Year-old Woman Research Articles

739 Atypical presentation of Takotsubo syndrome early after pacemaker implantation

Abstract Aims Takotsubo syndrome (TTS) is an acute stress-induced cardiomyopathy showing left ventricular (LV) dysfunction without obstructive coronary arteries disease. A sudden massive surge of circulatory catecholamines from an intense physical or emotional stress may play a central role in the pathogenesis of TTS. We report the case of an 87 years-old woman who developed TTS with uncommon presentation after permanent pacemaker (PM) implantation. Methods and results The patient was referred to our hospital for PM implantation because of advanced atrio-ventricular block (3:1). She suffered by rheumatoid arthritis (RA), arterial hypertension, and chronic kidney disease. Echocardiogram, performed before PM implantation, showed normal LV kinesis and normal ejection fraction (EF 60%). She was initially administered with infusion of Isoprenaline 2 mcg/min. The subsequent day, she underwent permanent dual-chamber pacemaker implantation without any complications. After 3 days, the patient complained severe asthenia and fever, together with increase of white blood cells and C reactive protein. Blood cultures were negative. We started antibiotic therapy and, suspecting a reactivation of RA, steroid therapy with infusion of methylprednisolone 40 mg/die. Electrocardiogram showed normal sinus rhythm and paced ventricular rhythm. PM interrogation showed normal function. Surprisingly, echocardiogram showed LV dysfunction with apical and medium segments akinesia, and severe EF reduction (35%). Coronary angiography documented absence of coronary obstructive lesions, assessing diagnosis of TTS. The patient was discharged 1 week after admission in good clinical condition. One week later, an echocardiogram showed apical akinesia, partial recovery of medium segments motility, and slight increase of EF (40%). The excess of catecholamines could lead to decreased cardiac muscular function and to spasm of coronary arteries: these events can lead to acute heart failure and decrease of LVEF. Furthermore, about 90% of patients with TTS are women, especially in postmenopausal period. Peculiarities of this case were the atypical symptoms of TTS and the combination of different predisposing stressors factors: female sex in postmenopausal period, anamnesis of chronic inflammatory disease, use of stress-inducing drugs (methylprednisolone and isoprenaline, the last associated with TTS after PM-implantation), atrio-ventricular block itself, and PM implantation procedure. Our findings remark that even a low-risk procedure could be a possible cause of TTS in patient with such risk factors. In our opinion, in this subset of patients, conscious sedation could be useful to reduce the stress load, together with an early procedure and consequently the minimal use of exogenous stress drugs like Isoprenaline, even if the patient is in a good clinical condition. Conclusions This case highlights TTS as a potential complication after PM implantation, especially in post-menopausal women with high pre-existing stress load.

453 An unexpected finding in an asymptomatic patient planned for non-cardiac surgery

Abstract Aims Left ventricular (LV) aneurysms and pseudoaneurysms are two complications of myocardial infarction, either symptomatic or silent, leading to death or serious morbidity in several cases and often precluding non-cardiac surgery. Here the differential diagnosis is challenging and multimodality imaging is often needed to assess the risk of heart rupture. Methods and results A 71 years-old woman was referred to our Cardiology Department for a preoperative evaluation before lung lobectomy. Her past medical history included multiple cardiovascular risk factors and abdominal aorta aneurysm. She also had severe peripheral arterial disease treated with femoral popliteal bypass surgery in June 2021. In August 2021 she suffered from vascular graft thrombosis requiring a redo surgery. During hospitalization, she was found to have a lung adenocarcinoma. The patient had an unremarkable cardiological history and was asymptomatic. EKG was unremarkable. Transthoracic echocardiography revealed a mildly impaired LV systolic function (EF = 40%), an inferolateral basal wall akinesia and a huge aneurysm with intracavitary thrombus and a wide neck arising right below the posterior mitral annulus. The annular distortion caused by the expanding aneurysm contributed to the development of mitral regurgitation (MR) by displacing the annulus and subvalvular apparatus, resulting in restriction of the posterior mitral valve leaflet, coaptation failure, and moderate MR. Coronary angiography demonstrated a severe 3-vessel coronary artery disease. To further characterize the aneurysm, a cardiac magnetic resonance was carried out. T1 weighted inversion recovery LGE 2-chamber and short axis views showed transmural LGE of the inferior wall and confirmed the presence of a saccular dilatation with thin wall, wide neck (5 × 6 cm) and large intracavitary thrombus at high risk of rupture. Since the presence of metastatic lesions was excluded, the patient underwent cardiac surgery followed by elective lobectomy. Intraoperative findings were consistent with LV aneurysm with a thin myocardial wall. Aneurysm and related thrombus were removed and the orifice was closed with a Dacron patch. In the same setting a myocardial revascularization with two coronary artery bypass grafts was also performed. Surgery was successfully performed without any complication. Intraoperative transesophageal echocardiography clearly revealed the aneurysm and witnessed the reduction of MR after the restoration of LV inferolateral wall geometry. Conclusions Our case highlights the importance of thorough evaluation prior to non-cardiac surgery using multimodality imaging, especially when incidental echocardiographic findings in asymptomatic patients occur. A careful pre-operative assessment of patients planned for non-cardiac surgery is the key to favourable postoperative outcome.

Acute Total Occlusion of the Left Circumflex Coronary Artery Presenting with Non-ST-segment Elevation Myocardial Infraction and Normal Electrocardiogram – A Case Report

Introduction
 In this case report, we report a patient with non-ST-segment elevation myocardial infarction (NSTEMI), presenting with recurrent chest pain typical of angina, a very high troponin I level despite normal electrocardiogram (ECG). On angiography, it turns out that the patient has acute total occlusion in the left circumflex artery (LCx).
 Case Report
 A 56 years-old woman presented to the emergency department with chief complaint of recurrent chest pain typical of angina 20 hours before admission. Vital signs were within normal limit. There were no murmur, additional heart sounds, and no rales or crackles. The ECG showed normal sinus rhythm, and there were no ST-T changes on serial examination. The first and second cardiac enzymes troponin I was high (> 10 mg/L). Chest X-ray examination showed cardiomegaly without signs of lung edema. Patient was diagnosed with high risk NSTEMI, hypertensive heart disease, and diabetes mellitus. Coronary showed an acute total occlusion in the LCx, which is determined as the culprit lesion for the ongoing myocardial infarction. A drug-eluting stent was deployed at the culprit lesion and the coronary flow was TIMI Flow 3. There was non-significant stenosis at the mid-right coronary artery. The echocardiography showed reduced left ventricular systolic function (LVEF 50%) with hypokinetic inferior-septal and inferior-lateral segment base to apical. Post-procedural follow-up was uneventful.
 Conclusion
 One of the learning points is that ECG may fail to detect acute total occlusion and rise in troponin level, despite the absence of ST-T changes, warrant urgent invasive strategy.

Novel approach in iris shade matching: mobile photography and custom ocular shade guide

Introduction: Custom ocular prosthesis have several advantages such as even distribution of pressure on the eye socket, highly esthetic iris, better comfort and eyelid movements, but this prosthesis requires a long fabrication time. The fabrication step that spent time the most is the iris shade matching. Case: A 19 years-old woman with a defect in her left eye reported to Dental Hospital Universitas Sumatera Utara. The patient revealed history of infection of the left eye due to measles leading to surgical enucleation when she was one year old. Clinical examination shows healthy conjuctiva with no sign of infection or inflammation covering the posterior wall of the anopthalmic socket. Management: The iris shade matching was done using mobile photography and custom ocular shade guide, allowing the fabrication of iris button in the same day with shade matching appointment. The mobile photography eliminated the need for the operator painting skill and save the fabrication time significantly. The custom occular shade guide compensated the color biased during the photo taking procedure. Conclusion: The novel approach using mobile photography and custom ocular shade guide simplified the iris shade matching, provide highly esthetic results, eliminate the needs for operator painting skills, and save a significant amount of time in fabrication.

A case of improvement of clozapine-induced low leukocyte counts by adenine, cepharanthin and ninjin-yoei-to in a patient with treatment-resistant schizophrenia

BackgroundAlthough clozapine is the optimal drug for patients with treatment-resistant schizophrenia, the drug has harmful adverse effects such as leukopenia. Adenine and cepharanthine are known to be effective for radiation- or drug-induced leukopenia. Furthermore, ninjin-yoei-to, a Chinese herbal medicine, augments the production of granulocyte-macrophage colony-stimulating factor. Thus, these drugs may be useful for clozapine-induced leukopenia.Case presentationA 21 years-old woman with schizophrenia was hospitalized for initiation of clozapine treatment. Despite concomitant use of adenine, cepharanthine, and lithium carbonate having activities of increasing leukocytes, a decrease in leukocyte counts occurred after the initiation of clozapine. Additional administration of ninjin-yoei-to increased leukocyte counts, which prevented the development of leukopenia.ConclusionsThis is the first case that concomitant use of adenine, cepharanthin, and ninjin-yoei-to exhibited the effectiveness of reversing the decrease in leukocytes caused by clozapine. Monitoring leukocyte counts and preventing leukopenia are essential for successful treatment with clozapine for refractory schizophrenia. These medicines may be a potential option for preventing clozapine-induced leukopenia.

A Case of Primary Squamous Cell Carcinoma of The Thyroid Gland

Primary squamous cell carcinoma of thyroid is a very rare malignant tumor with poor prognosis. It is usually diagnosed as an advanced disease infiltrating adjacent organs, and characterized by aggressive clinical course with an average postoperative survival time of less than 1 year. Recently, we had a 79- year-old woman with a painful neck mass who was diagnosed as primary squamous cell carcinoma of thyroid gland. She underwent total thyroidectomy and selective neck dissection(level Ⅲ, Ⅵ) with no further postoperative managements such as radiation therapy or chemotherapy; she died of poor general condition and pneumonia resulting from rapid progression of the lesion on the 38<sup>th</sup> day after surgery. We report this case with a review of relevant literatures.

Two case series of Chiladiti syndrome and a review of literature

Introduction: Chilaiditi’s syndrome was repeatedly an unforgettable case in Emergency Department due to its various symptoms. Methods: This case report consisted two reported cases of Chilaiditi syndrome. Then, we followed the methods of PRISMA for systematic review. Results: In this report, two cases of Chilaiditi syndrome with the different chief of complaint when admitted to the hospital. A 35-yearold woman presented to the Emergency ward with abdominal pain, while the older subject, a 67-year-old man complained of shortness of breath. Plain radiograph showed an elevated right hemidiaphragm and the presence of subphrenic air, making the diagnosis of Chilaiditi syndrome. Both patients were managed conservatively with nasogastric tube decompression and intravenous fluid. The follow up showed favorable results and symptoms resolved. Discussion: Chilaiditi syndrome might not be a rare entity, but a difficult syndrome to identify clinically due to its various unspecific symptoms. The radiological examination was needed to be carried out for the diagnosis. Conservative management led to favorable results. Conclusion: Clinicians should be more aware of the diagnosis of Chilaidity syndrome with its various symptoms. Radiological evidence should be obtained for the confirmed diagnosis, and conservative management was the modality choice. Keywords: Chilaiditi syndrome; radiology; conservative.

A Case Report on Treatment-Resistant Acute Exacerbation of Psychosis in Pregnancy

Background: This case is interesting because her psychosis was exacerbated at the same time as her new pregnancy onset, and the patient had multiple gestational records. Furthermore, her psychosis was treatment-resistant to Aripiprazole. Case Report: A 36 year-old woman with a gestational age of 27 weeks presented to the Behavioral Health Unit due to acute psychosis of carrying the “Devil’s child.” Conclusion: We hope this case report can serve as a basis for establishing management guidelines for patients with peripartum acute psychosis.

C59. Management of Subacute Painless Aortic Dissection Stanford A Debakey II in Patient With Undiagnosed Marfan Syndrome During Pregnancy

Abstract Background Pregnant women with Marfan’s syndrome needed multidisciplinary approach to evaluate pregnancy status, fetal and maternal outcome. Marfan’s syndrome was an inherited autosomal dominant with mutation of fibrillin-I (FBN1) gene. Pregnant woman with MFS can lead to aortic dissection. It’s increase 23% of maternal mortality and 35% of fetal death. Case Summary a 30 year-old pregnant woman referred from secondary hospital care with valvular heart disease (severe aortic regurgitation due to dilatation of the aortic root and severe mitral regurgitation). Due to her severe myopia, history of aortic dissection in her family, enlarged of aortic root, pulnus excavatum, scoliosis and arachnodactyly, de novo MFS was suspected. She was diagnosed with marfan’s syndrome according her systemic score was 10 (posive >7), and calculated aortic z score was 6.2 (positive >2). Intimal tears and dilatation of the aortic root were considered to terminate the pregnancy. It’s can result bad neonatal outcome. For the management of a potential vascular catastrophe , monitoring of delivery and repairing the aortic root, we needed to multidisciplinary approach. Discussion Patient with marfan’s syndrome during pregnancy, may develop painless aortic dissection because massive dilatation of aortic arch prevent compression of pain sensitive structure. Less evidence to manage pregnant woman with MFS with aortic root dilatation more than 45 mm and or progressively dilatation of aortic root ( more than 0.5 mm/year). This patient was categorized as class IV modified WHO classification with high risk maternal mortality and severe morbidity.

C59. Management of Subacute Painless Aortic Dissection Stanford A Debakey II in Patient With Undiagnosed Marfan Syndrome During Pregnancy

Abstract Background Pregnant women with Marfan’s syndrome needed multidisciplinary approach to evaluate pregnancy status, fetal and maternal outcome. Marfan’s syndrome was an inherited autosomal dominant with mutation of fibrillin-I (FBN1) gene. Pregnant woman with MFS can lead to aortic dissection. It’s increase 23% of maternal mortality and 35% of fetal death. Case Summary a 30 year-old pregnant woman referred from secondary hospital care with valvular heart disease (severe aortic regurgitation due to dilatation of the aortic root and severe mitral regurgitation). Due to her severe myopia, history of aortic dissection in her family, enlarged of aortic root, pulnus excavatum, scoliosis and arachnodactyly, de novo MFS was suspected. She was diagnosed with marfan’s syndrome according her systemic score was 10 (posive >7), and calculated aortic z score was 6.2 (positive >2). Intimal tears and dilatation of the aortic root were considered to terminate the pregnancy. It’s can result bad neonatal outcome. For the management of a potential vascular catastrophe , monitoring of delivery and repairing the aortic root, we needed to multidisciplinary approach. Discussion Patient with marfan’s syndrome during pregnancy, may develop painless aortic dissection because massive dilatation of aortic arch prevent compression of pain sensitive structure. Less evidence to manage pregnant woman with MFS with aortic root dilatation more than 45 mm and or progressively dilatation of aortic root ( more than 0.5 mm/year). This patient was categorized as class IV modified WHO classification with high risk maternal mortality and severe morbidity.

The effect of marijuana on labour market outcomes:evidence from medical marijuana laws

ABSTRACT We use the staggered roll out of medical marijuana laws (MMLs) as a plausibly exogenous shock to individuals’ marijuana used to identify the effect of marijuana on labour-market outcomes. While our analysis largely confirms that MMLs do not affect labour market outcomes, we find two results that are not seen in the prior literature. We find that MMLs increase the probability that a 30–39 year-old woman is in the labour force, and decrease the time that unemployed 20–29 year-old men spend looking for a job. While both results are imprecisely estimated, they are generally robust to a large number of robustness checks we employ.

PULMONARY LYMPHANGIOLEIOMYOMATOSIS IN THE OPERATING ROOM.

A 40 years-old woman with a previous history of a right pneumothorax in 2013 had a left pneumothorax with persistent air leak in 2020. The computerized tomography scan of the chest described diffuse emphysematous changes with multiple "small bullae" in the upper lobes. She was submitted to mechanical and chemical pleurodesis with a wedge apical resection by uniportal video-assisted thoracic surgery. Pathological findings confirm the diagnosis of pulmonary lymphangioleiomyomatosis.

Cortical Thinning and White Matter Loss in Sickle Cell Anemia Despite Chronic Exchange Transfusion Therapy

Neurovascular complications are a common and major cause of morbidity and mortality in patients with sickle cell disease (SCD). Prior studies have demonstrated cortical thinness (Kim et al. 2016) as well as reduced cerebral volume in children with SCD (Kawadler et al. 2013) when compared to age-matched controls. There is very limited data regarding cerebral volume in adults with SCD. Recently, our group showed that adults with SCD have reduced cerebral volumes when compared to race and age-matched controls (Santini et al. 2021a). A prior prospective study by Nitkunan et al. 2011. demonstrated brain atrophy rate of −0.914%±0.8% in older adults (mean 68 years old) with Small Vessels Disease, which is about twice the rate of healthy controls. Transfusion therapy has been effective in the primary and secondary prevention of strokes and silent infarcts in SCD. Automated erythrocytapheresis (exchange transfusion), in particular, is the most aggressive disease modifying-treatment in SCD, by rapidly diluting sickle hemoglobin and replacing it with normal hemoglobin. We hereby present a case of a 42 -year-old woman with sickle cell anemia (HbSS) who developed accelerated loss of cerebral volume within a three-year period despite chronic exchange transfusion therapy. The patient underwent brain MRI in 2016 and 2019 as part of an NIH-funded, prospective, longitudinal study of the neuroradiological correlates of cognitive dysfunction in SCD. Past medical history is notable for prior right hemispheric stroke for which she was placed on chronic exchange transfusion monthly with the goal of reducing HbS to <30%. T1-weighted images were acquired at 7T MRI using a customized RF coil (Santini et al. 2021b) and with the following parameters: 3D MPRAGE, TE/TI/TR = 2.17/1200/3000 ms, resolution 0.75 mm isotropic, total acquisition time = 5 min. The extent of atrophy was estimated using the longitudinal analysis as part of the Freesurfer package (version 7.1.1) and ITK-snap (version 3.8.0). The pre-exchange HbS was reliably maintained <30% throughout the observation period, during which the patient did not develop new strokes or neurological complications. Unfortunately, in spite of the patient's excellent adherence with the treatment and the achievement of the target HbS values, we observed progression of cerebral atrophy of 2.47% in volume in the hemisphere contralateral to the stroke between the two time points. The differences are also visible in the raw data (Figure 1). Chronic exchange transfusion is the most aggressive preventive treatment for the neurological sequelae of sickle cell disease. This case demonstrates an accelerated brain atrophy, suggesting that this treatment may not be fully protective against progressive cerebral atrophy. Unfortunately, the mechanism of brain atrophy in SCD is not fully understood. More longitudinal studies are needed to assess cortical changes and cerebral volume changes as this can lead to further understanding of their pathophysiology and to the development of therapeutic options to arrest the progression of cerebrovascular disease in this population. [Display omitted] DisclosuresNovelli: Novartis Pharmaceuticals: Consultancy.

Belantamab Mafadotin in Patients with Relapsed/Refractory AL Amyloidosis with Myeloma

Belantamab Mafadotin in Patients with Relapsed/Refractory AL Amyloidosis with Myeloma

Phase 1 Results of Novel Combination Therapy: BET Inhibitor PLX51107 with Azacitidine in Patients with Relapsed/Refractory (R/R) Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS)

Phase 1 Results of Novel Combination Therapy: BET Inhibitor PLX51107 with Azacitidine in Patients with Relapsed/Refractory (R/R) Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS)

A case report of atraumatic splenic rupture after coronary stenting and dual antiplatelet therapy: Causality or relationship?

Introduction and importanceAtraumatic splenic rupture(ASR) is a rare event with challenging management, due to absence of clinical history of trauma and delayed diagnosis. Current clinical report could provide detailed information regarding clinical presentation and management to physicians.Case presentationA 61 years-old woman underwent percutaneous coronary intervention(PTCA) after ST elevation myocardial infarction(STEMI). In the first day after PTCA epigastric abdominal disconfort was reported, and new PTCA excluded early complication. During hospitalization, due to anemization and hypotension CT scan was performed which revealed ASR with large hemoperitoneum. Emergency surgical splenectomy was performed. Postoperative course was uneventful and patient started 90 mg Ticageclor twice daily in the first post-operative day(POD) plus low molecular weight Heparin and restarted dual antiplatelet therapy(DAPT) the seventh POD. During follow up, patient underwent to assessment of platelet function showing normal level of DAPT inhibition. Due to the lack of pathological aggregation activity, DAPT was maintained.Clinical discussionASR is mainly linked to oncological, malformative, inflammatory and thromboembolic conditions. Despite anticoagulant and anti-aggregating drug-related ASR has been already described, we report the first case of drug-related ASR as immediate complication of PTCA due to DAPT. After surgery, careful anti-aggregating management was required to balance in stent restenosis and hemorragic risk. Assessment of platelet activity was performed to design a tailored anti-aggregating therapy.ConclusionDrug-related ASR is dangerous complication due to the high mortality rate and misleading symptoms. After major bleeding events, such as drug-related ASR, evaluation of platelet function could provide a tailored DAPT.

Severe Acute Motor Axonal Neuropathy associated with Influenza-A (H1N1) Infection and Prolonged Respiratory Failure - A Case Report.

Acute Motor Axonal Neuropathy (AMAN) is an immune-mediated disorder of the peripheral nervous system, part of the spectrum of the Guillain-Barre syndrome (GBS). An infectious event most often triggers it reported a few weeks before the onset. The reported case is of a 56 years-old woman who developed acute motor axonal neuropathy three weeks after respiratory infection with influenza A virus subtype H1N1. Despite early treatment with plasmapheresis and intravenous immunoglobulins, the patient remained tetraplegic, mechanically ventilated for five months, with repetitive unsuccessful weaning trails. The probable cause was considered to be phrenic nerve palsy in the context of acute motor axonal neuropathy. This case highlights that acute motor axonal neuropathy is a severe and life-threatening form of Guillain-Barre syndrome associated with significant mortality and morbidity. Neurological and physical recovery strongly depend on the inter-professional effort in an intensive care unit and neurology professionals.

Frozen Pelvis

Study Objective To demonstrate that a pelvis is never really frozen in a case of a deep infiltrative endometriosis. Design Surgical video of a pelvis completed affected by deep endometriosis with significant anatomical distortion. Setting We describe a case of a 37 years-old woman referred to our center complaining of severe dysmenorrhea, dyspareunia and chronic pelvic pain. The patient had no relevant past medical. The pre-operative investigation involved a transvaginal magnetic resonance imaging that showed an infiltrative endometriotic nodule on the paracervix and posterior vaginal fornix, with involvement of the left ovary and a retossigmoid nodule with 4cm of diameter and 8cm from de anal verge. The patient was in clinical treatment with dienogest, without response. We scheduled a surgical procedure for radical eradication of the deep infiltrating endometriosis. Patients or Participants One patient with a pelvis completed affected by deep endometriosis with significant anatomical distortion. Interventions A step-by-step surgical video, demonstrating a systematic approach in case of deep infiltrating endometriosis, indicating surgical landmarks and a proper technique. It emphasizes mainly the development of the avascular spaces, isolation of the ureteral course, identification of the parametrial ligaments, preservation of the cranial, middle and caudal parts of the hypogastric plexus, performance of retossigmoid resection. Measurements and Main Results full and complete excision of all endometriosis lesions and restore of the anatomy. Conclusion The main indication for surgical treatment in women with endometriosis is pain and impairment in quality of life and the radical eradication of deep endometriosis is related not only with the relieve of symptoms, but also with the minimization of recurrences. The nerve-sparing technique is considered a feasible, safety and reliability approach and clearly is associated with lower post-operative complication rate and better results in terms of debilitating impairments in neurological functions. To demonstrate that a pelvis is never really frozen in a case of a deep infiltrative endometriosis. Surgical video of a pelvis completed affected by deep endometriosis with significant anatomical distortion. We describe a case of a 37 years-old woman referred to our center complaining of severe dysmenorrhea, dyspareunia and chronic pelvic pain. The patient had no relevant past medical. The pre-operative investigation involved a transvaginal magnetic resonance imaging that showed an infiltrative endometriotic nodule on the paracervix and posterior vaginal fornix, with involvement of the left ovary and a retossigmoid nodule with 4cm of diameter and 8cm from de anal verge. The patient was in clinical treatment with dienogest, without response. We scheduled a surgical procedure for radical eradication of the deep infiltrating endometriosis. One patient with a pelvis completed affected by deep endometriosis with significant anatomical distortion. A step-by-step surgical video, demonstrating a systematic approach in case of deep infiltrating endometriosis, indicating surgical landmarks and a proper technique. It emphasizes mainly the development of the avascular spaces, isolation of the ureteral course, identification of the parametrial ligaments, preservation of the cranial, middle and caudal parts of the hypogastric plexus, performance of retossigmoid resection. full and complete excision of all endometriosis lesions and restore of the anatomy. The main indication for surgical treatment in women with endometriosis is pain and impairment in quality of life and the radical eradication of deep endometriosis is related not only with the relieve of symptoms, but also with the minimization of recurrences. The nerve-sparing technique is considered a feasible, safety and reliability approach and clearly is associated with lower post-operative complication rate and better results in terms of debilitating impairments in neurological functions.

Peritoneal tuberculosis mimicking advanced ovarian cancer case report: Laparoscopy as diagnostic modality.

Introduction and importancePeritoneal Tuberculosis is one of extrapulmonary tuberculosis that occurs in 1-2% of patients, its incidence is higher in developing countries. It is very difficult to diagnosed and can mimic advanced ovarian cases. Making an accurate diagnosis is vital, laparoscopy is a great modality for this purpose.Case presentationA 36 years-old woman got referred with abdominal distention and weight loss from an internist and digestive surgeon. The abdominal computed tomography said thickening of the stomach wall with ascites. Ultrasound concluded the uterus, ovary, and endometrium within normal. The CA 125 levels elevated to 1200 U/mL and the complete blood count was normal. We were making diagnosis of peritoneal tuberculosis, peritoneal carcinomatosis, and advanced ovarian cancer. We did the diagnostic laparoscopic and taking a biopsy sample, ascites with peritoneal carcinomatosis and omental cake were found, the peritoneal cavity was covered by miliary nodules. Histopathology results concluded peritoneal tuberculosis without malignancy signs. The patient was treated with tuberculosis drugs. The follow-up evaluations show significant clinical improvement.Clinical discussionWhen facing patients with massive ascites and elevated CA 125 without any ovary enlargement, a gynecologist should think that it may be a peritoneal TB case with peritoneal carcinomatosis and advance ovarian cancer possibility as differential diagnosis especially in developing countries. An exact diagnosis can be made using laparoscopy and histopathology examination.ConclusionLaparoscopy is the best modality to differentiate between peritoneal tuberculosis, peritoneal carcinomatosis, and advance ovarian cancer. The benefits are direct visualization and could take a biopsy for histology examination.

Nocardia abscessus brain abscess in an immunocompetent patient with bronchiectasis

A 56 year-old woman presented with new onset focal seizure with a history of bronchiectasis. Brain abscess was diagnosed by magnetic resonance. She was confirmed to be immunocompetent and had histoplasmosis, tuberculosis, and infective endocarditis ruled out. Nocardia sp. was isolated from the brain abscess and identified as Nocardia abscessus complex by 16S rRNA sequencing. She was discharged on trimethoprim/sulfamethoxazole. Nocardia sp. is a cause of brain abscesses in patients with underlying pulmonary structural disease like bronchiectasis. Nocardia identification is of paramount importance as it is not treated with empiric antimicrobial therapy.