laceration. Examination revealed a necrotic wound located on the distal phalanx of the index finger, accompanied by mild atrophy and discoloration. Subsequently, the patient underwent graft harvesting from the right chest wall flap, followed by primary closure of the donor site on the right chest wall. Upon a three-month follow-up, the patient expressed satisfaction, demonstrating proficient daily activities despite the injury being localized to the left hand. Utilizing a chest wall flap is less prevalent than employing regional or free flaps. Anterior chest wall flaps are specifically crafted on the anterolateral chest wall or within the infraclavicular region. The choice of a chest wall flap was determined to offer a less cumbersome graft and aligns with the patient's preference. The main goal of soft tissue reconstruction is to restore functionality, encompassing tasks such as exploration, sensation, and manipulation of objects, while simultaneously preserving the original length. Nonetheless, achieving this goal remains a complex challenge. Keywords: Necrotic finger, Reimplantation, Chest Wall Skin Flap, Soft Tissue Reconstruction

An extended brachial plexus blockade with an original method of catheter fixation: clinical case

BACKGROUND: For extended blockade of the brachial plexus from the supraclavicular access, the catheter is fixed in the supraclavicular region. Owing to the anatomical features of the supraclavicular fossa and the short inner part of the catheter, this fixation method cannot be fully considered reliable and convenient both for the personnel operating the catheter and the patient. The most convenient place for fixing the catheter is the infraclavicular region because of its flat surface. If a catheter is installed to the brachial plexus from the supraclavicular access and the catheter is passed under the skin in the infraclavicular region, then the catheter exit site on the skin will be located further from the surgical intervention area and the inner part of the catheter will be larger.&#x0D; CLINICAL CASE DESCRIPTION: This study describes a clinical case of blockade of the brachial plexus by interscalene access with catheterization for prolonged analgesia via supraclavicular access and fixation of the catheter under the skin in the subclavian region in an older patient with polymorbidity during surgical treatment of a closed fracture of the middle third of the humerus. In anesthetic provision, when inducing brachial plexus blockade via a supraclavicular approach, the catheter was fixed in the subcutaneous tunnel of the infraclavicular region for prolonged blockade of the brachial plexus.&#x0D; CONCLUSION: This fixation method prevented internal and external dislocation of the catheter, which contributed to high-quality and long-term postoperative analgesia, early patient activity, and absence of infectious complications and created comfortable conditions for the handling of the catheter for both the medical staff and the patient.

A Randomized Controlled Trial to Compare the Efficacy of Single versus Triple Injection Technique for Ultrasound-Guided Infraclavicular Block in Upper Limb Surgeries.

The ultrasound-guided infraclavicular brachial plexus block by triple-point injection method was aimed at blocking the three individual cords in the infraclavicular region.Recently, a single-point injection method which does not require visualization of cords to produce nerve block has been introduced. This study compared the block onset time, performance time, patient's satisfaction, and complications between the ultrasound guided triple-point injection and single-point injection methods. This randomized controlled trial was conducted in a tertiary care hospital. Sixty patients were divided into two groups - Group S: 30 patients received single-point injection method of infraclavicular block. Group T: 30 patients received triple-point injection method of infraclavicular block. Drugs used were 0.5% ropivacaine with 8 mg dexamethasone. The sensory onset time was significantly longer in Group S (11.13 ±1.83 min) than Group T (6.20 ±1.19min). No statistically significant difference was found between the two groups regarding mean motor onset time. The composite sensorimotor onset time was similar between the groups. The mean time to perform the block was significantly lesser in Group S (1.35 ±0.38 min) when compared to group T (3.44 ±0.61min). The patient satisfaction score, conversion to general anesthesia and complications were not significant among the two groups. We concluded that single-point injection method had a shorter performance time and similar total onset time with less procedural complications compared with triple point injection method.

“Bulging fissure sign” on chest radiograph: Strong predictor of central airway malignancy

A bulging fissure sign in a chest radiograph is usually associated with right upper lobe lung collapse with horizontal fissural effusion or collection. Etiology and pathophysiology traced to infective and noninfective causes. Commonly bulging fissure sign is described with lung malignancy in old age. Infective etiologies are infective types in children and adults with comorbid conditions. In this case report, we have reported a 54-year-old male presented with cough and hemoptysis with progressive worsening of shortness of breath. Clinically tubular breath sounds in the right infraclavicular region with egophony were heard. Chest X-ray documented right lung consolidation or mass lesion with bulging fissures. Bronchoscopy was done after clinical stabilization and showed endobronchial polypoidal growth in the right mainstem bronchus causing near-complete occlusion of the bronchial lumen. Endobronchial needle aspiration cytology and forceps-guided (forcep biopsy) histopathology suggestive of “squamous cell” type of lung malignancy for bulging fissure sign in our case. A high index of suspicion is must to rule out underlying malignancy and bronchoscopy is “gold-standard” test in cases with bulging fissure sign to confirm a diagnosis.

23 IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) EXPLOSION AFTER GUNSHOT: WHEN DEVICE PROTECTS TWICE

Abstract A 70 years old man presented to the emergency department with “accidental” gunshot wound at left hemithorax and left shoulder/arm. Initial clinical assessment showed stable vital signs and implantable cardioverter defibrillator(ICD) protruding outside from large wound in the infraclavicular region. The ICD, previously implanted for secondary prevention of ventricular tachycardia, appeared burned and the battery was exploded. Urgent chest computed tomography scan was performed with evidence of left omeral displaced fracture, large hematoma without arterial injury and many shotgun pellets in left shoulder/arm. The ICD generator was disconnected from passive fixation leads and removed. Patient was stabilized and omeral fracture was fixed. Following leads extraction was successfully performed in hybrid operating room with cardiac surgery standby considering the difficulty of the procedure, the type of leads (double coil, passive fixation) and the risk of complications. The patient was discharged home in good clinical conditions after re-implantation of novel ICD in right infraclavicular region. Emerging technologies are promising in making lead extractions safer and more accessible for patients worldwide. This clinicl case report will provide the most up-to-date indications and procedural approaches for lead extractions and insight on the future trends in this field.

Atypical Facial Pain Treatment With Peripheral Nerve Field Stimulation Using a Micro-Implantable and External Battery Impulse Generator

Atypical facial pain (AFP) is continuous, deep, poorly localized, often initiated by facial trauma or surgery and can involve multiple trigeminal nerve branches. Poor response to medical treatment is often found and ablative invasive procedures has been classically discouraged due to fear of worsening AFP symptoms. Peripheral nerve field stimulation (PNFS) is an emerging treatment for AFP but the optimal stimulation parameters are still being investigated. Pulse generator placement for craniofacial PNFS is usually in the infraclavicular region which can cause discomfort and is cosmetically disadvantageous.

A Deep Learning-Based Method with Prior Information for Auto-Delineation of Clinical Target Volume in Postmastectomy Radiotherapy

<h3>Purpose/Objective(s)</h3> Accurately delineating clinical target volumes (CTV) is essential for radiotherapy but is time-consuming and prone to inter-observer variation. The CTV for postmastectomy radiotherapy contains several sub-regions with irregular shape and low contrast boundaries. This is challenging for automation of CTV contouring by traditional deep learning (DL) method. Thus, we designed a DL based method with prior medical information for automatic CTV delineation in postmastectomy radiotherapy. <h3>Materials/Methods</h3> A total of 61 computed tomography scans of patients received postmastectomy were collected and evaluated. CTV contains chest wall, supraclavicular region and infraclavicular region. The training/validation/test number is 35/10/16. All data are resampled, normalized in preprocessing. The proposed DL-based method includes three steps. First, the CTV are divided into four sub-regions along the vertical axis according to its morphological properties. Secondly, the location of each sub-region is determined with a 3D Unet-architecture localization network. In this step, some related organs, such as clavicle, trachea and coracoid process are used as location landmark. Thirdly, four channels are generated from located sub-regions as the input of the final segmentation network. The mean Dice similarity coefficient (DSC), 95% Hausdorff distance (95HD) and subjective evaluation were used to assess the performance of this method. <h3>Results</h3> Auto-segmentation contours demonstrated a high level of accuracy when compared with reference contours in the testing cohorts (DSC, 0.92; 95HD, 4.65mm). We compared the proposed method with conventional 2D Unet and 3D Unet models. According to Table 1, this method had a better performance for all metrics over the entire CTV. The average segmentation time for one patient's CT was less than 10 seconds using DL method. In addition, it had an improved performance at the superior, inferior slices and slices with discontinuity. The contouring accuracy of the DL-based method was comparable to that of senior radiation oncologists. The clinical experts' subjective assessments showed that more than 90% of the predicted contours were acceptable for clinical usage. <h3>Conclusion</h3> This is the first attempt that combines medical prior information and the morphological properties of CTV to DL method for postmastectomy radiotherapy. This method has a superior stable performance and improve interpretability of DL-based model.

Double-tunneled catheter method for continuous peripheral nerve block.

Dear Editor, Continuous peripheral nerve block provided by an infusion through a peripheral nerve catheter is an attractive option for both the patient and the anesthesiologist. One of the main problems is dislodgement of the catheter, which can occur in up to 10% of cases.[1] Methods used to prevent peripheral catheter displacement are dressings, tissue glue, suturing and tunneling. The benefit of a dressing probably decreases with time, as the dressing becomes less sticky with time, and is interfered with by sweat or by ooze from the catheter site. Additionally, the site of catheter, presence of hairy skin and type of dressing have a large impact on occurrence of catheter displacement. Tunneling has been described as a method of reducing catheter displacement and infection rates, and seems to have a high rate of success.[2,3] Byrne et al.[4] compared the force requirement for extraction for peripheral nerve catheters under three different situations, tunneled, tunneled and double-tunneled catheters in a porcine model. They concluded that double tunneled catheters were associated with nearly a fourfold increase in force required for displacement compared with single-tunneled catheters, and a 17-fold increase in force of displacement compared with tunneled catheters in porcine model. Double tunneling is not much tested in human subjects. It could be because of chances of kinking of catheter at the site of second tunnel, lack of enough space, requirement of special care at the time of removal, and increase in infection rate due to two skin punctures. Infection is unlikely to be a major problem due to its very low incidence in short-term peripheral nerve catheters.[5] Double-tunneling allows catheter to circle the bridge of skin created between two loops of catheter Figure 1. In our case, we double tunneled the continuous catheter in the infraclavicular region after its placement under ultrasound guidance. We did not face any technical difficulty while inserting it. Insertion required the help of an assistant to stabilize the catheter during the procedure. The catheter was maintained for 48 hours and was removed without any problems. The patient did not complain of any scar formation on successive follow up. Catheter dislodgement is prevented due to the tightening of the bridge of skin in case any untoward force pulls it. This benefit of tunneling is less affected by the site of the catheter or the nature of the surrounding skin, unlike dressings. We have successfully extended the use of this technique to supraclavicular continuous catheter placements. Double-tunneling is a new technique of peripheral nerve catheter fixation which provides more protection from catheter dislodgement. The incidence of infection and scar formation needs to be studied further.Figure 1: Steps of double tunneling peripheral nerve catheterDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Ultrasound-Guided Retroclavicular Approach to the Infraclavicular Region (RAPTIR) Brachial Plexus Block for Anterior Shoulder Reduction

BackgroundShoulder dislocations are a common presenting injury to the emergency department (ED), with anterior dislocations comprising the majority of these cases. Some patients may tolerate gentle manipulation and reduction, but many require analgesia of some type. Oral or parenteral pain medication is often used alone or in combination with procedural sedation if gentle manipulation fails to achieve reduction. Recently, this treatment algorithm has grown to include regional anesthesia as a mode of analgesia for reduction of shoulder dislocations in the form of brachial plexus blocks. It has been well described that the interscalene and supraclavicular approach to the brachial plexus can be used to assist in reduction of anterior shoulder dislocations; however, there has yet to be any published literature regarding the use of ultrasound-guided retroclavicular approach to the infraclavicular region (RAPTIR) brachial plexus blocks for shoulder reduction.Case Report: We describe three patients who presented to the ED with anterior shoulder dislocations. The RAPTIR block was performed, provided effective analgesia, and facilitated successful shoulder reduction in all three patients.Why Should an Emergency Physician Be Aware of This? The RAPTIR nerve block is a safe and effective option for analgesia in the patient with an anterior shoulder dislocation. It may have advantages over other brachial nerve blocks and avoids the risks and disadvantages of procedural sedation and opioids.

MULTIPLE BRACHIAL PLEXUS SCHWANNOMAS - A RARE CASE

Background: Schwannoma is a benign encapsulated nerve sheath tumour that arises from the Schwann cells along the course of a nerve and can affect the third to 12th cranial nerves, peripheral and autonomic nerves. Schwannoma was first described by Verocay in 1908. Schwannoma rarely affects brachial plexus, accounting for 5% of all cases of schwannoma. Case: 38year old female patient presented with a left axillary mass noticed since 1 year. The mass was slowly increasing in size and was painful associated with tingling and numbness over medial aspect of left arm, forearm and hand. MRI was Suggestive of multiple, well defined, round to oval altered signal intensity lesions noted in infraclavicular region of axilla and upper arm on left side along the course of neurovascular bundles. On exploration left brachial plexus through left axillary approach , total of 11 nerve sheath tumours noted and dissected from territory of medial brachial cutaneous nerve and intercostobrachial nerve of the left arm. Histopathology report was suggestive of left axillary schwannoma with no evidence of malignancy. Conclusion: SchwannomaÂ’s around neck and axilla region are uncommon lesions arising from peripheral nerves and should be considered as one of the differential while evaluation.

Deep Learning-Aided Automatic Contouring of Clinical Target Volumes for Radiotherapy in Breast Cancer After Modified Radical Mastectomy

Purpose: The aim of this study is to develop a practicable automatic clinical target volume (CTV) delineation method for radiotherapy of breast cancer after modified radical mastectomy.Methods: Unlike breast conserving surgery, the radiotherapy CTV for modified radical mastectomy involves several regions, including CTV in the chest wall (CTVcw), supra- and infra-clavicular region (CTVsc), and internal mammary lymphatic region (CTVim). For accurate and efficient segmentation of the CTVs in radiotherapy of breast cancer after modified radical mastectomy, a multi-scale convolutional neural network with an orientation attention mechanism is proposed to capture the corresponding features in different perception fields. A channel-specific local Dice loss, alongside several data augmentation methods, is also designed specifically to stabilize the model training and improve the generalization performance of the model. The segmentation performance is quantitatively evaluated by statistical metrics and qualitatively evaluated by clinicians in terms of consistency and time efficiency.Results: The proposed method is trained and evaluated on the self-collected dataset, which contains 110 computed tomography scans from patients with breast cancer who underwent modified mastectomy. The experimental results show that the proposed segmentation method achieved superior performance in terms of Dice similarity coefficient (DSC), Hausdorff distance (HD) and Average symmetric surface distance (ASSD) compared with baseline approaches.Conclusion: Both quantitative and qualitative evaluation results demonstrated that the specifically designed method is practical and effective in automatic contouring of CTVs for radiotherapy of breast cancer after modified radical mastectomy. Clinicians can significantly save time on manual delineation while obtaining contouring results with high consistency by employing this method.

Submammary placement of implantable cardioverter defibrillators: a Singapore plastic surgeon experience.

The use of implantable cardioverter defibrillators (ICDs) in young women has been increasing in recent years owing to greater awareness about inherited cardiac conditions that increase the risk of sudden death. Traditional placement of ICDs in the infraclavicular region among young women often leads to visible scars, a constant prominence that causes irritation from purse or bra straps and can result in body image concerns and device-related emotional distress. In this case series, two women with long QT syndrome required placement of ICDs for prevention of sudden cardiac death. Submammary placement of ICDs was performed in collaboration with electrophysiologists. We describe our local experience and technique in submammary placement of ICDs as well as the challenges faced.

Innervation of the clavicle: a cadaveric investigation

BackgroundThis cadaveric study investigated the innervations of the clavicle and clavicular joints (ie, sternoclavicular and acromioclavicular joints).MethodsTwenty cadavers (40 clavicles) were dissected. A skin incision was made to permit exposure...

Diagnostic Validation Study. Relationship Between Optical Spectroscopy and Ankle Brachial Index Tests for Peripheral Artery Disease.

Ankle brachial index (ABI)is an essentialdiagnostic test for peripheral artery disease. It has some important limitationsso it can´t always be performed.In those cases, tissue oximetry based on near-infrared spectrum could overcome these limitations. Assessment ofthe relationship between ABI and tissue oximetry tests and the ability of the oximetry to detect postoperative improvement. Prospective observational study. Several measures were made by both, ankle pressure and tissue oximetry tests, in lower limbs. Absolute values were collected at foot level (anterior and posterior tibial arteries) and the indexes were calculated in relation to a control (upper limbs for ABI and left infraclavicular region for tissue oximetry). In order to evaluate the correlation between ankle pressure and tissue oximetry values, Pearson correlation coefficient and linear regression analyses were applied. T-Student and ROC curve analysis were made to evaluate thepostoperative improvement detected by bothankle pressureandtissue oximetry tests. 60 patients with peripheral artery disease were included. Ankle pressure and tissue oximetry were measured in 70 lower limbs, in 45 of them before and after revascularization. Compared to ankle pressure, tissue oximetry was able to detect improvement in absolute values and indexes after revascularization. This indexes improvement was parallel (P=0.234 for anterior tibial artery and P=0.356 for posterior tibial artery). We weren´t able to determine a cutoff point between both tests (ROC curve analysis).We observed a significative positive correlation in absolute values of both tests (Pearson correlation coefficient, r=0,281; P < 0.001). Tissue oximetry is able to detect improvement after revascularization of lower limbs.

Endovascular treatment with aortic endoprostheses for subclavian artery aneurysm secondary to late traumatic axillary-axillary arteriovenous fistula.

Traumatic arteriovenous fistulas (AVFs) involving the axillary and subclavian vessels are uncommon and account for 5 to 10% of all arterial traumas. The complex anatomy of this region makes treatment of this segment challenging. In this therapeutic challenge, we describe the case of a 73-year-old man, referred for progressive edema and ulceration involving the right upper limb and with a history of gunshot wound to the right infraclavicular region about 50 years previously. Angiotomography was performed and an axillary-axillary AVF was found, associated with tortuosity and aneurysmatic dilation of the subclavian artery downstream. He underwent endovascular intervention and a conical (monoiliac) 26 × 14 × 90 mm Braile® endoprosthesis was used in the aneurysmatic subclavian artery, posterior to the exit of the right vertebral artery and a 16 × 16 × 95mm Excluder® monoiliac endoprosthesis was placed overlapping the first prosthesis, showing a satisfactory result. Therefore, the possibility of successfully using aortic endoprostheses in an unusual and exceptional situation is described.

Variation in the Distribution of Nerves in the Front of Arm- A Cadaveric Study from South India

Introduction: Brachial plexus are the main nerve supply to the muscles of upper limb and the muscles of the flexor compartment arm are supplied by Musculocutaneous Nerve (McN). Any variations in the nerve innervation of the flexor muscles of arm should be documented as they have clinical implications. Aim: To observe and document the variations in the innervation of muscles of the front of arm and discuss its clinical implications with the help of available literature. Materials and Methods: This cross-sectional descriptive study was done in the Department of Anatomy, Siddhartha Medical College for a period of three years that is from October 2017 to October 2020 on 50 upper limbs, from 25 cadavers. The upper limbs were dissected to observe the innervations of muscles of front of arm. Contents of front of arm were observed. Incidence and percentage of variation in the population was tabulated. Results: Variations in the nerve supply of muscles of front of arm were noticed in 6% of the cases. In two cadavers (4%), all the muscles of right arm except coracobrachialis were innervated by a trifurcated branch from Median Nerve (MN) and the latter was supplied by a separate branch from lateral cord. In another left upper limb two separate branches innervated from lateral cord and supplied all the muscles of arm. In the present study, observed variations were more common on right side than on the left side. Conclusion: Knowledge of such variations are important for the surgeons during surgical exploration of axilla, nerve block in supraclavicular, infraclavicular or axillary region and also during nerve grafting. Also, the study highlights the incidence of variations in a particular region.

Endoscopic thyroidectomy: a single institute prospective observational study in India

Background: Endoscopic thyroidectomy (ET) is now an accepted treatment for benign and certain malignant thyroid diseases. It is clearly evident that ET is mainly done to lessen pain and avoid scar in the neck. Any procedure which involves using the endoscope to remove thyroid is often collectively called “endoscopic thyroidectomy.” In this article, we would like to share our institute experience in doing ET.Methods: We did ET on 85 patients from November 2014 to October 2019 mostly by the three-port technique. Preoperative assessment was done and surgery was done on those who met the inclusion criteria. All the cases were done with the insufflation of carbon dioxide gas. Per operative events were noticed and all the patients were followed up at least for 3 to 6 months postoperatively.Results: The mean age of the patient is 38 years and the majority are females (92.94%). Out of 85 cases, one case was converted to an open method (1.18%). The average operative time to complete the procedure was 67 minutes. Most of the cases were discharged on 2nd to 3rd postoperative days. Few patients had complications like hematoma/seroma formation, paresthesia over the infraclavicular region, skin thermal injury, vascular injury, and tracheal injury.Conclusion: ET gives excellent cosmesis and lessens the post-operative pain and thus lesser hospital stay even though the extent of the dissection is more than the conventional method. It has variable complications according to the techniques adopted and the size/volume of the surgically excised thyroid gland.

Asymptomatic-anaplasmosis confirmation using genetic and serological tests and possible coinfection with spotted fever group Rickettsia: a case report

BackgroundAnaplasmosis is an emerging acute febrile disease that is caused by a bite of an Anaplasma phagocytophilum–infected hard tick. As for healthy patients, reports on asymptomatic anaplasmosis resulting from such tick bites are rare.Case presentationA 55-year-old female patient visited the hospital with a tick bite in the right infraclavicular region. The tick was suspected to have been on the patient for more than 10 days. PCR and an indirect immunofluorescence assay (IFA) were performed to identify tick-borne infectious diseases. The blood sample collected at admission yielded a positive result in nested PCR targeting Ehrlichia- or Anaplasma-specific genes groEL and ankA. Subsequent sequencing confirmed the presence of A. phagocytophilum, and seroconversion was confirmed by the IFA involving an A. phagocytophilum antigen slide. PCR detected no Rickettsia-specific genes [outer membrane protein A (ompA) or surface cell antigen 1 (sca1)], but seroconversion of spotted fever group (SFG) rickettsiosis was confirmed by an IFA.ConclusionsThis study genetically and serologically confirmed an asymptomatic A. phagocytophilum infection. Although SFG rickettsiosis was not detected genetically, it was detected serologically. These findings indicate the possibility of an asymptomatic coinfection: anaplasmosis plus SFG rickettsiosis. It is, therefore, crucial for clinicians to be aware of potential asymptomatic anaplasmosis following a tick bite.

Was it Ewing’s? A Diagnostic and Therapeutic Dilemma

We present an atypical case of histopathology suggesting hemangioendothelioma and immunohistochemistry-proven Ewing's sarcoma in a 39-year-old lady who presented with multiple stony hard swellings involving the occipital region of the scalp, right cervical lymph node, right scapular region, left infraclavicular region of the chest, right anterior abdominal wall swelling, and inner aspect of right thigh. She underwent left-sided below-knee amputation for parosteal osteosarcoma in the left distal tibia 3years back. Palliative radiotherapy with dose of 30 Gy in 10 fractions over 2 weeks was administered to the right neck and right upper back following which she attained moderate pain relief but no reduction in swellings as was expected had it been a case of hemangioendothelioma or Ewing's sarcoma..