18 years old male. 4 months ago the patient was hospitalized due to epigastric abdominal pain, lack of appetite and weight loss. He was diagnosed with Crohn’s disease.
Hepatic biopsy, that was performed during this hospitslization, showed evidence of an overlap syndrome picture (cholangitis/hepatitis). He was initially treated with Cortisone and Azathioprine.
7-year-old boy with prodrome of right-sided and right face weakness, gait ataxia, and intermittent headaches. Head computed tomography demonstrated a tumor at the brainstem/posterior fossa, and then MRI confirmed a diffuse intrinsic pontine glioma (a typical brainstem glioma). Following initiation of dexamethasone (Decadron, steroid for vasogenic edema), the child has started experimental treatment with the medicine nimotuzumab to be followed with conventional radiotherapy.
A 50 years old female complained about appearance of detached pruritic symptomatology affecting the trunk and the scalp. The patient carried out numerous dermatology specialist examinations on the following 3 years. Her allergy tests results were negative and she diagnosed with a seborrhoeic dermatitis affecting the scalp. As the patient did not achieve any result with the prescribed therapies ,she carried out biopsy. The biopsy was consistent with a “Lichen Planopilaris.”
57-year-old male who was found to have back pain and hyperglobulinemia approximately. Marrow biopsy was consistent with IgG myeloma. He was treated with steroids and local radiotherapy with improvement in symptoms and a modest reduction in the M-component. He received melphalan-based autologous stem cell transplantation, which was complicated by reversible respiratory failure. Unfortunately, he relapsed and was treated with bortezomib and steroids for 6 cycles followed by thalidomide. The disease has responded to therapy.
21-year-old female with an acute onset of a unilateral sixth cranial nerve deficit. Brain MRI showed at least a dozen white matter lesions, one of them contrast-enhancing. Sensory evoked potentials showed a bilateral increase in latency. Multiple sclerosis was diagnosed, and the patient was treated by corticosteroids, followed by improvement of symptoms. The first follow-up revealed no focal neurological signs with a history of a transitory unilateral lower limb hyposthenia. On the second visit, a horizonto-rotatory nystagmus and irregular paraesthesia in the right toes are documented.
40 years old patient with clinical history that is consistent with Hashimoto’s thyroiditis. After an attempt to replace thyroid function with thyroid hormone in pills (Eutirox), the patient had reported multiple symptoms which might be suggestive for adverse side effects of Eutirox (double vision, tachycardia, disturbance of sleep, outbursts of anger). The patient consulted her family doctor and decided to reduce the dose of Eutirox.
27-year-old female with a diagnosis of suspected fibromyalgia. Her history includes long standing widespread musculo – skeletal pain connected to a feeling of general slight illness, as well as a series of accompanying symptoms: frequent migraines, cervicalgia, stomach disorders, chest pain and tachycardia . Therefore, she has carried out various follow-ups that each time detected a different problem for which the relevant therapy was set out.
50-year-old male complaining of gradual appearance of erectile dysfunction up to absolute impossibility of even just a single erectile event. His medical history is significant for Type II Diabetes Mellitus and prostatitis. He started taking Cialis, Levitra, and then Viagra without obtaining any benefit. He underwent EMG of the inferior limbs and hematochemical examinations, that revieled signs of diabetic polyneuropathy, and possible superimposed lumbosacral radiculopathy. The possibility to give intracavernous penile injections has been proposed.
21 years old female who provided us medical report of her endocrinological examination with diagnosis of “Basedow’s Hyperthyroidism in autoimmune non-nodular thyroid (Hashimoto’s thyroiditis). Under therapy with Tapazole at the dosage of 2 tablets daily with FT3 and FT4 values within normal limits and TSH=0.00” . In the light of such values and of the clinical picture, the specialist confirmed the current therapy with Tapazole (2 tablets daily) suggesting therapeutic dosage of 131 Iodine after examination at nuclear medicine department.
78-year-old female with history of diabetes, and meningioma complicated by neurologic deficits following surgery, was diagnosed with progressive iodine-refractory metastatic papillary thyroid carcinoma (PTC). Her initial work-up revealed lung metastasis. She underwent a right thyroidectomy and then left thyroidectomy and laryngectomy, and subsequently received I-131 on 8 occasions. She had a drop in thyroglobulin levels to the early treatments, but most recently, thyroglobulin has steadily increased.
39-year-old male was diagnosed to have a neuroendocrine tumour with synchronic liver metastases. The disease was treated with an etoposide-carboplatin combination, Interferon A, somatostatin analogue and Zebra fish egg derived dietary supplements. In early 2008, a tumour progression was noted in that the disease started to produce the epithelial tumour markers CEA and CA 19-9.
45-year-old male who presented with acute onset of flaccid paraparesis more pronounced on the left, sensation of current shocks in both legs and sensory level from the umbilicus downwards. The symptoms have reached their pick within less than a day. On examination the left lower limb was plegic and the right lower limb was partially weak. EMG was interpreted as demyelinating sensorimotor neuropathy. MRI showed hyperintense signals at the dorsal terminal segment of the marrow consistent with myelitis.
A 72 years old female that 8 years ago was diagnosed with adenocarcinoma of the sigma with liver metastasis.
72-year-old male had a TIA in 1995 and has been in chronic atrial fibrillation since 1992. In 2005 2 ablative procedures were ineffective. The main treatment strategy for his atrial fibrillation has consisted of rate control and oral anticoagulation. Despite several attempts of different medications (digoxin, beta-blockers) he has remained in atrial fibrillation with a relatively moderate to fast ventricular response.
67-year-old male began to complain of chronic pain in the left lower rib cage. The pain is stitch, ever-present, dull and localized at the level of his left last rib, and became slightly worse in the last 2 years. Recent image findings: MRI - "Ovalish hypoechogenic solid formation, Ultra sound - "Suspected intercostal neurinoma at ribs 10, 11 and 12.
21-year-old female with an acute onset of a unilateral sixth cranial nerve deficit. Brain MRI showed at least a dozen white matter lesions, one of them contrast-enhancing. Sensory evoked potentials showed a bilateral increase in latency. Multiple sclerosis was diagnosed, and the patient was treated by corticosteroids, followed by improvement of symptoms. The first follow-up revealed no focal neurological signs with a history of a transitory unilateral lower limb hyposthenia. On the second visit, a horizonto-rotatory nystagmus and irregular paraesthesia in the right toes are documented.
75-year-old male with a cutaneous squamous cell carcinoma resected from the right eyebrow in 2003. In 2006, the patient underwent resection of an ipsilateral squamous cell carcinoma in the parotid bed that was presumably a nodal metastasis. He then experienced local relapse treated with resection and adjuvant radiotherapy. There was recurrent disease involving the right cheek excised in 2008. In 2009, another recurrence led to resection with orbital exenteration. Pathology showed squamous cell carcinoma, with perineural invasion, and extension into the orbital muscles.
78-year-old male was diagnosed with possible mild Alzheimer’s disease. Medical history suggests a condition running a slow but steadily deteriorating course characterized by apathy as well as by impairment of memory, word finding difficulties and reduced vocabulary, impaired ability to make calculation and handle finances and difficulties in managing house work and going outside unsupervised. An episode with characteristics of delirium in the past is described as well. The neuropsychological evaluation describes moderate dementia.
43-year-old male suffered of cervical disc herniation, and therefore C5-6 and C6-7 discectomy and fusion were done. About one year later he experienced acute sciatica followed by hot pricking sensation in the arm and neck. MRI showed far lateral bulge of L3-4 on the left and small disc bulge on C4-5, and a larger C5-6 disc herniation. Neurological examination disclosed C6-C7 radiculopathy on the left, minimal weakness of biceps and triceps muscles and reduced biceps reflex. EMG and physical examination were consistent with bilateral radiculopathy, attributed to small disc herniation.
73-year-old male with a diagnosis of Parkinson's disease (PD) since 2001. The cause for this consultation is a problem in the left foot that appeared in 2005 and has worsened since. The diagnosis was "a serious pronated flat foot transverse to the left” causing pain radiating up to the thigh and hip and causing recurrent falls with serious injury.
52-year-old female with a diagnosis of stage IIIC Grade 3 endometrial cancer. Following the adequate surgery she was started on a chemotherapy protocol, including Taxol, Epirubicin and Cisplatinum. However the first course caused severe toxicity and was switched to Taxol and carboplatinum. One treatment option is by intense combination chemotherapy, and therefore the expert supports the protocol used by this case. Another option is endocrine manipulation by hormone therapy.
65-year-old male experienced loss of consciousness, and a CT scan showed a left temporal mass which was confirmed by MRI. The patient underwent Stereotacti biopsy of mass, and Histological examination gave a diagnosis of anaplastic astrocytoma. He started chemoradiation with fotemustine (nitrosourea alkylating agent). Repeated MRI showed progression with mass effect, mild uncal herniation and enlarging ventricles. He has stable expressive aphasia and hemisyndrome, lethargy and decreased motivation. His treatment was switched from phenobarbital to levetiracetam.
35-year-old female experienced an episode of lower back pain. Her doctor prescribed injections with Orudis, followed by further treatment with Voltaren. The treatment resulted in a simple remission of pain, that then re-appear at the same intensity as initially. The doctor established a new treatment that consisted of Indoxen and Bentelan. The patient experienced a remission of symptoms until even more intense lumbar pain returned spreading to the left leg. She recieved Voltaren, Muscoril, and Indoxen. Lumbar-sacral NMR showed disc central protrusion.
67 year old male, previously a heavy smoker, suffering for 2 months from weakness, diminished appetite and weight loss. Tests showed a mass in right arm, possibly attached to muscle, and tenderness in right ribs. Chest CT showed a mass in LLL, lung foci, suspected secondary spread and masses in upper abdomen. CT guided biopsy from right lung mass was consistent with non small cell carcinoma with extensive necrosis. SPECT bone scan showed many focal findings in the vertebrae L,D2,7, most of the ribs bilaterally and in the limbs- suspected for secondary pathology.
A 40 years old female has been suffering from cluster headache for the last 20 years. For the last 1.5 years it has been transformed from an episodic form to a chronic one. The patient reports an episodes of vertigo, for which she carried out otorhinolaryngology examination and brain NMR. On NMR was detected a periventricular lesion of about 1.2 cm, without mass effect. This lesion was probably present also 4 years ago, when the patient underwent another NMR.
The patient experienced an episode of lower back pain while carrying home shopping bags. Her family doctor diagnosed a “left lumbosciatic pain” and prescribed injections with vials of Orudis and Voltaren. The treatment resulted in temporary remission, therefore the patient started a new treatment regiment of Indoxen and Bentelan + acupuncture treatment which was partially beneficial.
35 years old male. 3 years ago an episode of lumbar pain. After an X-ray test and lumbar spine MNR a disc herniation was diagnosed. Later on, disorders showed up sporadically, and 15 days ago, as a result of backache recurrence, the patient decided to carry out diagnostic deepening performing a new lumbosacral magnetic resonance and an electromyographic examination.
66-year-old female underwent a left suboccipital craniotomy for resection of a tentorial meningioma. The postoperative course has been difficult, marked by deterioration associated with posterior temporal and cerebellar edema and hemorrhage. First she seems to be in good general conditions showing only a slight strength deficiency in the left upper limb, but about a month after the surgery she started showing asthenia and melena, and esophageal gastroduodenoscopy revealed a sclerosis of active arterial bleeding from duodenal ulcer.
41 year-old male was recently diagnosed as having multiple sclerosis (MS) after episodes of leg and shoulder weakness and parasthesis. Lately he experiences dizziness. His MRI showed several demyelinating lesions, other ancillary tests showed demyelinating damage to the auditory and visual pathway. Currently he has no functional or sensorial deficiencies. He was offered several immunomodulatory treatment options: Rebif, Betaferon and Copaxone, and asks about their pros, cons and complications, and about the differential diagnosis.
51-year-old female with vitamin D deficiency among other medical problems: high blood pressure, episodes of transient syncope, and sleep apnea. In the expert's opinion frequent changes and discontinuations of drugs as well as big intervals between one dose to another, can be responsible for hypertensive crisis. Therefore the expert recommends to stop too frequent investigations , and instead focus on appropriate treatment, that should be combination of Angiotensin Receptor Blocker and diuretics.
A very physically active 49-year-old male with a history of labile hypertension and hypercholesterolemia with an LDL cholesterol of 126 mg%. He underwent an exercise stress test which revealed reversible inferoseptal ischemia at a peak heart rate of 171 bpm and peak blood pressure of 195/85. In the expert's opinion, the results suggest that the patient has silent myocardial ischemia and may be at risk for sudden cardiac death, especially in light of the marked exertional level of activity.
53-year-old male with lower motor neuropathy affecting all 4 limbs. The neurologic examination showed left limb hyposthenia, left upper limb hypotrophy and diffuse fasciculations. The patient was diagnosed with “suspect motor neuron disease" and was treated with IVIG cycles with slight initial improvement, but later lack of response and worsening of the clinical condition.
A 43 years old woman man who presented with various symptoms consisting of visual disturbances, burning sensation in the eyes, headache, hypersensitivity to noise and dizziness. Repeated neurological examinations were reported normal. A thorough neurological work-up that included blood tests, brain MRI, EEG and echocardiography was normal.
52-year-old male with a one year history of lower motor neuropathy affecting the limbs, left upper and lower limbs clinically and all 4 limbs electrically. The neurologic examination showed left lower and left upper limb hyposthenia with mainly distal motor clumsiness, appearance of left upper limb hypotrophy and diffuse fasciculations. The patient was diagnosed with “suspect motor neuron disease" and was treated with IVIG cycles with slight initial improvement, but later lack of response and worsening of the clinical condition.
67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.
55-year-old female was diagnosed with glioblastoma after suffering increasing headaches, and was treated with radiation with concurrent Temodal. MRI exam that was performed after 2 additional cycles of CCNU showed tumor progression. The expert recommends different further treatment options.
51-year-old-male, complained of low back pain and has been diagnosed as having multiple myeloma (MM), light chain disease of the lambda type. His past medical history is remarkable for a cardiac disease. The expert believes it is cardiomyopathy, which can be amyloidotic (related to the MM) or hypertensive-atherosclerotic, or combined. The patient received anti-MM induction type of treatment (VTD combination), followed by high-dose cyclophosphamide (HDC) and autologous stem cell transplantation. The patient's low platelet count is of concern.
67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.
74-year-old male has suffered over six months from pancytopenia. The main problem has been the symptomatic anemia, which required blood transfusions. Bone marrow aspiration revealed some myelodysplasia, and immune therapy has been prescribed. The expert suggests possible differential diagnosis of pancytopenia and recommends to establish a definite diagnosis before discussing treatment.
81-year-old male that suffers from mixed incontinence with a prominent component of stress incontinence, following a transurethral procedure. Initially attempts were made to gain continence by a Lenzi's procedure, electro stimulation and various anticholinergis. All in all without satisfactory response. He underwent implantation of an artificial sphincter, the AMS AS 800 (AUS) that provided continence and the patient was content with the end result. The AUS was functioning fine until the patient underwent a road accident trauma, then a sphinteric prosthesis malfunction occurred.
58-year-old male diagnosed with sigmoid colon diverticulosis. In the past (2000&2008) he underwent trans urethral resections of bladder lesions which were diagnosed to be glandular cystitis cystica. Follow up cystoscopy performed lately revealed two new strawberry like lesions close to the bladder neck. Urine cytology was negative for malignant cells, pelvic ultrasound demonstrated a thickened bladder. The patient was offered another resection surgery.
47-year-old female who had the onset of persistent vertigo. The first evaluations revealed right beating nystagmus on gaze straight and to the right, unsteady gait with limb ataxia, and positive head thrust to the left. Improvement seemed to be occurring in that gait deviation with eyes closed was no longer present. Vestibular physical therapy exercises were started. On the next evaluations there was paroxysmal positional vertigo from the left ear and minimal neurosensory hearing loss. An audiogram showed minor neurosensory deafness.
47-year-old female with a diagnosis of Multiple Sclerosis ,who suffers from progressive tetraparesis, more pronounced in the lower extremities. Her treatment included mitoxantrone and Interferon-beta treatment, both were discontinued because of side effects. Her movement difficulties, due to the left lower limb rigidity, are increasing progressively.
5-year-old boy was diagnosed with neurofibromatosis type 1 (NF1) eight months after birth. He has displayed café-au-lait spots, axillary freckling, macrocephaly, sphenoid dysplasia, brain hamartomas, right temporal arachnoid cyst, and optic glioma. Visual evoked potentials showed evidence of bilateral functional deficit.
66-year-old male with a 6-year history of sensory symptoms in the feet and hands. He describes a sensation of cold and stinging in the feet; and numbness in the hands, especially at night. Nerve conduction and EMG demonstrated axonal and demyelinative sensorimotor neuropathy with neurogenic changes in muscles. Follow-up nerve conduction testing that was performed 2 years later showed similar findings.
