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Hyperthyroidism in autoimmune non-nodular thyroiditis

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.

Motor Neuropathy

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.

Stage 4 Neuroblastoma

1.5-year-old male suffered from eye swelling. His MRI revealed expansive lesion of left lateral orbital wall origin, with compression on the lateral rectus muscle. Later he was hospitalized due to fever and vomiting in left orbital lesion, suspecting a metastatic neuroblastoma. His eye examination revealed exophthalmus of the eye with exophoria and light dysfunction of the lateral rectus. His biopsies were indicative of stroma-poor neuroblastoma.

Motor Neuropathy – additional opinion

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.

Lichen planopilaris (follicular lichen planus) affecting the scalp

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.”

Erectile Dysfunction in Diabetes

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.

Visual disturbances of unknown etiology

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.
 

Stage 4 Neuroblastoma – additional opinion

1.5-year-old male suffered from eye swelling. His MRI revealed expansive lesion of left lateral orbital wall origin, with compression on the lateral rectus muscle. Later he was hospitalized due to fever and vomiting in left orbital lesion, suspecting a metastatic neuroblastoma. His eye examination revealed exophthalmus of the eye with exophoria and light dysfunction of the lateral rectus. His biopsies were indicative of stroma-poor neuroblastoma.

Chronic Pain in the Lower Rib Cage – Suspected Intercostal Neurinoma

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.

Suspected Fibromyalgia

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.

Autoimmune hepatitis/cholangitis in patient with Crohn’s disease.

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.

Left Knee Arthralgia

65-year-old female that suffers from pain in the left knee underwent examinations that showed femoral-tibial arthrotic manifestations, external degenerative meniscal tear and moderate joint effusion. A diagnosis of external degenerative meniscal tear was established. Further medical tests showed marked degeneration of the meniscal fibrocartilage, diffuse femoral-tibial arthrotic abnormalities, subchondral cysts and edema of the spongious bone, as well as rarefaction of the cartilage matrix, and manifestations of chondropathy.

Left cervicobrachialgia following cervical discectomy

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.

Child suffering from NF-1 and optic nerve glioma

5-year-old boy with diagnosis of neurofibromatosis type 1 underwent ophthalmological evaluation that showed picture of slight reduction in visual acuity of the right eye and severe hypovision of the left eye with slight reduction of the bilateral visual field. MRI showed presence of a big expansive lesion and of right temporopolar arachnoid cyst. The treating doctors recommended an urgent surgery in order to reduce the cerebral hypertension.

Asthenic-dispeptic syndrome post laparoscopic cholecystectomy

48-year-old male underwent laparoscopic cholecystectomy for symptomatic cholelithiasis. During post-surgery he developed intense abdominal colics and a situation of hepatitis, probably from medicines as the tests carried out. Performed tests revealed changes of haematic values related to the hepato-renal function. MR-cholangiography showed cystic formation in the right lobe of the liver, and tumor markers that gave evidence of an increase of alpha-fetoprotein which should be monitored.

Degenerative Maculopathy - additional opinion

81-year-old female with age related macular generation in both eyes. In the expert's opinion, she suffers from Non- Neovascular AMD with high risk characteristics to transform to the Neovascular form, and therefore she should have a retinal follow-up every 4 months, and receive the AREDS formulations of vitamins and minerals, that reduce the risk of losing vision from this condition.

Massive Portal and Mesenteric Vein Thrombosis

47-year-old male presented with un-provoked portal and mesenteric vein thrombosis that caused persistent radiating pains of upper abdominal quadrants. The examinations found heterozygous factor II mutation, and family survey for the factor II mutation was recommended. The patient started anticoagulant therapy. In the expert's opinion, the main risk factors for portal vein thrombosis are: Prothrombotic disorder, abdominal inflammation, cirrhosis, cancer, abdominal intervention and abdominal infection.

Artificial Urinary Sphincter Reimplantation

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.

Hepatic metastases from prostatic adenocarcinoma

A 66 year old man that was diagnosed with prostate cancer underwent radical prostatectomy 2 years ago. Pathology result of the surgical specimen revealed poorly differentiated prostate carcinoma with positive surgical margins. He was treated with antiandrogens and adjuvant radiation therapy. Since the beginning of the last year and under hormonal monotherapy with Casodex his PSA levels doubled. PET CT of the abdomen and the pelvis revealed hepatic lesion.

Facial pain after thyroidectomy

A 47 years old female underwent total thyroidectomy for papillary carcinoma of the thyroid, followed by treatment with radioactive Iodine (I131).
Since then, the patient has been suffering from severe facial pain (left>right), dry mouth and recurrent local infections. She was diagnosed with bilateral sialadenitis, and was repeatedly treated with endoscopy and repeat washing. Medical treatment for neurogenic pain wasn't helpfull, as well as visits to different salivary gland specialists.

Post Traumatic Double Pelvic Fracture

73-year-old female with history of backache and diagnosis of Adult Scoliosis, fell down getting a back trauma at the level of the left hip and inferior limb. After severe symptomatic worsening X-ray examination was performed. The findings were: asymmetric pelvis, bilateral coxarthrosis, coarse arthrosic and osteophytosic manifestations, discopathies and disc arthrosis. The prescribed therapy included Piroxicam, Tioside, Depalgos, and low-molecular-weight-heparin therapy that was later replaced by NSAIDs by injection

Right foot pain

38-year-old female started to suffer pain in her right foot on without a notable trauma. She was examined by several orthopeadic doctors and she got different opinions. The first diagnosed medium sprain of right foot and slight tumefaction on forefoot, and suggested her paracetamol administration that was with no benefit. The second specialist diagnosed sesamoiditis and right plantar fasciitis with 3rd degree cavus-valgus feet and recommended Depomedrol + Lidocaine, Pennsaid drops and NSAIDs. As part of the examinations she underwent an MR with and without Gadolinium.

Chronic relapsing, non progressing eruption of purpuric papulovesicular lesions

A 57 year old female complained about appearance of red to dark red pruritic bullous lesions . These lesions were, and still are, located on the legs from the knee to the ankles, and on the back of the feet. These manifestations appeared in variable phases during the next 4 years, with episodes of more numerous pustules appearing in some periods, and more isolated in other periods.

Post traumatic pain in knee

A 37 years old female suffered from multiple traumas caused by road accident with admittance to emergency room- multiple contusions, cervicalgia(due to whiplash) and contusion-laceration injury to left knee. An MRI scan of the knee was performed two months later (MRI findings are attached below) and the patient was examined by a specialist who gave a diagnosis of medial meniscal tear and femur-kneecap pain in the left knee. A broken medial meniscus of the left knee diagnosis should lead to an arthroscopic operation.

Multiple Sclerosis_2

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.

NF-1 and optic nerve glioma – additional opinion

5-year-old boy with diagnosis of neurofibromatosis type 1 underwent ophthalmological evaluation that showed reduction in visual acuity and reduction of the bilateral visual field. MRI showed presence of a big expansive lesion and of temporopolar arachnoid cyst. The treating doctors recommended an urgent surgery in order to reduce the cerebral hypertension. In the expert's opinion, after having seen the images, the arachnoid cyst has not changed that much, and probably has little impact or effect, and therefore meanwhile no surgery is warranted.

Multiple Sclerosis_1

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.

Cluster headache

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.

Bilateral Pronatory Syndrome Greater in the right foot – additional opinion

10-year-old female with pain and swelling of the right foot was diagnosed bilateral pronatory syndrome. The specialist recommended foot surgery for the lengthening of the Achilles tendon and application of retrograde endorthesis screw. The expert disagrees with the necessity of this procedure, and suggests differential diagnosis and conservative treatment that includes pain killers, soft shoes with soft insoles inside and mild elevation of the medial longitudinal arch of the feet.

Demyelinizing Disease

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.

Guillain-Barré Syndrome / Acute Myeloradiculoneuritis

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.

Persistent Vertigo

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.

Severe Osteoporosis and Multiple Vertebral Fractures

82-year-old female with severe osteoporosis manifests with vertebral fractures. During treatment with Risedronate, she suffered another fracture. In the expert's opinion, taking into account the patient's age, the presence of fractures and low BMD, the patient is at a very high risk to develop a recurrent fracture so treatment must be given. The expert recommends to rule out secondary causes for osteoporosis such as vitamin D deficiency, to keep a healthy as possible way of life, and change the treatment with Risedronate to Forteo (Teriparatide).

Long-term results of mandibular bone grafting operations

48-year-old male who had undergone multiple surgical attempts to augment mandibular bone for implant placement ('pins'). The patient received the opinion of a spesialist who spotted severe atrophy in the right mandibular posterolateral area. He reported on the condition of the mucosa with high insertion of frenii in the level of the alveolar ridge. Also the report related to occlusion problem and temporo mandibular dysfunction. In 2007, the patient received a report following a neurophysiological examination of the masseter muscle showing a change in sensation from the lower alveolus.

Low back pain due to spondylosis and degenerative disc disease

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.

Right Knee Pain

41-year-old male that in the past decade had suffered 2-3 times a year from bilateral knee pain which resolved spontaneously. Last year he had episodes of thumb pain that had lasted for several weeks and had affected grasp movements. The patient had responded to NSAID treatment for 2 weeks. MRI of the right knee showed Mild endoarticular effusion in the sub-quadriceps recess, chondropathy of the femoropatellar joint and lesion of the medial meniscus.

Spinal column pathology - additional opinion

39-year-old male experienced in 1994 intense lower back pain after lifting weights, with spontaneous resolution. In 2006, he again experienced lower back pain radiating into both thighs. A lumbar MRI showed degenerative changes and EMG test showed L5 nerve root irritation. His physical examination demonstrated increased reflexes and a concern for cervical stenosis was entertained. Further cervical MRI and lumbar studies showed arthritic changes, and the thoracic MRI showed evidence of spinal cord compression. The surgeon suggested posterior thoracic laminectomy.

Left lumbosciatic pain from double disc protrusion

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.

Possible Anorexia, Vomiting, Failure to Gain Weight and Linear Growth Retardation

21-month-old female who was born at almost 29 weeks weighing only 650g and with birth height of 31 cm. Her major problems have been poor feeding, failure to gain weight and linear growth retardation. The poor feeding has been handled by an NG tube and subsequently, food administration through a direct gastric tube via a gastrostomy. She gradually gained weight to the extent of being overweight for her height. Laboratory evaluation revealed low absolute numbers of neutrophils low lymphocyte count. Endocrynology and Genetics workup were normal.