[ { "id": "multiclinsum_test_1245_en.txt", "fulltext": "A 24-year-old gentleman with no past medical history had been experiencing debilitating chest pains for 2 years. He described these as varying in intensity, worsened by exercise, and relieved partially by analgesia. They were not associated with palpitations or syncope.\nUnfortunately, due to his symptoms he had to give up his studies and minimize his physical activity. He had trialled multiple analgesics (daily paracetamol and tramadol) with partial relief of symptoms.\nHe underwent serial investigations at his local cardiology unit, including a cardiac CT which identified an absence of pericardium on the left side of the heart. He was referred to the Adult Congenital Heart Disease (ACHD) team at The Royal Brompton Hospital.\nWhen first reviewed in the ACHD clinic he was not cyanosed, in sinus rhythm with no evidence of cardiovascular decompensation. His apex beat however was grossly displaced to the left and more so on lying supine. His first heart sound was normal, second split, there was also a soft one-sixth systolic heart murmur. The rest of his examination was unremarkable.\nHis electrocardiogram showed him to be in sinus rhythm at 78 b.p.m., with normal conduction times but a poor R wave progression and an intermittently changing axis.\nA chest radiography which showed situs solitus, levocardia, with a left aortic arch, no displacement of the heart to the left, and a protrusion at the level of the left atrial appendage at the left upper quadrant of the heart.\nHis echocardiogram showed a structurally normal heart with maintained ventricular function. Stress echocardiography showed mild right ventricular dilatation at rest with increase in right ventricular volume directly after exercise. A cardiac CT revealed a partial absence of pericardium on the left side with a small layer of pericardium on the upper right heart border. The heart was grossly shifted leftwards and posteriorly, highly suggestive of enhanced heart mobility. Similarly, no pericardium could be seen on cardiac magnetic resonance imaging (CMR). There was lung tissue in between the base of the heart and diaphragm , the heart was displaced to the left of the chest and the RV appeared dilated .\nThe patient’s symptoms were thought to be due to his absent pericardium and related to cardiac mobility. We were struck by the discrepancy of the erect Chest X-ray (CXR) and supine CMR with regards to cardiac position, mobility, and the severity of disabling symptoms. We thus discussed the patient at our ACHD Multidisciplinary Team meeting and offered him surgery, in an attempt to immobilize his heart, hoping to improve his symptoms and quality of life.\nThe heart was exposed via a left postero-lateral thoracotomy. There was complete pericardial agenesis on the left side and on the diaphragmatic surface. Several 0.4 mm thickness Gore-tex® patches were sutured together to create a large sheet and this was sutured down with widely spaced interrupted 3-0 Prolene® sutures to the posterior mediastinum, starting at the level of the left pulmonary artery, posterior to the left atrial appendage and along the left hilum and inferior pulmonary ligament, to the diaphragm and down. This was then brought forward to the anterior chest wall and then fixed anteriorly along the anterior chest wall with the superior end free (see Figure ). A left pleural drain was inserted and a paravertebral catheter for analgesia, followed by routine multilayered chest closure.\nThe post-operative course was uneventful apart from a small left apical pneumothorax with a small pleural effusion. Both resolved spontaneously within days.\nEchocardiography on Day 5 showed that the RV was of normal size with no evidence of pericardial effusion nor compression of cardiac chambers. The patient was discharged 8 days after his procedure on simple analgesia, mobilizing well with improved symptoms.\nThree months from surgery the patient had come off analgesia completely, with resolution of his debilitating chest pains. He was resuming his University studies and restoring normality in his life.", "summary": "A 24-year-old otherwise fit and well patient, with debilitating exertional chest pain was found to have complete pericardial agenesis on the left side and on the diaphragmatic surface. There was gross cardiac mobility demonstrated on cardiac magnetic resonance imaging. His pericardium was reconstructed surgically using Gore-tex® patches. There were no complications, and the patient was discharged 8 days later. Three months later at follow-up, the patient required no analgesia and has had complete resolution of his chest pains.", "subclaim_evaluations": [ { "subclaim": "The patient is a 24-year-old man.", "support_label": "supported" }, { "subclaim": "The patient had debilitating exertional chest pain.", "support_label": "supported" }, { "subclaim": "The patient had complete pericardial agenesis on the left side.", "support_label": "supported" }, { "subclaim": "The patient had complete pericardial agenesis on the diaphragmatic surface.", "support_label": "supported" }, { "subclaim": "Cardiac magnetic resonance imaging showed gross cardiac mobility.", "support_label": "supported" }, { "subclaim": "The patient underwent surgical pericardial reconstruction.", "support_label": "supported" }, { "subclaim": "Gore-tex® patches were used for pericardial reconstruction.", "support_label": "supported" }, { "subclaim": "The patient was discharged 8 days after surgery.", "support_label": "supported" }, { "subclaim": "The patient had no complications after surgery.", "support_label": "supported" }, { "subclaim": "At 3-month follow-up, the patient required no analgesia.", "support_label": "supported" }, { "subclaim": "At 3-month follow-up, the patient had complete resolution of chest pain.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1052_en.txt", "fulltext": "A 57-year-old Greek man was referred to our facility with pain, hemorrhage and a gangrenous smell due to a so-called wound on his penis. A physical examination revealed the complete absence of his penis and a large chasm in the lower abdominal wall, which made it possible to see parts of the lower pelvis, such as the spermatic cords, the destroyed basis of the corpora cavernosa and the residual stump of the urethra. The scrotum and the testicles were stiff and were possibly invaded by the cancer. In the chasm margins, we could detect hemorrhagic and necrotic areas . The inguinal lymph nodes were palpable, hard and mobile. Our patient was in a good general condition and his body temperature was normal. From his medical history, he had discovered a lesion in his inner prepuce 18 months before. He had requested medical advice at a private health center concerning that lesion. According to his recollection, a biopsy had been taken and he was diagnosed as having penile cancer (this biopsy could not be found, as he did not ask for a copy of it at the time and the private health center failed to track our patient's data as he was never hospitalized there). The physicians at the time suggested he should undergo a partial penectomy, but he refused and stopped seeking medical treatment.\nThe lesion slowly progressed, eventually involving the whole penis. He could not specify the exact time his penis sloughed off completely. He was not circumcised. Standard laboratory test results showed that his values were within normal limits except for a small rise in white blood cell count (14,750 cells/μL) and microcellular anemia (hemoglobin = 9.8 g/dL, hematocrit = 31.2%). A chest X-ray did not show any remarkable findings. An abdominal computed tomography (CT) scan showed lymph nodes of a pathological size and number, bilateral in the iliac vessels and inguinal areas as well as an erosion of the pubic bone . We proceeded with a chest CT scan, which did not show any distant metastases or lymph nodes. On the first day of his hospitalization, we obtained biopsies from the chasm margins and identified a poorly differentiated SCC. The clinical staging was T4N3M0 and our patient was treated with chemotherapy and regional radiotherapy. We also performed a bilateral cutaneous ureterostomy, with a Gibson incision in order to protect the corroded tissues from further urine impregnation . From a combination of regional radiotherapy and bilateral cutaneous ureterostomy, total dryness of the wound was achieved. During his extended hospitalization, he presented with deep vein thrombosis in the right shin vein and seizures that were attributed to small ischemic brain strokes after a brain CT scan. Debulking and flap coverage of the wound was not considered possible, firstly because of deep vein thrombosis, epileptic seizures and his poor general condition increased the risk from operation and secondly the size of the chasm combined with very poor vascularization of the region (a topical angiography was performed). Gradually, our patient developed depression, denial of feeding and loss of weight. He died 18 months after his first admission and six months after his last follow-up admission to our clinic.", "summary": "Our case report does not concern a new manifestation of penile cancer, but an interesting presentation with clinical significance that emphasizes the need to diagnose and treat penile cancer early. It is an unusual case of a neglected penile cancer in a 57-year-old Greek man that led to auto-amputation of the penis and a large chasm in the lower abdominal wall. The clinical staging was T4N3M0 and our patient was treated with a bilateral cutaneous ureterostomy, chemotherapy and radiotherapy. Our patient died 18 months after his first admission in our clinic.", "subclaim_evaluations": [ { "subclaim": "The case report is not about a new manifestation of penile cancer.", "support_label": "supported" }, { "subclaim": "The case report describes an interesting presentation with clinical significance.", "support_label": "supported" }, { "subclaim": "The case emphasizes the need to diagnose and treat penile cancer early.", "support_label": "supported" }, { "subclaim": "The case involves a 57-year-old Greek man.", "support_label": "supported" }, { "subclaim": "The man had a neglected penile cancer.", "support_label": "supported" }, { "subclaim": "The neglected penile cancer led to auto-amputation of the penis.", "support_label": "supported" }, { "subclaim": "The neglected penile cancer led to a large chasm in the lower abdominal wall.", "support_label": "supported" }, { "subclaim": "The clinical staging was T4N3M0.", "support_label": "supported" }, { "subclaim": "The patient was treated with a bilateral cutaneous ureterostomy.", "support_label": "supported" }, { "subclaim": "The patient received chemotherapy.", "support_label": "supported" }, { "subclaim": "The patient received radiotherapy.", "support_label": "supported" }, { "subclaim": "The patient died 18 months after his first admission to the clinic.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2359_en.txt", "fulltext": "A 68-year-old Caucasian male presented for surgical evaluation with a right mid-infraclavicular chest mass from referral of his primary care physician . Three years prior, the patient presented with a mass at the same location, subsequently diagnosed as a lipoma and locally excised with no surgical complications. At the time of the previous surgery, it was incidentally discovered and diagnosed that the patient also had diffuse B cell lymphoma, complete remission status post chemotherapy. Family, psychosocial, drug, and other surgical history were noncontributory. Over the past three years, the mass increased in size, but did not have any discoloration, discharge, or pain; however, due to the patient’s past medical history and immunocompromised state, the patient expressed concern and presented for elective excision of the mass.\nOn physical exam, a mass was palpated at the midclavicular line of the right upper chest, within the right first intercostal space. The mass was directly under the scar from previous excision, with no skin discoloration, telangiectasia, or visible raised nodules. The patient denied any pain, tenderness, or discharge associated with the new mass. Radiological testing was performed to determine the exact location and depth of invasion. CT chest with and without contrast revealed an ill-defined, cutaneous mass, while MRI chest was nondiagnostic.\nSurgical excision was performed under local anesthesia, with a wide, elliptical incision to the level of the underlying bony structures to ensure clean margins. Excised specimen measured 5.5 cm × 3.5 cm × 2 cm with surrounding 4 cm × 1.6 cm × 0.4 cm of skin attached. The resulting wound was closed using interrupted 4–0 plain gut sutures for the full thickness, with 3–0 Vicryl subdermal and 4–0 Monocryl subcuticular reinforcing sutures.\nThe specimen was sent to pathology for cryosectioning; however, due to increase in cellularity at the posterior margin, permanent fixation was performed. Within the submitted specimen, a subcutaneous firm nodule measuring 1.6 cm × 1 cm × 0.7 cm was located in the superior aspect with a 0.1 cm surrounding margin. Microscopic examination with hemolysin and eosin staining showed whorled myoid with spindled nuclei in storiform array throughout the dermis and extending into the subcutaneous fat with widening fibrous septa (, ). The specimen was also composed of uniform, small elongated cells and scant cytoplasm with frequent mitotic figures and giant cells. The sample stained positively for CD34 and ultimately diagnosed as DFSP .\nAs a result of the close margin excision, the patient was referred for radiation therapy with imatinib for recurrence prevention. Upon the last two follow-ups status post imatinib treatment, there have been no signs of recurrence.", "summary": "Here we present an atypical presentation of DFSP in a patient with a recurrent mass that was initially diagnosed as a lipoma, with supporting literature and clinical considerations for post-surgical management DISCUSSION: In its earlier stages, DFSP can mimic other benign or malignant dermatological pathologies, which can complicate diagnosis purely via history and physical exam. Atypical features such as prior surgical management, morphology, and location can complicate the clinical diagnosis of DFSP. Immunohistochemistry is often required for definitive diagnosis as DFSP is CD34+ and is histologically described as spindle-cells in whorled or storiform pattern, with uniform, small elongated cells.", "subclaim_evaluations": [ { "subclaim": "DFSP can present atypically.", "support_label": "supported" }, { "subclaim": "A patient had a recurrent mass initially diagnosed as a lipoma.", "support_label": "supported" }, { "subclaim": "DFSP can mimic benign dermatological pathologies.", "support_label": "supported" }, { "subclaim": "DFSP can mimic malignant dermatological pathologies.", "support_label": "supported" }, { "subclaim": "DFSP diagnosis can be complicated by prior surgical management.", "support_label": "supported" }, { "subclaim": "DFSP diagnosis can be complicated by morphology.", "support_label": "supported" }, { "subclaim": "DFSP diagnosis can be complicated by location.", "support_label": "supported" }, { "subclaim": "Immunohistochemistry is often required for definitive DFSP diagnosis.", "support_label": "supported" }, { "subclaim": "DFSP is CD34+.", "support_label": "supported" }, { "subclaim": "DFSP is histologically described as spindle-cells in whorled or storiform pattern.", "support_label": "supported" }, { "subclaim": "DFSP histology shows uniform, small elongated cells.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1941_en.txt", "fulltext": "We obtained a verbal informed consent from the patient and a written informed consent from a family member of the patient for publication of this case.\nAn 83-year-old man was transported to our emergency department, with a tentative diagnosis of heat stroke. He had previously been fit and healthy, except for undergoing colorectomy for colorectal cancer 8 years ago. He also received a central venous port system, a BardPort Titanium implantable port with its and 8.0 Fr Groshong® silicone catheter (Bard Access Systems, Inc., Salt Lake, USA) which was inserted through the right internal jugular vein, for chemotherapy.\nHe was transferred to the intensive care unit, where surface cooling and intravenous hydration were performed to treat heat stroke. He made a rapid recovery, and he had become able to eat on the same day.\nNext morning, he suddenly developed ventricular fibrillation. Cardiopulmonary resuscitation was performed immediately, his trachea was intubated, and he was sedated with continuous infusion of propofol. He had not complained any chest pain before the occurrence of ventricular fibrillation, and the electrocardiography indicated neither arrythmias nor ST changes, before and after the occurrence of ventricular fibrillation. Analysis of arterial blood taken after resuscitation indicated no abnormalities in the blood gases and the blood electrolyte; troponin was not measured. A chest radiograph, which was taken after resuscitation , indicated a previously placed central venous catheter access port, without any obvious abnormalities.\nEmergency coronary angiography, performed shortly after ventricular fibrillation, identified a 90% stenosis of the left anterior descending coronary artery. The cardiologists considered that this was not the direct cause of ventricular fibrillation, as the extent to which the blood flow in the coronary artery would not bring about ventricular fibrillation. The angiography instead identified a more likely cause: a foreign body in the coronary sinus.\nClose re-examination of the chest radiograph taken after resuscitation showed a long catheter-like foreign body (approximately 20 cm) in the heart . Chest computed tomography also confirmed the presence of the foreign body . We diagnosed that a long catheter-like foreign body, likely to be a fragmented central venous catheter, was in the coronary sinus.\nIn the angiography suite, physicians attempted to remove the foreign body. However, the attempts were abandoned, as the pull of the catheter resulted in repeated ventricular fibrillation. The patient was successfully resuscitated. Surgical removal was planned the next day.\nOn the next day, the patient was transferred to an operating room, and routine monitors, such as a pulse oximeter, a blood pressure cuff, and electrocardiogram, were attached. We prepared an electric defibrillator, and cardiac surgeons were present in the room. The breathing system of an anesthesia machine was connected to the tracheal tube, and general anesthesia was induced with sevoflurane 1.5% and fentanyl 0.1 mg; neuromuscular blockade was achieved with rocuronium 50 mg. Anesthesia was maintained with sevoflurane and oxygen in air.\nThe patient underwent sternotomy, and transesophageal echocardiography identified the fractured catheter in the coronary sinus . The right atrium was opened under cardiopulmonary bypass. Surgeons could remove the fractured catheter (approximately 20 cm in length) , but with great difficulty, by gently pulling the edge of the catheter with rotating movement. After the operation, the electrocardiogram indicated no arrhythmia or cardiac ischemia.\nOn the next day of the operation, his family requested strongly to treat the coronary stenosis, and thus, cardiac physicians placed a stent in the left anterior descending artery without complications. He was discharged from the hospital on postoperative day 14, to a rehabilitation facility, and he went home at a later day.", "summary": "An 83-year-old man with heat stroke was transferred to our emergency department, where he was treated and became able to eat on the same day. He had been fit and healthy, except for colorectomy and chemotherapy using a central venous access port placed in the right upper jugular vein 8 years ago. The next day, he suddenly had ventricular fibrillation. Cardiopulmonary resuscitation was successful. Emergency coronary angiography showed a catheter-like foreign body in the coronary sinus. Physicians failed to remove the foreign body using catheter therapy, and ventricular fibrillation occurred repeatedly. After induction of general anesthesia, the fractured catheter was removed surgically. Postoperative course was uneventful.", "subclaim_evaluations": [ { "subclaim": "The patient was an 83-year-old man.", "support_label": "supported" }, { "subclaim": "The patient had heat stroke.", "support_label": "supported" }, { "subclaim": "He was transferred to the emergency department.", "support_label": "supported" }, { "subclaim": "He was treated and became able to eat on the same day.", "support_label": "supported" }, { "subclaim": "He had a colorectomy 8 years ago.", "support_label": "supported" }, { "subclaim": "He had chemotherapy using a central venous access port.", "support_label": "supported" }, { "subclaim": "The port was placed in the right upper jugular vein.", "support_label": "supported" }, { "subclaim": "The next day, he had ventricular fibrillation.", "support_label": "supported" }, { "subclaim": "Cardiopulmonary resuscitation was successful.", "support_label": "supported" }, { "subclaim": "Emergency coronary angiography showed a catheter-like foreign body in the coronary sinus.", "support_label": "supported" }, { "subclaim": "Physicians failed to remove the foreign body using catheter therapy.", "support_label": "supported" }, { "subclaim": "Ventricular fibrillation occurred repeatedly.", "support_label": "supported" }, { "subclaim": "The fractured catheter was removed surgically after induction of general anesthesia.", "support_label": "supported" }, { "subclaim": "The postoperative course was uneventful.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1110_en.txt", "fulltext": "A 52-year-old female with complaints of the right knee pain and swelling was referred to us in the outpatient clinic with a diagnosis of Baker’s cyst. The pain increased on squatting and climbing stairs and was associated with swelling in the posteromedial aspect of the knee joint for the past 11 months. There was no history of the previous trauma, no intermittent locking of the knee joint, and unremarkable medical history. On examination, there was a solitary, firm, cystic, fluctuant, immobile, and slightly tender swelling on the posteromedial aspect of the right knee joint of size around 4 3 cm with no local signs of inflammation. There was joint line tenderness on the medial aspect with positive McMurray’s test for a medial meniscus tear and no ligamentous instability. Knee range of motion was 0–120 with terminal flexion painful. The plain radiograph showed evidence of early osteoarthritis of the medial compartment along with patellofemoral arthritis. MRI knee demonstrated a large well-defined cystic lesion medial to semimembranosus and semitendinosus at the posteromedial aspect of the right knee joint of size around 3.9 3.0 2.5 cm with few thin internal septations. The lesion was hyperintense on T2-weighted and fat suppression images while it was hypointense on T1 weighted image ( and ) also noted was a horizontal tear in the posterior horn and body of the medial meniscus and oblique tear in the posterior horn of the medial meniscus. The patient was posted for surgery and underwent arthroscopic partial medial meniscectomy and open excision of the cyst in its entirety along with its stalk through a medial incision under spinal anesthesia . The base of the cyst was traced and sutured with the synovial lining, thereby repairing the defect. The excised sample was sent for histopathological evaluation and found to be a cystic structure lined by flattened epithelium with walls made of fibrocollagenous tissue infiltrated sparsely with lymphonuclear infiltrate and foamy histiocytes which were consistent with a meniscal cyst. Post-operative period was uneventful and at 2-year follow-up, there was no recurrence, pain, instability, or locking of knee joint. The patient had 0–120 active, painless range of motion at the knee joint. The patient was able to return to her daily activities without any limitations.", "summary": "We report a case of a large symptomatic medial parameniscal cyst in 52-year-old female which was clinically misdiagnosed as Baker's cyst. The patient had swelling over the posteromedial aspect of the right knee with difficulty and pain on squatting. Magnetic resonance imaging (MRI) reported horizontal tear in the posterior horn of medial meniscus and parameniscal cyst adjacent to medial meniscus with features of early osteoarthritis of the knee. She was successfully treated with open excision and repair of the defect of the cyst along with arthroscopic partial medial meniscectomy.", "subclaim_evaluations": [ { "subclaim": "The patient was a 52-year-old female.", "support_label": "supported" }, { "subclaim": "She had a large symptomatic medial parameniscal cyst.", "support_label": "supported" }, { "subclaim": "The cyst was initially misdiagnosed as a Baker's cyst.", "support_label": "not_supported" }, { "subclaim": "She had swelling over the posteromedial aspect of the right knee.", "support_label": "supported" }, { "subclaim": "She had difficulty and pain on squatting.", "support_label": "supported" }, { "subclaim": "MRI showed a horizontal tear in the posterior horn of the medial meniscus.", "support_label": "supported" }, { "subclaim": "MRI showed a parameniscal cyst adjacent to the medial meniscus.", "support_label": "supported" }, { "subclaim": "MRI showed features of early osteoarthritis of the knee.", "support_label": "supported" }, { "subclaim": "She was treated with open excision and repair of the cyst.", "support_label": "supported" }, { "subclaim": "She was treated with arthroscopic partial medial meniscectomy.", "support_label": "supported" }, { "subclaim": "The treatment was successful.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2892_en.txt", "fulltext": "A 39-year-old woman was admitted complaining of sudden-onset headache, nausea, and vomiting for 1 day. She had a history of hypertension for 10 years and denied any history of diabetes, hyperlipidemia, autoimmune diseases, or other remarkable illnesses. She was alert and could correctly obey commands. Physical examination was unremarkable except for neck stiffness. Her blood glucose, electrolytes, blood cell counts, coagulation test, and antinuclear antibody series were within normal limits during laboratory investigations.\nHead computed tomography (CT) showed a subarachnoid hemorrhage (SAH) concentrated in the perimesencephalic cistern . CT angiography (CTA) showed that the bilateral ICAs were absent in the skull base . The bilateral MCAs and anterior arteries were normal. An aneurysm was identified in the PCA region .\nHead digital subtraction angiography (DSA) showed that the bilateral internal maxillary arteries and ascending pharyngeal arteries were confluent with the cavernous portion of the ICAs at the skull base. And the bilateral ICAs above the cavernous portion of the ICAs, the MCAs, and the anterior cerebral arteries were normal . The right vertebral artery (VA) was fine, while the left VA was well developed . Moyamoya-pattern collateral vessels could be seen in the bilateral PCAs region, the distal part of the PCA was composed of abnormally fine vessels, and an aneurysm was clearly identified in the left moyamoya-pattern collateral vessels .\nShe was diagnosed as bilateral carotid RM, moyamoya-like vessels in the PCA region, intracranial pseudoaneurysm, and SAH. Management of the aneurysm was difficult, and wait and see management was adopted. The patient experienced an uneventful recovery and was discharged 1 week later. Follow-up CT performed 44 days later showed complete resolution of the SAH . Head DSA revealed that the pseudoaneurysm disappeared spontaneously while the moyamoya-pattern collateral vessels were unchanged, the distal part of the PCAs became finer and smaller, and the transdural compensation of the posterior meningeal artery was visible . The patient was in good condition during follow-up, she returned to her normal activities.", "summary": "A 39-year-old woman was admitted complaining of sudden-onset headache, nausea, and vomiting. Further investigation revealed subarachnoid hemorrhage (SAH), carotid RM, a moyamoya collateral pattern in the PCA region, and a pseudoaneurysm in the moyamoya-like vessels. The patient was treated conservatively, recovered well and was discharged 1 week later. Follow-up angiography showed that the aneurysm had disappeared.", "subclaim_evaluations": [ { "subclaim": "The patient is a 39-year-old woman.", "support_label": "supported" }, { "subclaim": "She was admitted with sudden-onset headache.", "support_label": "supported" }, { "subclaim": "She reported nausea.", "support_label": "supported" }, { "subclaim": "She reported vomiting.", "support_label": "supported" }, { "subclaim": "Subarachnoid hemorrhage was diagnosed.", "support_label": "supported" }, { "subclaim": "A carotid RM was found.", "support_label": "supported" }, { "subclaim": "A moyamoya collateral pattern was observed in the PCA region.", "support_label": "supported" }, { "subclaim": "A pseudoaneurysm was identified in the moyamoya-like vessels.", "support_label": "supported" }, { "subclaim": "The patient was treated conservatively.", "support_label": "supported" }, { "subclaim": "She recovered well.", "support_label": "supported" }, { "subclaim": "She was discharged 1 week after admission.", "support_label": "supported" }, { "subclaim": "Follow-up angiography showed the aneurysm had disappeared.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_38_en.txt", "fulltext": "A 66-year-old male patient was referred to our department with a right intraventricular mass that had been diagnosed as anaplastic ependymoma on open biopsy at another hospital.\nHe had been followed because of diabetes mellitus, hyperlipidemia, and carotid artery stenosis but had been otherwise well. Two months before admission to our department, he had undergone magnetic resonance imaging (MRI) of the head, which incidentally revealed a mass lesion in the right lateral ventricle, for which he had been referred to the neurosurgery department at another hospital. He underwent a biopsy and the tumor was diagnosed as an anaplastic ependymoma. Although he had been initially referred to a Radiation Oncology Department for adjuvant radiation therapy, the provider referred him to our Department of Neurosurgery because of concerns that the residual tumor was not suitable for radiotherapy without prior cytoreduction.\nPhysical examination showed some short-term memory impairment, and ophthalmological examination revealed a visual field compromise (quadrantanopia) likely related to access corridor chosen for the biopsy. There was no focal motor weakness, major sensory deficit, dysmetria, or ataxia.\nComputed tomography (CT) showed two hyperdense foci in the inferior horn and the atrium of the right lateral ventricle with peri-lesional edema of the ipsilateral temporo-occipital parenchyma [Figure and ]. The intraventricular lesions showed heterogeneous enhancement on postcontrast T1-weighted imaging (T1WI), on which the lesions appeared to arise from the choroid plexus [Figure –]. The postcontrast T1WI also showed additional tumor dissemination in the left lateral ventricle and around the brain stem . Further whole-spine imaging showed leptomeningeal dissemination in the lumbar region (not shown).\nThe patient was taken to surgery and underwent subtotal removal of the tumor in the right lateral ventricle via an inferior temporal gyrus approach [Figure and ]. The tumor was solid, densely adherent to the choroid plexus but floating in the ventricle .\nHistopathologically, the tumor showed diffuse, tightly packed monotonous neoplastic cells with large, round, or slightly irregular nuclei and a scant to moderate amount of eosinophilic cytoplasm . There were numerous mitotic figures and foci of focal necrosis. Perivascular pseudorosettes were not discernible. On immunohistochemical staining panels, the tumor cells were positive for leukocyte common antigen (LCA), CD20 , CD30, CD79a, bcl-2, bcl-6 , and MUM-1; and negative for cytokeratins, epithelial membrane antigen, S-100 protein, and glial fibrillary acidic protein.\nOphthalmological examination showed no intraocular lesions. CT of the chest, abdomen, and pelvis was interpreted as normal and bone marrow biopsy showed no atypical lymphocytic infiltrate. The patient was thus diagnosed with primary diffuse large B-cell CNS lymphoma likely originating in the choroid plexus.\nThe patient underwent chemotherapy with high-dose methotrexate (3500 mg/m2) every 14 days for three courses, followed by a course of chemotherapy with carboplatin (360 mg calculated by using the Calvert formula) and etoposide (80 mg/m2) 14 days after the third administration of high-dose methotrexate. After chemotherapy, cerebrospinal fluid (CSF) samples were obtained for cytology, which was negative for malignant cells. After the patient had undergone whole-brain irradiation (1.8 Gy × 22), postcontrast T1WI showed complete resolution of all previously visible CNS disease. Physical examination showed persistent quadrantanopia—unchanged from the patients status prior to subtotal removal of tumor—and amelioration of his short-term memory impairment. Because meningeal dissemination recurred during the follow-up period, the patient is currently again receiving chemotherapy with high-dose methotrexate in our department (8 months after surgery).", "summary": "A 66-year-old male patient was referred to our department with a right intraventricular mass that had been diagnosed by biopsy at another hospital as anaplastic ependymoma. The patient underwent subtotal removal of the tumor via a transcortical inferior temporal gyrus approach. The mass was attached to the choroid plexus in the right atrium. Histopathological examination showed diffuse large B-cell lymphoma. Ophthalmological examination, blood tests, computed tomography of the whole body, and bone marrow biopsy did not show any other lesion, leading to the diagnosis of primary choroid plexus lymphoma. The patient underwent chemotherapy with three courses of high-dose methotrexate and one course of carboplatin and etoposide followed by whole-brain irradiation (1.8 Gy × 22).", "subclaim_evaluations": [ { "subclaim": "The patient is a 66-year-old male.", "support_label": "supported" }, { "subclaim": "The patient was referred with a right intraventricular mass.", "support_label": "supported" }, { "subclaim": "The mass was diagnosed by biopsy as anaplastic ependymoma at another hospital.", "support_label": "supported" }, { "subclaim": "The patient underwent subtotal removal of the tumor via a transcortical inferior temporal gyrus approach.", "support_label": "supported" }, { "subclaim": "The mass was attached to the choroid plexus in the right atrium.", "support_label": "supported" }, { "subclaim": "Histopathological examination showed diffuse large B-cell lymphoma.", "support_label": "supported" }, { "subclaim": "Ophthalmological examination did not show any other lesion.", "support_label": "supported" }, { "subclaim": "Blood tests did not show any other lesion.", "support_label": "not_supported" }, { "subclaim": "Computed tomography of the whole body did not show any other lesion.", "support_label": "supported" }, { "subclaim": "Bone marrow biopsy did not show any other lesion.", "support_label": "supported" }, { "subclaim": "The diagnosis was primary choroid plexus lymphoma.", "support_label": "supported" }, { "subclaim": "The patient received three courses of high-dose methotrexate.", "support_label": "supported" }, { "subclaim": "The patient received one course of carboplatin and etoposide.", "support_label": "supported" }, { "subclaim": "The patient underwent whole-brain irradiation at 1.8 Gy × 22.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_51_en.txt", "fulltext": "A 67-year-old Caucasian woman with an unremarkable medical and breast history was referred to our breast unit with a screen-detected right breast mass. Mammography had revealed a fairly well-circumscribed 2 cm lesion located deep and in close proximity to the nipple and was graded as M3 on the Breast Imaging Reporting and Data System scale. Her physical examination and ultrasound showed no abnormalities. A subsequent diagnostic biopsy revealed an infiltrating ductal carcinoma with an adenoid cystic component. The patient was treated with simple mastectomy and sentinel node biopsy. The histologic examination revealed a lesion of 1.7 cm maximum diameter with mixed infiltrating NOS ductal carcinoma and ACC characteristics. The four sentinel nodes were all free of cancer. She had a good post-operative course and remained well with no evidence of recurrence 24 months later.\nThe tumor was whitish tan and was ill defined in appearance and firm in consistency. No nipple or skin involvement was present. Both the nuclear grade of the lesion and the Bloom-Richardson grade were two based on the overall appearance of the tumor. The lymph nodes were negative. The tumor was staged as T1N0M0 and was estrogen receptor (ER)- and progesterone receptor (PR)-negative. The proliferative activity was low as measured by the Ki-67 labeling method (12%). Immunohistochemically, overexpression of the proto-oncogene HER2/neu was found in 15% of the carcinomatous cells. In fluorescence in situ hybridization analysis, which was performed at a later stage, no protein amplification was ascertained.\nTwo histological patterns were blending into each other without a clear-cut boundary between them . The dominant pattern, comprising more than 70%, was an ordinary, moderately differentiated ductal carcinoma NOS. It consisted of tubule islands and cribiform structures with epithelial cells exhibiting a high nuclear-to-cytoplasmic ratio, dark nuclear chromatin, and inconspicuous nucleoli. The mitotic index was low (< 2/10 hematopoietic tissue).\nThe rest of the histological pattern was limited and mainly consisted of well-defined nests and pseudo-glandular structures occasionally filled with homogeneous basophilic (periodic acid-Schiff stain-positive) material. Interestingly, the neoplasmic nests contained predominantly basaloid cells with sparse cytoplasm coexisting with epithelial cells with more abundant eosinophilic cytoplasm .", "summary": "We describe a case of mixed adenoid cystic cancer of the breast with infiltrating ductal carcinoma in a 67-year-old Caucasian woman who underwent mastectomy with sentinel node biopsy.", "subclaim_evaluations": [ { "subclaim": "The patient was a 67-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient was Caucasian.", "support_label": "supported" }, { "subclaim": "The patient had mixed adenoid cystic cancer of the breast.", "support_label": "supported" }, { "subclaim": "The patient had infiltrating ductal carcinoma.", "support_label": "supported" }, { "subclaim": "The patient underwent mastectomy.", "support_label": "supported" }, { "subclaim": "The patient underwent sentinel node biopsy.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1695_en.txt", "fulltext": "A 53-year-old Japanese woman with a 30-year clinical history of anorexia nervosa (155 cm, 32 kg, body mass index: 13.3 kg/m2) was found unconscious at home. On admission to the Emergency Department, she was in a coma with a consciousness level of 6 on the Glasgow Coma Scale (E3V1M2). Her other vital signs initially recorded in the Emergency Department were as follows: body temperature, 35.1°C; heart rate, 83 beats/min; blood pressure, 84/62 mmHg; respiratory rate, 12 breaths/min; and percutaneous oxygen saturation, 98% (on oxygen 10 L/min via a non-rebreather mask). A laboratory examination showed remarkable hypoglycemia with a blood sugar concentration of 8 mg/dL, anemia with a hemoglobin concentration of 8.2 g/dL, hypopotassemia with a potassium concentration of 3.4 mmol/L, thrombocytopenia with a platelet count of 128,000/μL, and coagulopathy with an international normalized ratio of the prothrombin time of 1.49 and activated partial thromboplastin time of 36.2 s. After the intravenous administration of 20 g of glucose and 20 mg of thiamine, her blood sugar concentration increased to 230 mg/dL, and her consciousness level returned to 14 on the Glasgow Coma Scale (E3V5M6). Transthoracic echocardiography showed akinesis of the heart apex and a reduced left ventricular ejection fraction of 20%, consistent with takotsubo cardiomyopathy. She was obviously emaciated and malnourished but did not have a short neck or neck deformities. A computed tomography scan showed no vascular anomaly around the neck or thorax. A diagnosis of hypoglycemia-induced takotsubo cardiomyopathy [, ] with anorexia nervosa was made. She was admitted to the intensive care unit to receive close monitoring, correction of blood sugar and electrolytes, and continuous intravenous heparin administration (5000 U/day) for the prevention of thrombus in the akinetic ventricular apex.\nOn hospital day 2, this patient suddenly developed refractory ventricular fibrillation and suffered from cardiopulmonary arrest. A rigorous resuscitation attempt using chest compressions, electrical defibrillation, endotracheal intubation, and intravenous adrenaline administration was immediately initiated by intensive care unit physicians and nurses. Spontaneous circulation was restored in approximately 15 min. A CVC was required for continuous intravenous infusion of inotropic agents and vasopressin. The right neck was then sterilized with 1% chlorhexidine digluconate, and her head was tilted to the left by approximately 30°. On a pre-procedural ultrasound (US) examination, no vascular-like structures were visible behind the posterior wall of the right IJV. The right IJV was punctured by an experienced cardiologist under US guidance with the short-axis out-of-plane technique using an 18-gauge introducer needle contained in an Arrow triple lumen central venous catheter kit (Teleflex Medical Japan, Tokyo, Japan). Although the angle and depth of the needle appeared to be appropriate if the patient had not been emaciated, the right IJV was completely collapsed at the time of the US-guided puncture, and blood was not aspirated. Non-pulsatile dark-colored blood was smoothly aspirated during gentle withdrawal of the needle, and then a guide wire, dilator, and CVC were inserted without resistance. Immediately after the CVC placement, she developed enlarging swelling around the neck. Contrast-enhanced computed tomography showed massive contrast media extravasation around the neck and mediastinum , whereas the tip of the CVC was correctly placed in the right IJV. The patient was considered at a high risk for open repair. Therefore, transarterial embolization was planned. After 6-Fr short sheath introduction (Radifocus Introducer II; Terumo, Tokyo, Japan) from her right brachial artery, a pigtail catheter (4-Fr; Cook Medical, Bloomington, IN, USA) was advanced into the brachiocephalic trunk with the support of a 0.035″ hydrophilic guidewire (Radifocus guidewire M; Terumo, Tokyo, Japan). Brachiocephalic artery angiography showed a characteristic “blush” appearance of the ruptured right thyrocervical trunk . After selective arterial embolization using a microcatheter (Masters Parkway Soft; Asahi Intecc, Aichi, Japan) and 33% N-butyl-2-cyanoacrylate, the extravasation completely disappeared and hemostasis was achieved. A schema of the operative course at the catheterization laboratory is shown in Figure S in the supplementary information file. After receiving 22 units of packed red blood cells, 20 units of fresh frozen plasma, and 20 units of platelet concentrate, the patient was returned to the intensive care unit where correction of body fluid imbalance, hypothermia, acidemia, and coagulopathy was continued. Secondary infection and multiorgan dysfunction developed approximately 2 weeks later, and the patient died from sepsis on hospital day 16. An autopsy was not performed because her family refused.\nThe search strategy was determined a priori by the survey team, which comprised anesthesiologists (YO and KS), an interventional radiologist (EU), emergency physicians (NN, IY, and JK), and a librarian (MJ, listed in the Acknowledgments). On June 2022, all reported cases of thyrocervical trunk injury associated with IJV puncture were searched for in the MEDLINE database from inception using the following keywords: “thyrocervical trunk” AND “internal jugular vein puncture”; “thyrocervical trunk” AND “central venous catheter”; “thyroid artery” AND “internal jugular vein puncture”; and “thyroid artery” AND “central venous catheter”. PubMed® was used to search the MEDLINE database. Cross-referencing was also performed using the reference list of articles included in this review. The following types of articles were excluded from the analysis: (1) they were not case reports or case letters, (2) they were not in English, and (3) they did not describe thyrocervical trunk injury associated with IJV puncture. This search produced 25 articles of which 10 relevant reports and cases were included in this review [–] . We reviewed the variables of age, sex, underlying medical conditions of the patients, number of punctures, use of real-time US guidance, characteristics of the operator, treatment, and outcome.\nThe clinical characteristics of thyrocervical trunk injury after IJV puncture described in this review, including our patient, are shown in Table . Seven articles described pseudoaneurysm of the thyrocervical trunk or its branches [–], three reported massive bleeding arising from the thyrocervical trunk or its branches [, ], and one reported CVC misplacement in the right inferior thyroid artery . The cases in the literature review consisted of four men and seven women, aged 33 to 71 years. More than 80% (9/11) of thyrocervical trunk injuries were associated with a landmark puncture without using real-time US guidance. More than half (6/11) of the thyrocervical trunk injuries were associated with multiple (≥ 2) attempts. Aneurysm or active bleeding arising from a thyrocervical trunk injury was successfully managed by surgical repair (4/11) or endovascular treatment (5/11). Endovascular embolization using 33% N-butyl-2-cyanoacrylate for the treatment of vascular complications associated with CVC placement has not been reported previously.", "summary": "A 53-year-old Japanese woman with anorexia nervosa developed refractory ventricular fibrillation. After returning spontaneous circulation, a CVC was successfully placed at the initial attempt in the right internal jugular vein using real-time ultrasound guidance. Immediately after CVC placement, she developed enlarging swelling around the neck. Contrast-enhanced computed tomography showed massive contrast media extravasation around the neck and mediastinum. Brachiocephalic artery angiography showed a \"blush\" appearance of the ruptured right thyrocervical trunk. After selective arterial embolization with 33% N-butyl-2-cyanoacrylate, the extravasation completely disappeared and hemostasis was achieved.", "subclaim_evaluations": [ { "subclaim": "The patient is a 53-year-old Japanese woman.", "support_label": "supported" }, { "subclaim": "The patient had anorexia nervosa.", "support_label": "supported" }, { "subclaim": "The patient developed refractory ventricular fibrillation.", "support_label": "supported" }, { "subclaim": "A central venous catheter was placed in the right internal jugular vein.", "support_label": "supported" }, { "subclaim": "The central venous catheter was placed using real-time ultrasound guidance.", "support_label": "supported" }, { "subclaim": "The central venous catheter was placed at the initial attempt.", "support_label": "supported" }, { "subclaim": "The patient developed enlarging swelling around the neck immediately after CVC placement.", "support_label": "supported" }, { "subclaim": "Contrast-enhanced computed tomography showed massive contrast media extravasation around the neck.", "support_label": "supported" }, { "subclaim": "Contrast-enhanced computed tomography showed contrast media extravasation in the mediastinum.", "support_label": "supported" }, { "subclaim": "Brachiocephalic artery angiography showed a 'blush' appearance of the ruptured right thyrocervical trunk.", "support_label": "supported" }, { "subclaim": "Selective arterial embolization was performed with 33% N-butyl-2-cyanoacrylate.", "support_label": "supported" }, { "subclaim": "The extravasation completely disappeared after embolization.", "support_label": "supported" }, { "subclaim": "Hemostasis was achieved after embolization.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1012_en.txt", "fulltext": "The present case reports a 37-year-old man suffering from metastatic osteosarcoma originating in the distal part of the left femur. In March 2018, the patient entered the hospital with pain in the left leg as the major symptom. An MRI scan showed a large tumor with extramedullary parts and an intraosseous diameter of 13 cm. The histological examination of the biopsy showed a mostly epithelioid, in part osteoblastic, high-grade osteosarcoma. In the CT scans of the thorax and abdomen, there was no metastasis detectable. Before surgery, the patient was treated with a neoadjuvant regimen analog to the EURAMOS-1 trial with two cycles of doxorubicin and cisplatin and four cycles of high-dose MTX. In the intermediate staging performed by a further CT scan before surgical resection of the tumor, there was still no sign of distant metastasis. In the restaging-MRI of the left thigh the tumor showed a decrease in size. Limb saving surgical resection of the entire tumor (R0) was performed in August 2018. The tumor showed regression with 30% vital tumor cells (grade IV Salzer-Kutschnik).\nSurgery was followed by an adjuvant chemotherapy analog to the EURAMOS-1-protocol containing two cycles of doxorubicin and cisplatin, two further cycles of Doxorubicin and eight cycles of high-dose MTX. The start of adjuvant chemotherapy was delayed for two weeks because of a wound infection.\nThe final staging after the last chemotherapy cycle showed two new pulmonary metastases in the CT scan of the lung. Hence, curatively intended surgical resection was performed in April 2019.\nIn September 2019, the patient had a seizure and in an MRI of the brain multiple cerebral metastases became visible. A neurosurgical resection of a symptomatic metastasis was performed, followed by a total brain irradiation with a boost on parafalcial and occipital metastases.\nIn a systemic restaging performed by a total body FDG-PET-CT scan and an MRI of the brain, the patient then showed a rapid systemic disease-progression with metastases affecting the lung, the mediastinum, the left adrenal gland, the brain, soft tissue, bones, and the skin. (, , )\nIn a molecular testing of the most recent tissue sample of the resected brain metastases, the tumor showed a high expression of PD-L1 (TPS 90% CPS 92%) but microsatellite stability (MSS). The patient was still in a good performance state (ECOG 1). A salvage chemotherapy containing the in osteosarcoma therapy established drugs ifosfamide and etoposide was not performed because of an acute kidney failure in the patient’s history and a high amount of cumulative neurotoxicity after the total brain irradiation. Benefit-risk ratio was not considered being favorable for this option. Referring to the case of a patient with advanced osteosarcoma reported by Nuytemans et al. , who reached a stabilization of disease-progression undergoing immunotherapy with nivolumab and ipilimumab, an individual therapy attempt with the same treatment combination was conducted, as there was no further established therapy and no ongoing study available.\nStarting in December 2019, we exposed the patient to the immunotherapy combination of Nivolumab 3 mg/kg and Ipilimumab 1 mg/kg every 3 weeks for four times analog to the established treatment protocol for kidney cancer. In the following restaging performed by a PET-CT scan and an MRI of the brain 3 months after starting the therapy, the patient showed a clear response to the therapy with a profound remission of all tumor lesions (, , ). In some of the lesions, a minimally elevated uptake of FDG remained residually, whereas the lesions were not metrically measurable any more in the corresponding CT scan. In brain MRIs, minimal residual structures were interpreted as gliosis after total brain irradiation and immunotherapy. A definite distinction between inflammation or scar and minimal tumor residuals was not possible in PET-CT scans and MRIs.\nIn February 2020, the patient suffered from herpes zoster as a complication, which was treated with brivudine for 7 days.\nThe patient developed a mild facial palsy of the right side in March 2020, which can be considered as a side effect of the immunotherapy. In an examination of the cerebrospinal fluid, a slightly increased cell count of 9/nl could be detected but no signs of VZV encephalitis or meningeosis carcinomatosa, respectively.\nIn March 2020, the patient developed an immunotherapy-related pneumonitis with clinically mild symptoms but clear correlations in CT scans of the lung and noticeably reduced diffusion capacity in a subsequent lung-function examination. Therefore, immunotherapy had to be discontinued, and nivolumab maintenance could not be started according to protocol.\nFor treatment of pneumonitis, the patient received prednisolone with an initial dose of 50 mg per day (0.5 mg/kg). Because of decreasing signs of pneumonitis in control CT scans and an improving diffusion capacity in lung function, prednisolone could be quickly tapered to 7.5 mg, and re-exposure to nivolumab was feasible in June 2020. In the actual PET-CT scan and MRI of the brain, the patient still showed a profound remission of all tumor lesions, and there was no detectable sign of a relapse (, ). Currently, prednisolone is completely tapered, and the patient undergoes nivolumab maintenance (240mg) every 2 weeks. The performance state has further improved, and the patient is starting reintegration into work.\noutlines the patient’s history.", "summary": "This report presents the case of a 37-year-old patient with metastatic advanced osteosarcoma, who had no more established options for tumor treatment left. PD-L1 expression in the most recent tumor sample was high (tumor proportion score (TPS) 90%, combined positive score (CPS) 92%) but no MSI could be detected. In an individual therapy attempt, an ongoing and profound remission of all tumor manifestations due to four cycles of immunotherapy with ipilimumab and nivolumab was reached. Despite discontinuation of immunotherapy for 3 months due to therapy-related pneumonitis, remission of all tumor manifestations was ongoing, and no detectable relapse in restaging before onset of Nivolumab-maintenance could be observed.", "subclaim_evaluations": [ { "subclaim": "The patient is a 37-year-old individual.", "support_label": "supported" }, { "subclaim": "The patient has metastatic advanced osteosarcoma.", "support_label": "supported" }, { "subclaim": "The patient had no more established options for tumor treatment.", "support_label": "supported" }, { "subclaim": "PD-L1 expression in the most recent tumor sample was high.", "support_label": "supported" }, { "subclaim": "The tumor proportion score (TPS) was 90%.", "support_label": "supported" }, { "subclaim": "The combined positive score (CPS) was 92%.", "support_label": "supported" }, { "subclaim": "No microsatellite instability (MSI) could be detected.", "support_label": "supported" }, { "subclaim": "The patient received four cycles of immunotherapy with ipilimumab and nivolumab.", "support_label": "supported" }, { "subclaim": "A profound remission of all tumor manifestations was achieved.", "support_label": "supported" }, { "subclaim": "The remission was ongoing despite discontinuation of immunotherapy for 3 months.", "support_label": "supported" }, { "subclaim": "The discontinuation was due to therapy-related pneumonitis.", "support_label": "supported" }, { "subclaim": "No detectable relapse was observed in restaging before the onset of Nivolumab-maintenance.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3098_en.txt", "fulltext": "9-year-old female patient was admitted to the emergency department (ED) with respiratory distress. She had a history of six months of less severe dyspnea and symmetrical polyarthritis of large and small joints (proximal interphalangeal, 2nd and 3rd metatarsophalangeal joints, wrists, elbows, ankles, and knees), with functional limitations and intermittent fever (38-39°C), associated with malar rash aggravated by sun exposure, alopecia, petechiae on trunk and neck, generalized lymphadenopathy, and unmeasured weight loss. Therefore, she was started on 6.5 mg/kg/day hydroxychloroquine and 100 mg/kg/day cefepime (maintained for 10 days). Pulse therapy with methylprednisolone was not initiated at this time due to the possibility of infection.\n\nLaboratory tests, imaging studies, and a myelogram were then performed. A chest ultrasound was performed in the emergency room, revealing a left pleural effusion of 0.7 cm. This was complemented by a chest radiograph that showed a lingual atelectasis. The myelogram results revealed a hypocellular marrow with <1% blasts, mild granulocytopenia, and erythropoenia. The patient met the 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria for SLE (presence of acute cutaneous lupus, alopecia, arthritis, serositis, hemolytic anemia, thrombocytopenia, antinuclear antibodies (ANA), anti-DNA, and antiphospholipid antibodies). Thus, prednisone 1 mg/kg and azathioprine 2 mg/kg were added to the prescription after these results.\n\nThree days after admission, the patient developed a significant worsening of the general condition, worsening of dyspnoea, muffled heart sounds, jugular vein distension, haemodynamic instability and intense pallor. An echocardiogram was performed, which showed a large pericardial effusion with diastolic collapse of the right atrium. The patient received a transfusion and underwent a pericardiocentesis followed by pleuropericardial seal drainage. Due to the obstruction of the drain, a new approach was adopted the next day, without major complications. A new echocardiogram was performed two days later, showing moderate left ventricular systolic dysfunction, an ejection fraction of 60% and moderate tricuspid regurgitation. The therapies with furosemide 2 mg/day and spironolactone 2 mg/day were then initiated. Intravenous immunoglobulin (1 g/kg/day) was administered in two subsequent days due to persistent autoimmune bicytopenia. The echocardiogram two weeks later showed no pathological signs.\n\nAntigenemia for CMV was requested after a positive serological result with titers of 15/200,000 cells. Therapy with ganciclovir 5 mg/kg/day was initiated. After ten days of treatment, the antigenemia persisted (28/200,000 cells), and the dose of ganciclovir was, therefore, doubled. After eight days, another antigenemia presented titers of 1/200,000 cells. The patient maintained treatment with ganciclovir 10 mg/kg/day for two more weeks, with good clinical and laboratory improvement and was discharged with oral valganciclovir 20 mg/kg/day.\n", "summary": "A nine-year-old female patient was admitted to the emergency department with severe dyspnoea, hypofonetic murmurs, jugular vein distension, haemodynamic instability and intense pallor. She had been undergoing outpatient treatment for mild dyspnoea, polyarthritis, fever and various skin manifestations for six months. An echocardiogram revealed pericardial effusion. The patient underwent pericardiocentesis followed by pleuropericardial seal drainage without complications. Investigation continued with the completion of clinical and laboratory criteria for SLE and the presence of CMV antigenemia of 15/200,000 cells. Medication was initiated to control SLE and CMV, with good clinical and laboratory response.\n", "subclaim_evaluations": [ { "subclaim": "The patient is a nine-year-old female.", "support_label": "supported" }, { "subclaim": "She was admitted to the emergency department.", "support_label": "supported" }, { "subclaim": "She had severe dyspnoea.", "support_label": "supported" }, { "subclaim": "She had hypofonetic murmurs.", "support_label": "not_supported" }, { "subclaim": "She had jugular vein distension.", "support_label": "supported" }, { "subclaim": "She had haemodynamic instability.", "support_label": "supported" }, { "subclaim": "She had intense pallor.", "support_label": "supported" }, { "subclaim": "She had been undergoing outpatient treatment for six months.", "support_label": "supported" }, { "subclaim": "An echocardiogram revealed pericardial effusion.", "support_label": "supported" }, { "subclaim": "The patient underwent pericardiocentesis.", "support_label": "supported" }, { "subclaim": "The patient underwent pleuropericardial seal drainage.", "support_label": "supported" }, { "subclaim": "The procedure was without complications.", "support_label": "supported" }, { "subclaim": "Investigation continued with the completion of clinical and laboratory criteria for SLE.", "support_label": "supported" }, { "subclaim": "CMV antigenemia was 15/200,000 cells.", "support_label": "supported" }, { "subclaim": "Medication was initiated to control SLE.", "support_label": "supported" }, { "subclaim": "Medication was initiated to control CMV.", "support_label": "supported" }, { "subclaim": "There was a good clinical response.", "support_label": "supported" }, { "subclaim": "There was a good laboratory response.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_68_en.txt", "fulltext": "In May 2017, a 51-year old female presented to our hospital with over 1 week of fatigue. She has medical history of donating both bone marrow and PBSCs 8 yrs ago for her brother with severe aplastic anemia (SAA). G-CSF was used to mobilize hematopoietic stem cells for PBSC collection. Complete blood count (CBC) showed lymphocytosis (Lymphocyte 10*10^9/L), moderate anemia (Hb 61 g/L) and thrombocytopenia (PLT 20*10^9/L). Peripheral blood smear demonstrated 30% of blast cells. Bone marrow biopsy showed lymphoblastic leukemia involving a markedly hypercellular marrow . Flow cytometry showed the blasts expressed CD10, CD19, CD22, CD38, HLA-DR, but not CD13, CD33, CD117, or cytoplasmic MPO. Chromosomal analysis showed a normal female karyotype. The diagnosis of B-ALL was made. VDP regimen (Vindesine, Daunorubicin, Prednisone) was started after her diagnosis and bone marrow aspirate 14 days later revealed complete remission (CR). Then 2 cycles of VDLP regimen (Vindesine, Daunorubicin, Prednisone, Pegaspargase) and 2 cycles of MA (Mitoxantrone, Cytosine arabinoside) + Pegaspargase (PEG-Asp) regimen were administered. During this period, the patient remained in remission and cerebrospinal fluid (CSF) remained clear after intermittent four time lumbar punctures. Minimal residue disease (MRD) monitoring by flow cytometry after each cycle did not detect blast cells with abnormal phenotype. Considering she has no other HLA-identical siblings or unrelated donors from China Bone Marrow Bank at that time and her brother, who was perfectly stable, a special type of auto-HSCT using her brother’s PBSCs was performed in December 2017. Before the transplantation, whole exome sequencing (WES) was done for both the donor and recipient to rule out occult genetic abnormalities in the stem cells. Results showed that only the patient, not her brother, has genetic mutations including SF3B1 and BRAF mutation associated with hematological malignancies in her hematopoietic cells, not oral mucosal cells [–]. Myeloablative conditioning regimen (Melphalan 140 mg/m2 d-3/d-2/d-1, Cytarabine 1 g/m2 d-3/d-2, Cyclophosphamide 60 mg/Kg d-3/d-2) was used. A total of 2.34*10^6/kg CD34+ cells, 13.0*10^8/kg MNCs from peripheral blood were collected and transfused into the patient. Neutrophil engraftment occurred at day + 11 and platelet engraftment occurred at day + 14. VP regimen (Vindesine, Prednisone) and MTX + 6-MP regimen were used for maintenance therapy. Bone marrow aspirate and flow cytometry showed that the patient remained in complete remission 3 months after transplantation. In May 2018, the patient’s CBC showed leukocytosis and bone marrow aspirate indicated disease relapsed with 53.33% blast cells. Flow cytometry showed the blasts expressed CD10, CD19, HLA-DR and partially expressed CD11b. Genetic testing using polymerase chain reaction (PCR) technique found that SF3B1 and BRAF exome mutation was negative. Re-induction chemotherapy with VDP regimen was administered, the patient achieved CR. However, after another 2 cycles of high-dose MTX+ PEG-Asp regimen, disease relapsed. In November 2018, CD19 CAR-T therapy followed by HLA-identical unrelated hematopoietic stem cell transplantation was applied and the patient remains in remission for 7 months till now.", "summary": "This case report describes a 51-year old female diagnosed with acute lymphoblastic leukemia who donated both bone marrow and peripheral blood stem cells 8 yrs ago for her brother with severe aplastic anemia. Whole exome sequencing revealed leukemic genetic lesions (SF3B1 and BRAF mutation) only appeared in the donor sister, not the recipient, and an unusual type of hematopoietic stem cell transplantation with the recipient's peripheral blood stem cells was done. The patient remained in remission for 3 months before disease relapsed. CD19 CAR-T therapy followed by HLA-identical unrelated hematopoietic stem cell transplantation was applied and the patient remains in remission for 7 months till now.", "subclaim_evaluations": [ { "subclaim": "The patient is a 51-year-old female.", "support_label": "supported" }, { "subclaim": "She was diagnosed with acute lymphoblastic leukemia.", "support_label": "supported" }, { "subclaim": "She donated bone marrow 8 years ago.", "support_label": "supported" }, { "subclaim": "She donated peripheral blood stem cells 8 years ago.", "support_label": "supported" }, { "subclaim": "The recipient was her brother.", "support_label": "not_supported" }, { "subclaim": "The recipient had severe aplastic anemia.", "support_label": "not_supported" }, { "subclaim": "Whole exome sequencing was performed.", "support_label": "supported" }, { "subclaim": "Leukemic genetic lesions were found in the donor sister.", "support_label": "not_supported" }, { "subclaim": "The SF3B1 mutation was found in the donor sister.", "support_label": "not_supported" }, { "subclaim": "The BRAF mutation was found in the donor sister.", "support_label": "not_supported" }, { "subclaim": "The recipient did not have the SF3B1 mutation.", "support_label": "supported" }, { "subclaim": "The recipient did not have the BRAF mutation.", "support_label": "supported" }, { "subclaim": "An unusual type of hematopoietic stem cell transplantation was performed.", "support_label": "supported" }, { "subclaim": "The recipient received peripheral blood stem cells.", "support_label": "supported" }, { "subclaim": "The patient remained in remission for 3 months.", "support_label": "supported" }, { "subclaim": "The disease relapsed after 3 months.", "support_label": "supported" }, { "subclaim": "CD19 CAR-T therapy was applied.", "support_label": "supported" }, { "subclaim": "HLA-identical unrelated hematopoietic stem cell transplantation was performed.", "support_label": "supported" }, { "subclaim": "The patient remained in remission for 7 months after the transplant.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_513_en.txt", "fulltext": "We present the case of 32-year-old female patient who presented to the urologist with fever lasting for the previous two months, usually 37°C to 38°C, with occasional temperature leaps to 40°. Laboratory blood tests showed leukocytosis with cell counts up to 19,000. The patient did not complain of lumbar pain. Urinalysis showed leukocyturia, erythrocyturia, and slight positivity for protein. The patient was treated with a combination of amoxicillin, clavulonic acid, and cefuroxime. Abdominal ultrasound and multiphase CT depicted a large, expansive, heterogenous mass in the lower pole of the left kidney measuring 92 × 59 × 76 mm. CT scans showed a renal neoplastic mass with increased peripheral inhibition and poor central inhibition, possibly due to central necrosis. The tumor was unsharply demarcated from the surrounding parenchyma and pelvic system . Regional lymphadenopathy was present, but there were no signs of propagation in the main renal vein or perinephric fat tissue, and there were no signs of liver or bone metastasis. Chest CT showed no signs of lungs metastasis or mediastinal lymphadenopathy. In order to determine the final histopathological diagnosis, histopathological and immunohistochemical analyses were performed, complemented by reverse transcryptase-polymerase change reaction (RT-PCR). Gross examination of the slitted specimen showed a sharply circumscribed tumor measuring 9 × 6 × 6 cm and replacing a large part of the kidney. The renal tumor displayed infiltrated parenchyma but no expansion into the pelvic system and ureter or signs of spreading into the main renal vein. Gross appearance of the tumor was white-yellow with large necrotic areas. The microscopic analysis of perinephric fat tissue, regional lymph nodes, and the left adrenal gland revealed no signs of metastasis. Microscopic analysis showed that the tumor was composed of solid nests and stripes of tumor cells with small oval and round nuclei, and some of the nuclei contained small nucleoli . The tumor cell cytoplasm was scanty and pink with coarser appearance of chromatin. Mitotic figures were also found. Immunohistochemical analysis included MIC2 gene product/CD 99 , neuron-specific enolase (NSE) , CD3, CD 20, chromogranin, synaptophysin, vimentin, and neurofilament. Immunohistochemical staining revealed positive expression of CD99 and NSE in all tumor cells. The tumor cells did not stain with CD3, CD 20, chromogranin, synaptophysin, vimentin, or neurofilament. RT-PCR analysis for EWS-FLI1 fusion proteins was positive for type II 191 pb and negative for type I 125 pb. Diagnosis of rPNET set on the basis of characteristic morphological characteristics and results of immunohistochemical analysis was confirmed by RT-PCR. After nephrectomy, the patient received 14 cycles of a VAC/IE regiment adjuvant chemotherapy comprised of vincristine, doxorubicin, cyclophosphamide, ifosfamide, and etoposide. Our patient was disease-free for nine years and eight months. Blood and urine laboratory test values were in the normal range.\nThe study was approved by the institutional ethical committee and conducted according to the principles of the declaration of Helsinki of the world medical association. The authors declare that they have no conflicts of interest. The authors did not receive any grants for writing this article.", "summary": "We present the case of a 32-year-old female patient with primary renal PNET/EWS diagnosed nine years and eight months earlier. The patient presented with acute flank pain in the left lumbar region, hematuria, and episodes of high body temperature of 40°C. Abdominal ultrasound (US) and subsequently performed computed tomography (CT) revealed a large renal mass of heterogenous structure. The kidney tumor had central necrotic hypodense areas and strongly peripherally enhanced solid parts on postcontrast CT images. Immunohistochemistry revealed positivity for CD99 and neuron-specific enolase (NSE). Tumor cells were negative for CD3, CD 20, chromogranin, synaptophysin, vimentin, and neurofilament. Reverse transcription polymerase change reaction (RT-PCR) revealed EWS/FL1 translocation type 2. The patient underwent nephrectomy and polychemotherapy. The follow-up nine years and eight months after the diagnosis showed no evidence of tumor.", "subclaim_evaluations": [ { "subclaim": "The patient is a 32-year-old female.", "support_label": "supported" }, { "subclaim": "The patient had primary renal PNET/EWS.", "support_label": "supported" }, { "subclaim": "The diagnosis was made nine years and eight months before the current report.", "support_label": "not_supported" }, { "subclaim": "The patient presented with acute flank pain in the left lumbar region.", "support_label": "not_supported" }, { "subclaim": "The patient had hematuria.", "support_label": "supported" }, { "subclaim": "The patient had episodes of high body temperature of 40°C.", "support_label": "supported" }, { "subclaim": "Abdominal ultrasound was performed.", "support_label": "supported" }, { "subclaim": "Computed tomography was performed.", "support_label": "supported" }, { "subclaim": "CT revealed a large renal mass of heterogeneous structure.", "support_label": "supported" }, { "subclaim": "The kidney tumor had central necrotic hypodense areas on postcontrast CT.", "support_label": "supported" }, { "subclaim": "The tumor had strongly peripherally enhanced solid parts on postcontrast CT.", "support_label": "supported" }, { "subclaim": "Immunohistochemistry showed positivity for CD99.", "support_label": "supported" }, { "subclaim": "Immunohistochemistry showed positivity for neuron-specific enolase.", "support_label": "supported" }, { "subclaim": "Tumor cells were negative for CD3.", "support_label": "supported" }, { "subclaim": "Tumor cells were negative for CD20.", "support_label": "supported" }, { "subclaim": "Tumor cells were negative for chromogranin.", "support_label": "supported" }, { "subclaim": "Tumor cells were negative for synaptophysin.", "support_label": "supported" }, { "subclaim": "Tumor cells were negative for vimentin.", "support_label": "supported" }, { "subclaim": "Tumor cells were negative for neurofilament.", "support_label": "supported" }, { "subclaim": "RT-PCR revealed EWS/FL1 translocation type 2.", "support_label": "supported" }, { "subclaim": "The patient underwent nephrectomy.", "support_label": "supported" }, { "subclaim": "The patient received polychemotherapy.", "support_label": "supported" }, { "subclaim": "The follow-up nine years and eight months after diagnosis showed no evidence of tumor.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_209_en.txt", "fulltext": "The Columbia University Medical Center IRB (AAAR0802) exempted this retrospective case report from review.\nA 36-day-old female was fussy for a day and then developed respiratory distress. She was born at term, and a New York State newborn screen was negative. In the Pediatric ER, she was tachycardic (260 beats/minute) and hypothermic (32.4 degrees C) with prolonged capillary refill and faint distal pulses. She was placed on continuous positive airway pressure via nasal prongs. Adenosine was given twice via an intraosseous line for supraventricular tachycardia with conversion to sinus rhythm. She was then intubated for worsening respiratory distress and placed on an FiO2 of 1.0. An echocardiogram was notable for decreased biventricular systolic function and left to right shunting through a patent foramen ovale. A dobutamine infusion was started. Arterial cannulation was unsuccessful; transcutaneous pulse SO2 was consistently 100% during rewarming. Results from the first blood gas (all blood gas results were reported uncorrected for temperature) drawn from a catheter placed in the IVC (by Seldinger technique; sutured in place after advancing to its full length overlying the L3 vertebral body; ) were pH 7.01, PCO2 33 mm Hg, PO2 101 mm Hg, SO2 94%, and lactate 18 mmol/L. Early during rewarming, the IVC SO2 remained above 90% and was as high as 99% ; declines in IVC SO2 and lactate during the first 3 hours of rewarming correlated (Spearman r: 0.94; p = 0.002). An arterial catheter was then placed, and the FiO2 weaned. B-type natriuretic peptide was increased (4578.5 pg/mL). Capillary refill and distal pulses improved, and dobutamine was discontinued at 8 hours; a repeat echocardiogram the next day showed improved (though still diminished) biventricular systolic function with continued left to right shunting through a patent foramen ovale. Hypothermia and hyperlactatemia resolved over 10 and 12 hours, and IVC SO2 was 80% on hospital day 2. The patient was diagnosed with supraventricular tachycardia secondary to Wolff-Parkinson-White syndrome. Prior to discharge a week later, serum acylcarnitine profile, lactate, pyruvate, thyroid stimulating hormone, and thyroxine were all normal.\nIVC PO2 values were corrected retrospectively for the patient's temperature .", "summary": "A 36-day-old female was fussy for a day and then developed respiratory distress. In the Pediatric ER, she was tachycardic (260 beats/minute) and hypothermic (32.4 degrees C) with prolonged capillary refill and faint distal pulses. Adenosine was given twice via an intraosseous line for supraventricular tachycardia, with conversion to sinus rhythm. Blood drawn from an IVC catheter was significant for uncorrected (for temperature) oxygen saturation of 94% and lactate 18 mmol/L; corrected and uncorrected IVC oxygen saturation early during rewarming were >90%. During rewarming, declines in uncorrected IVC oxygen saturation and lactate correlated. Hypothermia and hyperlactatemia resolved after 10 and 12 hours.", "subclaim_evaluations": [ { "subclaim": "The patient is a 36-day-old female.", "support_label": "supported" }, { "subclaim": "She was fussy for a day before developing respiratory distress.", "support_label": "supported" }, { "subclaim": "She was tachycardic at 260 beats/minute in the Pediatric ER.", "support_label": "supported" }, { "subclaim": "She was hypothermic at 32.4 degrees Celsius.", "support_label": "supported" }, { "subclaim": "She had prolonged capillary refill.", "support_label": "supported" }, { "subclaim": "She had faint distal pulses.", "support_label": "supported" }, { "subclaim": "Adenosine was given twice via an intraosseous line.", "support_label": "supported" }, { "subclaim": "The adenosine was given for supraventricular tachycardia.", "support_label": "supported" }, { "subclaim": "The adenosine caused conversion to sinus rhythm.", "support_label": "supported" }, { "subclaim": "Blood was drawn from an IVC catheter.", "support_label": "supported" }, { "subclaim": "The uncorrected oxygen saturation was 94%.", "support_label": "supported" }, { "subclaim": "The lactate level was 18 mmol/L.", "support_label": "supported" }, { "subclaim": "The corrected and uncorrected IVC oxygen saturation were >90% early during rewarming.", "support_label": "supported" }, { "subclaim": "During rewarming, declines in uncorrected IVC oxygen saturation and lactate correlated.", "support_label": "supported" }, { "subclaim": "Hypothermia resolved after 10 hours.", "support_label": "supported" }, { "subclaim": "Hyperlactatemia resolved after 12 hours.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2822_en.txt", "fulltext": "An 84-year-old Chinese woman was admitted with gradual abdominal distension.\nThe patient’s symptoms started 1 year ago. And she had poor appetite and a weight loss of 5 kg within the past 2 wk. She denied any symptoms associated with abdominal pain, fever and chills, nausea and vomiting, etc.\nThere was no prior history of trauma, hepatitis, allergy, or alcohol or tobacco usage.\nNo special.\nPhysical examination showed that she was in medium nutritional status with an icteric appearance. Vital signs were within normal ranges. The abdomen was asymmetrically enlarged, more in the right upper quadrant, without tenderness. Bowel movements occurred about 3-4 times per minute.\nLaboratory examination showed significantly increased serum levels of PIVKA-II (> 30000 mAU/mL; reference: < 32 mAU/mL), CA12-5 (428 U/mL; reference: < 35 U/mL), and CA19-9 (51.67 U/mL; reference: < 39 U/mL). Serum aspartate aminotransferase (AST) (97.03 IU/L; reference: < 40 IU/L), alanine aminotransferase (ALT) (64.73 IU/L; reference: < 40 IU/L), total bilirubin (TBIL) (61.19 µmol/L; reference: < 21 µmol/L), and direct bilirubin (DBIL) (36.42 µmol/L; reference: < 3.4 µmol/L) levels were moderately increased. Serum prothrombin time (PT) (33.3 s; reference: 11.0-15.0 s) and activated partial thromboplastin time (aPTT) (54.0 s; reference: 28.0-43.5 s) levels were also elevated slightly. However, serum albumin (ALB) (23.88 g/L; reference: > 35 g/L), prealbumin (PLAB) (17.3 mg/L; reference: 180-390 mg/L), and choline esterase (CHE) levels (1750 IU/L; reference: 3000-13000 IU/L) were significantly low.\nFollowing an initial abdominal ultrasound examination, an enhanced computed tomography (CT) scan was performed, which revealed multiple round cysts in the liver with clear boundaries. The largest cyst was located in the right lobe of the liver, with mild dilatation of the intrahepatic bile duct, and a size of approximately 20.1 cm × 12.2 cm × 19.6 cm. There was no contrast enhancement in either the arterial or venous phase .", "summary": "An 84-year-old Chinese woman was admitted with gradual abdominal distension. Her symptoms started 1 year ago, and she had poor appetite and a weight loss of 5 kg within the past 2 wk. She denied any symptoms associated with abdominal pain, fever and chills, nausea and vomiting, etc. The abdomen was enlarged, more in the right upper quadrant, without tenderness. Laboratory examination showed significantly increased serum levels of PIVKA-II, CA12-5, and CA19-9. A computed tomography scan revealed multiple round cysts in the liver with clear boundaries. The largest cyst was 20.1 cm × 12.2 cm × 19.6 cm in size, located in the right lobe of the liver with mild dilatation of the intrahepatic bile duct, but there was no contrast enhancement. Percutaneous drainage on the largest hepatic cyst and polycinnamol sclerosing agent injection into the cyst cavity were performed. After treatment, the patient's symptoms relieved and the elevated serum tumor makers reduced to the normal levels dramatically.", "subclaim_evaluations": [ { "subclaim": "The patient is an 84-year-old Chinese woman.", "support_label": "supported" }, { "subclaim": "She was admitted with gradual abdominal distension.", "support_label": "supported" }, { "subclaim": "Her symptoms started 1 year before admission.", "support_label": "supported" }, { "subclaim": "She had a weight loss of 5 kg within the past 2 weeks.", "support_label": "supported" }, { "subclaim": "The abdomen was enlarged, more in the right upper quadrant.", "support_label": "supported" }, { "subclaim": "Serum levels of PIVKA-II, CA12-5, and CA19-9 were significantly increased.", "support_label": "supported" }, { "subclaim": "A computed tomography scan revealed multiple round cysts in the liver with clear boundaries.", "support_label": "supported" }, { "subclaim": "The largest cyst was 20.1 cm × 12.2 cm × 19.6 cm in size.", "support_label": "supported" }, { "subclaim": "The largest cyst was located in the right lobe of the liver.", "support_label": "supported" }, { "subclaim": "There was mild dilatation of the intrahepatic bile duct.", "support_label": "supported" }, { "subclaim": "There was no contrast enhancement in the cyst.", "support_label": "supported" }, { "subclaim": "Percutaneous drainage was performed on the largest hepatic cyst.", "support_label": "not_supported" }, { "subclaim": "A polycinnamol sclerosing agent was injected into the cyst cavity.", "support_label": "not_supported" }, { "subclaim": "The patient's symptoms improved after treatment.", "support_label": "not_supported" }, { "subclaim": "Elevated serum tumor markers reduced to normal levels after treatment.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_899_en.txt", "fulltext": "A 65-year-old male patient was referred to our hospital due to interventricular septal perforation following myocardial infarction. The patient was presented to the previous hospital with chest pain. Despite undergoing percutaneous coronary intervention (PCI) and attempted thrombus aspiration, reperfusion could not be achieved (See Fig. ). The patient’s condition became unstable, and transthoracic echocardiography (TTE) revealed interventricular septal rupture and left-to-right ventricle shunt. Consequently, the patient was transferred to our hospital. Upon arrival, the electrocardiogram (ECG) showed QS wave on V1-V3 and persistent ST elevation, along with acute kidney injury (AKI) characterized by serum creatinine levels 4–5 times higher than baseline. TTE showed an ejection fraction (EF) of 50%, a mosaic flow near the apical septum, leading to the diagnosis of ventricular septal perforation (VSP), with an akinesia of the anterior left ventricular wall. The patient opted for emergency surgery. The initial procedure involved general anesthesia and cardiopulmonary bypass (CPB) with drainage from the right atrium and a venting tube in the left ventricle (LV). Cardiac arrest was induced through mild hypothermia using antegrade and retrograde cold blood cardioplegia.\nBriefly, a median sternotomy was performed, the pericardium was opened, and the heart was exposed and examined. The right chamber appeared enlarged, and the apex displayed pallor with a wide infarct area. An incision was made in the infarcted region of the LV myocardium, parallel to the interventricular septum, extending approximately 7 cm toward the apex, the VSP then been located . The double patch technique, as previously described by Takahashi et al. , was employed using bovine pericardial patches. The bovine patch was cut with a diameter 2 cm larger than the VSP for the right ventricle (RV) patch (R-patch), while the left ventricle (LV) patch (L-patch) was sized adequately to exclude the VSP, the infarcted area of the LV, and the LV incision. After confirming hemostasis, the heart was closed, and the patient was transferred to the intensive care unit (ICU) (See Fig. ).\nThe patient remained in the ICU for 9 days. Dialysis was required initially due to worsening kidney injury from the preoperative AKI, but the patient’s condition stabilized, and continuous dialysis was no longer necessary. TTE performed 2 weeks after surgery indicated a shunt, but no signs of heart failure were observed. Thus, the patient received medication and was discharged 23 days after the surgery.\nAs an outpatient, the patient returned to the hospital after 22 days with chest discomfort. Mild pleural effusion was confirmed, and transesophageal echocardiography (TEE) revealed a left-to-right shunt through the previous patch. Following approximately 6 days of medication administration in the hospital, the patient’s condition stabilized, and discharge was granted. However, the patient returned again after 2 weeks of being discharged, presenting with general malaise and decreased kidney function. TTE showed blood flow from the left to right ventricle, with EF of 55% and Qp/Qs = 1.7. Cardiac computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the presence of a midventricular perforation measuring approximately 12 mm in diameter, leading to the decision to proceed with VSP repair surgery (See Fig. ).\nThe second surgery was performed on the 15th day after initiating medication in the hospital. A median incision was made, carefully exposing the heart, and establishing a CPB machine. The second surgery employed a double patch technique. Briefly, trans epicardial echocardiogram was performed to locate the VSP. The RV was accessed near the right ventricular outflow tract (RVOT) through a 4 cm incision toward the apex, positioned 1 cm laterally to the left anterior descending artery (LAD). As the distal LAD had already been damaged from the previous myocardial infarction, the RV was cautiously dissected to avoid injury to the first diagonal branch of LAD. The ruptured wall was confirmed, and RVOT was observed, with trabeculae being cut to enhance visibility . A bovine pericardium patch, measuring 3 cm in diameter and circular in shape, was prepared. The thread was passed from the LV lumen to the LV free wall and from the interventricular septal wall to the RV lumen using 3 − 0 MH sutures. The patch was then pulled into the LV chamber by pulling the thread, and a single ligation was used for suturing, as shown in Fig. Another patch was prepared in a similar manner, with the thread applied from the opposite side and sutured with continuous sutures, securing it to the front side of the interventricular septum. A thread was passed from the LV free wall, near the previous suture, to the RV free wall, closing the RV with teflon felt and tying it with a mattress suture. An additional continuous suture was applied externally between the LV teflon felt and RV teflon felt to ensure closure. A pacing lead was placed in the right atrium and right ventricle, and an intra-aortic balloon pump (IABP) was inserted through the right common femoral artery. After confirming hemostasis, the chest was closed.\nThe patient remained in the ICU for 5 days, with a maximum creatinine level of 1.55, and experienced no postoperative complications. The IABP was removed 3 days after surgery, and the pacing lead was removed 4 days later. The patient was discharged 4 days after the removal of the pacing lead, displaying stability and no signs of heart failure.", "summary": "A 65-year-old male were re-administered to our hospital due to recurrent VSP. He was during follow up after undergone emergency VSP closure surgery 2 months earlier, utilizing the bovine double patch technique via left ventriculostomy. The initial VSP was located in the apical part of the interventricular septum, while the recurrent VSP appeared in the upper middle portion of the interventricular septum (Fig. 1). As the previous patch remained intact, the second surgery employed the bovine double patch technique via right ventriculostomy. The patient's condition remained stable without the development of heart failure symptoms.", "subclaim_evaluations": [ { "subclaim": "The patient is a 65-year-old male.", "support_label": "supported" }, { "subclaim": "The patient was re-administered to the hospital due to recurrent VSP.", "support_label": "supported" }, { "subclaim": "The patient had undergone emergency VSP closure surgery 2 months earlier.", "support_label": "not_supported" }, { "subclaim": "The initial VSP was located in the apical part of the interventricular septum.", "support_label": "supported" }, { "subclaim": "The recurrent VSP appeared in the upper middle portion of the interventricular septum.", "support_label": "not_supported" }, { "subclaim": "The previous patch remained intact.", "support_label": "not_supported" }, { "subclaim": "The second surgery employed the bovine double patch technique.", "support_label": "supported" }, { "subclaim": "The second surgery was performed via right ventriculostomy.", "support_label": "supported" }, { "subclaim": "The patient's condition remained stable.", "support_label": "supported" }, { "subclaim": "The patient did not develop heart failure symptoms.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2091_en.txt", "fulltext": "A 15-year-old girl presented with a history of progressive limping for 8 years. Another symptom was diffuse bone pain for 3 years. Family and drug histories were unremarkable. On physical examination, a large, firm, and non-tender mass was palpable in the right thyroid lobe. Left hip range of motion was limited in all directions, both actively and passively, and tenderness was present on left femoral head palpation. The rest of the physical examination was normal.\nBiochemical tests were performed and initial laboratory test results were as follows: serum calcium: 10.8 mg/dL (range: 8.5 - 10.5 mg/dL); phosphorus: 2.4 mg/dL (range: 2.9 - 5.1 mg/dL); iPTH: 2876 pg/mL (range 15 - 65 pg/mL); 25-hydroxy vitamin D3: 13.76 ng/mL (range 15 - 65 ng/mL); thyroid-stimulating hormone (TSH): 3.11 µIU/mL (range 0.51 - 4.34 µIU/mL); and alkaline phosphatase (ALP): 7410 IU/L (range: 180 - 1200 IU/L). While PHPT could be associated with other endocrinopathies, the complementary evaluations, such as insulin-like growth factor-1 (IGF-1) and prolactin measurements were done .\nThe plain pelvic radiography demonstrated a left femoral neck fracture. Spine radiography displayed wedge fractures at thoracic and lumbar spine levels . Bone mineral density (BMD) showed low bone density (lumbar spine's Z-core: -3.7). According to the above-mentioned test results, including elevated PTH, borderline high serum calcium, decreased phosphorus, and elevated ALP, primary hyperparathyroidism was considered as the most probable diagnosis.\nDual-phase sestamibi scintigraphy was performed for the patient after intravenous (IV) injection of 540 MBq of 99mTc-MIBI. The early scan images (at 20 minutes) revealed high thyroid uptake in the right lobe with a suppressive effect on the left side. Increased radiotracer uptake was seen in the right lobe without proper washout on delayed images, which was higher and larger than is expected with PAs . A thyroid scan was also done two days later, after IV injection of 185 MBq of 99mTc from the anterior view to rule out a thyroid nodule. This scan revealed a focal decreased uptake in the upper pole of the right lobe, which was smaller compared with the finding of the parathyroid scan . The discrepancy between the two scans led to further investigation into the underlying pathology. Neck ultrasound revealed an enlarged right thyroid lobe compatible with intra-lobar necrosis and echogenic regions with the approximate size of 20 mm compatible with the parathyroid gland ( and ).\nThe patient was referred to an experienced surgeon for neck exploration and parathyroidectomy. She underwent open surgery. The parathyroid mass had infiltrated to the surrounding thyroid tissue; hence, right thyroidectomy, isthmectomy, and right inferior parathyroidectomy were performed. The remaining parathyroid glands were examined during the operation and were normal. She experienced hungry bone syndrome postoperatively, which was managed appropriately. Finally, serum calcium and iPTH levels decreased to a level of 8.7 mg/dL (8.5 - 10.5 mg/dL) and 24 pg/mL (15 - 65 pg/mL), respectively. The operative phosphorus level was 2.3 mg/dL.\nGross histopathologic examination revealed a well-defined cream-colored mass measuring 2.5 × 1.5 × 1.0 cm. IHC helped with the confirmation of diagnosis .\nHistologic examination showed uniform chief cells presenting as nodules and sheet growth with proliferated blood vessels that were separated by a broad fibrous capsule from the adjacent thyroid tissue. The tumor had invaded the capsule and blood vessels. IHC staining for CD34 confirmed vascular invasion. IHC was also diffusely positive for CK in the tumor and tumor cells attached to endothelial cells. Ki67 was also positive in 2% - 3% of tumor cells. However, other markers, such as CD45, thyroid transcription factor 1 (TTF-1), and Pax5 were negative (-).\nWhole exome sequencing (WES) study was done for the assessment of familial hyperparathyroidism and MEN1. The genetic study demonstrated no mutation in CDC73 and menin genes. However, there was an incidental mutation in the breast cancer 1 (BRCA1) gene.\nWe performed an extensive search using different databases, including Medline, PubMed, Scopus, ScienceDirect, and Google Scholar to find all published cases of PC in children and adolescents. We used the following combination of keywords: parathyroid carcinoma or parathyroid cancer or parathyroid neoplasm or parathyroid malignancy, and pediatrics or child or adolescent or boy or girl. We could find 16 papers reporting 17 cases of pediatric PC from 1972. summarizes the published papers.\nAccording to these reports, the male to female ratio was 0.6. The youngest and oldest patients were 8 and 16 years old, respectively. The most common initial presenting symptoms were related to hypercalcemia, including anorexia, vomiting, polyuria, polydipsia, fatigue, bone pain, and renal calculi. Sixty percent had a palpable neck mass. Nearly 50% had skeletal involvement, including fracture and deformity. Only three patients had experienced weight loss. Pancreatitis was a rare condition diagnosed in one case. Nearly 20% had metastasis, most common sites were lung and cervical lymph nodes, and all cases with pulmonary involvement had experienced relapse and hypercalcemia after the initial operation. The range of serum calcium and iPTH was 12 - 20.7 mg/dL and 300 - 8638 pg/mL, respectively. IHC had been reported in two cases, which were both positive for parafibromin . Three cases had deletion mutation of CDC73, and another case was negative with regard to menin gene mutation. Three patients had a positive family history of primary hyperparathyroidism. There was no predominant tumor location site at the neck.", "summary": "A 15-year-old girl presented with progressive limping and bone pain for 8 years. She was referred by an orthopedic surgeon because of elevated intact parathyroid hormone (iPTH) for further evaluation. Physical examination revealed a large, firm, and non-tender neck mass, left hip tenderness, and limited range of motion. The initial biochemistry tests showed a borderline high calcium level of 10.8 mg/dl, an elevated iPTH level of 2876 pg/mL, and a decreased phosphorus level of 2.4 mg/dL. The 99mTechnetium (Tc) sestamibi scan displayed early intense activity in the right thyroid lobe persisting in the three-hour repeat scan, compatible with a parathyroid lesion. The patient underwent right-sided neck exploration and parathyroidectomy. Intraoperative and pathology findings confirmed the diagnosis of PC. Immunohistochemistry (IHC) staining revealed creatine kinase (CK) and CD31 in endothelial cells of the tumor. Ki67 staining was also positive in 2% - 3% of tumor cells. The whole exome sequencing (WES) study was negative for cell division cycle 73 (CDC73) and multiple endocrine neoplasia 1 (MEN1) genes.", "subclaim_evaluations": [ { "subclaim": "The patient is a 15-year-old girl.", "support_label": "supported" }, { "subclaim": "She had progressive limping and bone pain for 8 years.", "support_label": "supported" }, { "subclaim": "She was referred by an orthopedic surgeon.", "support_label": "supported" }, { "subclaim": "She had elevated intact parathyroid hormone (iPTH).", "support_label": "supported" }, { "subclaim": "Physical examination revealed a large, firm, and non-tender neck mass.", "support_label": "supported" }, { "subclaim": "The initial calcium level was 10.8 mg/dl.", "support_label": "supported" }, { "subclaim": "The initial iPTH level was 2876 pg/mL.", "support_label": "supported" }, { "subclaim": "The initial phosphorus level was 2.4 mg/dL.", "support_label": "supported" }, { "subclaim": "The 99mTechnetium sestamibi scan showed early intense activity in the right thyroid lobe.", "support_label": "supported" }, { "subclaim": "The activity persisted in the three-hour repeat scan.", "support_label": "not_supported" }, { "subclaim": "The findings were compatible with a parathyroid lesion.", "support_label": "supported" }, { "subclaim": "The patient underwent right-sided neck exploration and parathyroidectomy.", "support_label": "supported" }, { "subclaim": "Intraoperative findings confirmed the diagnosis of parathyroid carcinoma.", "support_label": "supported" }, { "subclaim": "Immunohistochemistry staining revealed creatine kinase (CK) in endothelial cells of the tumor.", "support_label": "supported" }, { "subclaim": "Immunohistochemistry staining revealed CD31 in endothelial cells of the tumor.", "support_label": "not_supported" }, { "subclaim": "Ki67 staining was positive in 2% - 3% of tumor cells.", "support_label": "supported" }, { "subclaim": "Whole exome sequencing was negative for CDC73.", "support_label": "supported" }, { "subclaim": "Whole exome sequencing was negative for MEN1.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3360_en.txt", "fulltext": "A 43-year-old female presented in outpatient clinic with a history of a left adnexal cyst associated with foul-smelling PV discharge for the past 3–4 months. The patient was also under medication, tab. Thyroxine sodium-50 μg per day for hypothyroidism since 2 years. Physical examination revealed no abnormalities on per-abdominal assessment. The lesion in the liver was accidental finding during the ultrasonography of the abdomen and pelvis. Ultrasonography (USG) and CT scans identified a 9 × 8.7 × 8.4 cm well defined hypodense lesion in the right lobe of the liver, with a differential diagnosis of focal nodular hyperplasia in CT scan. The patient got admitted and surgery (hemihepatectomy) was done.\n\nHistopathological findings\nIn pathology department, a hemihepatectomy specimen was received. Gross examination of the specimen revealed a well-defined nodular growth measuring 9 × 7 × 5 cm within the liver, with a cut surface displaying a grey-white to brownish appearance. No areas of necrosis were observed.\nMicroscopic examination of multiple sections from the tumor mass revealed a well-circumscribed lesion characterized by spindle-shaped tumor cells arranged in fascicles and concentric pattern around numerous thin-walled capillaries. The tumor cells were exhibiting elongated nuclei and moderate cytoplasm. No atypia, mitosis, or necrosis were observed. All submitted margins were free of tumor cells. Surrounding liver parenchyma did not reveal any significant morphological changes.\n\nImmunohistochemistry\nImmunohistochemical staining done were Smooth Muscle Actin (SMA), h-Caldesmon, Desmin, CD34, STAT6, DOG1, S100 and ALK. Our differentials include neural tumors like schwannoma, so S100 was negative, solitary fibrous tumors, CD 34 and STAT6 were negative and vascular tumor, CD 34 was negative. Positivity for SMA and h-caldesmon, confirmed the myopericytic nature of the tumor. CD34 highlighted blood vessel endothelial cells. DOG-1, ALK and Desmin were negative, which ruled out the close differentials like GIST, Inflammatory myofibroblastic tumor and leiomyoma and further supporting the diagnosis of myopericytoma.\n\nDiagnosis\nBased on the clinical, radiological, and histopathological findings, the diagnosis of myopericytoma of the liver was established.\n\nTherapeutic intervention\nBased on the radiological findings, hemihepatectomy was already done. No further intervention was needed after histopathological report.\n\nFollow-up and outcomes\nAs the lesion was benign and completely resected, the patient was completely recovered. There were no clinical signs and symptoms related to disease and ultrasonography of the abdomen and pelvis was normal on follow up at 6th months.", "summary": "We reported a case of myopericytoma in a 43-year-old female with a history of a left adnexal cyst and foul-smelling per vaginal discharge with no significant findings in per abdominal examination. Imaging studies initially suggested the possibility of hemangioma in ultrasonography and further CT scan was advised which gave the possibility of focal nodular hyperplasia.", "subclaim_evaluations": [ { "subclaim": "The patient is a 43-year-old female.", "support_label": "supported" }, { "subclaim": "The patient had a history of a left adnexal cyst.", "support_label": "supported" }, { "subclaim": "The patient had foul-smelling per vaginal discharge.", "support_label": "supported" }, { "subclaim": "There were no significant findings in per abdominal examination.", "support_label": "supported" }, { "subclaim": "Ultrasonography suggested the possibility of hemangioma.", "support_label": "not_supported" }, { "subclaim": "A CT scan was advised.", "support_label": "supported" }, { "subclaim": "The CT scan gave the possibility of focal nodular hyperplasia.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2314_en.txt", "fulltext": "A five-day-old full-term female baby delivered by cesarean section cried immediately at birth. The mother had no comorbid conditions and described her pregnancy as normal. During the pregnancy, the mother had an X-ray of her leg, but she was unaware of her pregnancy at the time. There is no family history of congenital anomalies, and the baby is born to parents that are unrelated. The baby was born with a trunk-like appendage that was arising from the superomedial canthus of the left eye, 26 mm × 12 mm in size, with a small tract with Cerebrospinal fluid discharge. The left nasal cavity was hypoplastic with left anophthalmia. No cleft palate, cleft lip, or choanal atresia was noted. .\nA two-dimensional Echocardiography (2D echo) revealed complex cyanotic congenital heart disease, including double outlet Right Ventricle with a large ventricular septal defect of 8 mm, malposed great vessels, mild valvular right ventricular outflow tract obstruction (RVOTO) with a pressure gradient of 26 mmHg, small Patent ductus arteriosus (PDA) with a left to right shunt and confluent branched pulmonary arteries. Two ostium Secundum atrial septal defects (ASD) were noted of 4 mm and 25 mm with a normal biventricular structure and function. On Magnetic resonance imaging (MRI) of the brain, mild hydrocephalus, bilateral colpocephaly (larger than normal occipital horns due to undeveloped white matter in the posterior cerebrum) with bilateral periventricular white matter hypodensities and corpus callosum agenesis were noted. Computed tomography (CT) imaging with a 3D reconstruction of the face revealed minor bony defects of the left nasal bone, frontal process of the maxilla, and absent nasal turbinates.Bilateral maxillary and ethmoid sinuses were underdeveloped, to a greater degree on the child's left side. CT imaging of the thorax and abdomen revealed a hemivertebra involving the T10 vertebral body causing focal scoliosis with right-sided convexity.\nOur patient’s parents deferred treatment and chose to wait till the child grows older.", "summary": "A full-term female baby delivered by cesarean section cried immediately at birth. The mother reported having a normal pregnancy but has a history of x-ray during her first trimester. The baby was born with a rare presentation of proboscis lateralis which was accompanied by multiple anomalies, including but not limited to bilateral colpocephaly, corpus callosum agenesis, complex cyanotic congenital heart disease, and hemivertebra of the T10 body.", "subclaim_evaluations": [ { "subclaim": "The baby was delivered by cesarean section.", "support_label": "supported" }, { "subclaim": "The baby cried immediately at birth.", "support_label": "supported" }, { "subclaim": "The mother reported a normal pregnancy.", "support_label": "supported" }, { "subclaim": "The mother had a history of x-ray during her first trimester.", "support_label": "supported" }, { "subclaim": "The baby was born with proboscis lateralis.", "support_label": "supported" }, { "subclaim": "The baby had bilateral colpocephaly.", "support_label": "supported" }, { "subclaim": "The baby had corpus callosum agenesis.", "support_label": "supported" }, { "subclaim": "The baby had complex cyanotic congenital heart disease.", "support_label": "supported" }, { "subclaim": "The baby had hemivertebra of the T10 body.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2160_en.txt", "fulltext": "A 71-year-old female patient with thalassemia minor and hypertension was diagnosed in 1999 with early-stage right breast cancer. She underwent breast-conserving surgery and axillary dissection; pathology showed a small tumor, less than 2 cm, node-negative invasive ductal carcinoma. Hormone receptors (HRs) were positive but HER2 was negative. After the surgery, she received chemotherapy [cyclophosphamide, methotrexate, and 5-fluorouracil (CMF)] followed by radiotherapy and adjuvant tamoxifen for 5 years. She did well and was very adherent to clinical and mammographic follow-up until 2015, when she had an intractable cough. Imaging studies showed a left hilar lesion and multiple osteolytic bone metastases, including the left scapula, left shoulder, left iliac bone, and the fourth and seventh dorsal vertebrae. Fine needle aspiration from the left hilum, through endobronchial ultrasound, confirmed breast cancer metastasis. Similarly to the original tumor, hormone receptors were positive (ER 90%, PR 30%) and HER2 was negative. Therefore, she was started on endocrine therapy with fulvestrant, which kept her progression free for 2 years. She was then switched to exemestane and everolimus; however, this regimen was discontinued owing to grade II pneumonitis and prenephrotic range proteinuria. At that time, the patient was enrolled in a double-blind randomized clinical trial testing CDK4/6 inhibitors along with aromatase inhibitors. A few months later, the patient was taken off the study owing to disease progression, and was found to be on the placebo arm. Following the US Food and Drug Administration (FDA) approval of CDK4/6 inhibitors, she was started on ribociclib and letrozole, which she tolerated relatively well. Nonetheless, because of persistent neutropenia, the dose of ribociclib was reduced to 400 mg daily; on days 1–21 of a 28-day cycle.\nAlmost 20 weeks after starting ribociclib and letrozole, she noticed small, rounded, well-demarcated hypopigmented lesions over both hands with expanding patches reaching up to the mid forearms . Three weeks later, new similar lesions started to appear over her face and feet. The patient had no personal or family history of autoimmune diseases. The patient was seen at the dermatology clinic and was offered treatment with topical immunomodulators (calcineurin inhibitors), which she refused, and was kept on topical steroids with little improvement.", "summary": "A 71-year-old female patient was diagnosed initially with early-stage right breast cancer (HR+/HER2-) and was treated with breast-conserving surgery followed by chemotherapy, radiotherapy, and hormonal therapy. A few years later, she developed metastatic disease to the hilar lymph nodes, and to multiple skeletal sites, including the left scapula, left shoulder, left iliac bone, and dorsal vertebrae, for which she was treated with ribociclib and letrozole. While on treatment, she developed hypopigmented lesions involving both hands, feet, and face, which were described as vitiligo-like lesions.", "subclaim_evaluations": [ { "subclaim": "The patient is a 71-year-old female.", "support_label": "supported" }, { "subclaim": "She was diagnosed with early-stage right breast cancer.", "support_label": "supported" }, { "subclaim": "The breast cancer was HR+/HER2-.", "support_label": "supported" }, { "subclaim": "She was treated with breast-conserving surgery.", "support_label": "supported" }, { "subclaim": "She received chemotherapy.", "support_label": "supported" }, { "subclaim": "She received radiotherapy.", "support_label": "supported" }, { "subclaim": "She received hormonal therapy.", "support_label": "supported" }, { "subclaim": "A few years later, she developed metastatic disease to the hilar lymph nodes.", "support_label": "supported" }, { "subclaim": "She had metastatic disease to multiple skeletal sites.", "support_label": "supported" }, { "subclaim": "The skeletal metastases included the left scapula.", "support_label": "supported" }, { "subclaim": "The skeletal metastases included the left shoulder.", "support_label": "supported" }, { "subclaim": "The skeletal metastases included the left iliac bone.", "support_label": "supported" }, { "subclaim": "The skeletal metastases included the dorsal vertebrae.", "support_label": "supported" }, { "subclaim": "She was treated with ribociclib.", "support_label": "supported" }, { "subclaim": "She was treated with letrozole.", "support_label": "supported" }, { "subclaim": "While on treatment, she developed hypopigmented lesions.", "support_label": "supported" }, { "subclaim": "The hypopigmented lesions involved both hands.", "support_label": "supported" }, { "subclaim": "The hypopigmented lesions involved both feet.", "support_label": "supported" }, { "subclaim": "The hypopigmented lesions involved the face.", "support_label": "supported" }, { "subclaim": "The lesions were described as vitiligo-like.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1455_en.txt", "fulltext": "A 62-year-old woman came to our center with extremely severe hydronephrosis and multiple right renal calculi found by annual physical check. She reported no renal colic, nausea or fever and had no current use of any medications. Her temperature was 36.7 °C, pulse 89 bpm, respiratory rate 18 bpm, and non-invasive blood pressure 130/57 mmHg. Unenhanced CT scan demonstrated extremely severe hydronephrosis and multiple right renal calculi with the largest diameter of 2 cm . Urine routine was positive for nitrites and leukocyte esterase, and microscopical examination showed + + + for leucocyte.\nAfter thorough examination, we performed prone-position mini-percutaneous nephrolithotomy under spinal anaesthesia. A single tract was created under the guidance of ultrasound to directly reach the median calyceal group. After the insertion of a guidewire, the channel was dilated to 16Fr with a fascia dilator. During the operation, swollen mucosa could hardly be seen through turbid purulent urine. Multiple golden stones embedded in the renal pelvis were fragmented with holmium laser and flushed out, and a considerable number of the stones were removed. After 2 h’ lithotripsy, the operation finished after successful indwelling of a 6Fr double-J stent and a 16 F nephrostomy tube.\nTwo hours postoperatively, the patient complained of chilly and shiver. Her blood pressure dropped to 85/60 mmHg, and blood tests showed C-reactive protein 31.4 mg/L, White blood cell 9.55 × 109/L, D-dimer 570.0 ng/ml. Symptoms were relieved after empirically intravenous infusion of 300 mg biapenem bid and micro-pump injection with dopamine.\nThree days later during the CT scan, the patient abruptly developed respiratory distress and loss of consciousness. Her blood pressure dropped to 76/45 mmHg, and oxygen saturation decreased to 85% under nasal catheter inhalation of oxygen. Clinical findings indicated the possibility of PE with shock. Supported by multi-channel intravenous rehydration, micro-pump injection with norepinephrine and mask oxygen inhalation, her blood pressure fluctuated between 108–124 and 65–78 mmHg. However, the patient still complained of dyspnea and chest pain, and her blood oxygen saturation remained unstable at an average of 92% under mask oxygen inhalation. Emergency laboratory tests showed a D-dimer of more than 3300 ng/ml. Considering the rising level of D-dimer and the patient’s clinical manifestation, we decided that PE might be the most likely diagnosis. Thus, we administrated anticoagulant therapy with 4000 U low molecular weight heparin (LMWH) at once and offered emergency CTPA, which revealed multiple embolisms in her left pulmonary artery and its branches . Meanwhile, doppler echocardiography showed that the patient’s left ventricular ejection fraction (LVEF) was 52% with severe tricuspid regurgitation, and experienced sonographers estimated that pulmonary arterial systolic pressure was about 40 mmHg (mild pulmonary hypertension). Doppler ultrasonography of lower limbs revealed intermuscular venous thrombosis in her left leg.\nIt was a contradictory situation with both the urgent need for thrombolysis therapy and the high vulnerability of surgery field bleeding. In order to solve the life-threatening problem first, our multi-disciplinary team administrated 50 mg of Alteplase ivgtt which was completed within 2 h for thrombolysis, and then transferred the patient to intensive care unit (ICU) for further life-supporting therapy. In order to prevent venous thromboembolism (VTE), 0.4 ml LMWH was subcutaneously injected every 12 h in ICU. Routine re-examination of the lower limbs venous ultrasonography and echocardiography was ordered to monitor the patient’s condition. Sonographers reported the remission trend of tricuspid regurgitation and pulmonary hypertension. Intermuscular venous thrombosis in her left leg could no longer be detected 6 days after the thrombolysis treatment.\nOn the 6th postoperative day, the patient suddenly developed unconsciousness and anhelation in ICU, and her blood oxygen saturation progressively dropped to 85%. Urgent intubation, mechanical ventilation and blood transfusion were applied to correct the patient’s anemia. Gradually, her oxygen saturation rose to 98%, but crimson and opaque drainage fluid kept flowing through her nephrostomy tube without any sign to stop even after clamping the catheter for 30 min. Her hemoglobin (Hb) level was still decreasing progressively . All the above clues were indicative of post thrombolysis bleeding. Diffused contrast medium in the middle and lower part of the right kidney was seen during DSA . SRAE was then performed under general anesthesia. The patient reported no obvious discomfort and generally recovered after conventional symptomatic treatment and blood transfusion. Anticoagulant treatment method was gradually changed to oral application of Warfarin 3 mg qn, and the patient was approved to be discharged 26 days postoperatively. She returned to her daily activity and reported no obvious discomfort, and during re-examination, the echocardiography showed LVEF of 70% with no obvious abnormality.", "summary": "A 62-year-old woman was admitted to our hospital with extremely severe hydronephrosis and multiple right renal calculi. After thorough examination, she received prone-position mini-percutaneous nephrolithotomy under spinal anaesthesia. Three days postoperatively, the patient complained of chest pain and dyspnea. Computed tomography pulmonary angiogram (CTPA) showed multiple embolisms in the left pulmonary artery and its branches. Symptoms were relieved after anticoagulant and thrombolysis therapy. On the 6th postoperative day, the patient developed shortness of breath, computed tomography angiography (CTA) showed massive hemorrhage in the right kidney, diffused contrast medium in the middle and lower part of the right kidney was seen during digital substraction angiography (DSA). Superselective right renal artery embolization (SRAE) was then applied using coil to occlude the responsible artery. The patient generally recovered under conscientious care and was approved to be discharged 26 days postoperatively.", "subclaim_evaluations": [ { "subclaim": "The patient was a 62-year-old woman.", "support_label": "supported" }, { "subclaim": "She was admitted with extremely severe hydronephrosis.", "support_label": "supported" }, { "subclaim": "She had multiple right renal calculi.", "support_label": "supported" }, { "subclaim": "She received prone-position mini-percutaneous nephrolithotomy.", "support_label": "supported" }, { "subclaim": "The procedure was performed under spinal anaesthesia.", "support_label": "supported" }, { "subclaim": "Three days postoperatively, she complained of chest pain.", "support_label": "supported" }, { "subclaim": "Three days postoperatively, she had dyspnea.", "support_label": "supported" }, { "subclaim": "Computed tomography pulmonary angiogram showed multiple embolisms in the left pulmonary artery.", "support_label": "supported" }, { "subclaim": "Computed tomography pulmonary angiogram showed embolisms in the branches of the left pulmonary artery.", "support_label": "supported" }, { "subclaim": "Symptoms were relieved after anticoagulant therapy.", "support_label": "not_supported" }, { "subclaim": "Symptoms were relieved after thrombolysis therapy.", "support_label": "supported" }, { "subclaim": "On the 6th postoperative day, she developed shortness of breath.", "support_label": "supported" }, { "subclaim": "Computed tomography angiography showed massive hemorrhage in the right kidney.", "support_label": "not_supported" }, { "subclaim": "Digital substraction angiography showed diffused contrast medium in the middle and lower part of the right kidney.", "support_label": "supported" }, { "subclaim": "Superselective right renal artery embolization was applied.", "support_label": "supported" }, { "subclaim": "The embolization used coil to occlude the responsible artery.", "support_label": "not_supported" }, { "subclaim": "The patient was discharged 26 days postoperatively.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2105_en.txt", "fulltext": "A 62 year old Caucasian female was hospitalized for six days for treatment of a chronic obstructive pulmonary disease (COPD) exacerbation. Management included steroids and antibiotics. Home medications included clopidogrel for coronary artery disease. Her weight was 46.58 kilograms with a BMI of 17.7 and an estimated glomerular filtration rate (eGFR) of 60.65 ml/min. During the hospitalization she was treated for DVT prophylaxis with enoxaparin 40 mg by subcutaneous injection daily.Seven days after discharge, the patient returned to the emergency department complaining of diffuse abdominal pain, increasing abdominal girth, and anterior wall bruising. An abdominal CT scan confirmed a large RSH . Both general surgery and interventional radiology were consulted. She was managed conservatively. Her hematocrit dropped from 34.8 to 25.3%; however, she declined transfusion of blood products. During the course of her stay, the patient experienced acute hypoxic respiratory failure and did not wish to be intubated. Her medical status deteriorated and, with support from her family, the patient chose to be made comfortable with minimal supportive care. She expired due to sepsis and respiratory failure two days after re-admission.\nA 79 year old male Caucasian was admitted for worsening dyspnea and management of atrial fibrillation with rapid ventricular rate and COPD exacerbation. His clinical course was further complicated by resistant gram negative and gram positive pneumonia and hypoxic respiratory failure. His weight was 59 kilograms with a BMI of 18 and initially his eGFR was 41.98 ml/min. He received subcutaneous abdominal injections of both prophylactic enoxaparin 30 mg and insulin sliding scale therapy. On day 2, his eGFR was calculated at 53.94 and his enoxaparin dose was increased to 40 mg daily.On day 5, he was noted to have abdominal pain and a noncontrast CT scan confirmed a left RSH that expanded considerably over 12 hours on follow up CT. Interventional radiology was consulted but ultimately the patient was managed conservatively with fluid resuscitation and close observation. His hematocrit dropped from 46 to 25.8%. The patient was discharged after 15 days to a long term acute care facility for further management of his respiratory failure and healthcare associated pneumonia.\nAn obese 44 year old Caucasian female with multiple chronic medical problems was readmitted to our facility from a ventilator capable extended care facility for sepsis and acute on chronic hypoxic respiratory failure. Comorbidities included spina bifida and central obesity with a BMI of 27. She was admitted on warfarin therapy for a history of recent deep vein thrombosis; however, she was subtherapeutic, with an International Normalized Ratio (INR) of 1.59. She was, therefore, treated with full dose enoxaparin 80 mg by subcutaneous injection twice daily. Her eGFR was 148.65 ml/min. Coumadin was held as the patient was treated with anitfungal and antimicrobial therapy that could prolong her INR.On day 8, she complained of abdominal pain and a CT scan confirmed a large right RSH . Repeat CT scan one day later showed extension of the hematoma and concern for possible active arterial extravasation. Both general surgery and interventional radiology were consulted. The patient underwent a failed attempt at embolization due to access complications. Due to hemorrhagic shock she required transfusion with 10 units of RBCs and pressure support ventilation in the intensive care unit. Her hematocrit dropped from 34.9 to 20.6%. Anticoagulation was reversed with fresh frozen plasma, vitamin K, and one dose of recombinant factor VIIa. The patient subsequently underwent successful embolization with thrombin and coiling of the right inferior epigastric artery by vascular surgery two days after the initial hematoma. Serial CT scans confirmed no further bleeding. After two weeks, anticoagulation therapy was reinstituted without further evidence of bleeding. The patient was ultimately discharged to a long term acute care facility for continued management of her chronic respiratory failure.", "summary": "Case number one: A 62 year old chronically ill Caucasian female develops a rectus sheath hematoma seven days after hospital discharge. The previous hospitalization included low molecular weight heparin administration for deep vein thrombosis prophylaxis. The patient ultimately chooses comfort care and expires due to sepsis and respiratory failure. Case number two: A 79 year old Caucasian male develops a rectus sheath hematoma during hospital admission where LMWH is used for deep vein thrombosis prophylaxis. He is managed conservatively; however, his hematocrit drops from 46 to 25.8%. Case number three: A 44 year old chronically ill Caucasian female is treated with therapeutic low molecular weight heparin for recent deep vein thrombosis during a hospital admission. She develops a large rectus sheath hematoma requiring embolization as well as blood transfusion.", "subclaim_evaluations": [ { "subclaim": "A 62 year old chronically ill Caucasian female develops a rectus sheath hematoma seven days after hospital discharge.", "support_label": "supported" }, { "subclaim": "The previous hospitalization included low molecular weight heparin administration for deep vein thrombosis prophylaxis.", "support_label": "supported" }, { "subclaim": "The patient chooses comfort care.", "support_label": "supported" }, { "subclaim": "The patient expires due to sepsis and respiratory failure.", "support_label": "supported" }, { "subclaim": "A 79 year old Caucasian male develops a rectus sheath hematoma during hospital admission.", "support_label": "supported" }, { "subclaim": "LMWH is used for deep vein thrombosis prophylaxis.", "support_label": "supported" }, { "subclaim": "The patient is managed conservatively.", "support_label": "supported" }, { "subclaim": "The patient's hematocrit drops from 46 to 25.8%.", "support_label": "supported" }, { "subclaim": "A 44 year old chronically ill Caucasian female is treated with therapeutic low molecular weight heparin for recent deep vein thrombosis.", "support_label": "supported" }, { "subclaim": "She develops a large rectus sheath hematoma.", "support_label": "supported" }, { "subclaim": "The hematoma requires embolization.", "support_label": "supported" }, { "subclaim": "The hematoma requires blood transfusion.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_817_en.txt", "fulltext": "The patient was a 72-year-old man with no pertinent medical history. An upper gastrointestinal imaging (UGI) performed for GC screening revealed an abnormality wherein there was a horizontal inversion of the upper gastrointestinal tract and deformation of the stomach body. Upper endoscopy showed an elevated lesion with an ill-defined border in the anterior wall of the lower-third of the stomach body , and histopathological examination revealed a moderately differentiated tubular adenocarcinoma. Contrast-enhanced multidetector computed tomography (MDCT) showed inverted thoracic and abdominal organs and illustrated the wall thickness of the stomach body, which had no obvious metastasis . Furthermore, the aortic arch to the thoracic aorta was in the normal anatomical position ; hence, the case was diagnosed as SIP. The 3D angiography revealed a complete right–left reversal of the abdominal arteries . SI is known to be frequently associated with chronic sinusitis and bronchiectasis, and this clinical triad is called the Kartagener syndrome . However, chronic sinusitis and bronchiectasis were not seen in this patient.\nPreoperative staging of GC was clinical Stage IIB (cT3N0M0) according to the tumor/node/metastasis (TNM) classification of malignant tumors 8th edition.\nLDG with D2 lymph node dissection (LND) and modified delta-shaped Billroth-I reconstruction was performed. Although this case was SIP, the abdominal organs were completely inverted ; hence, this operation could be performed with the usual LDG symmetrically . Five trocars were placed in the left–right reversal of the usual LDG in our hospital. The surgeon and the assistant performed this operation by reversing the standing position and the roles of the left and right hands from the usual LDG. The surgeon had to operate the energy device with the non-dominant hand. However, the surgeon used the energy device with the dominant hand for supra-pancreatic LND. The problem encountered with this method was that the forceps of the left hand crossed the energy device; however, the supra-pancreatic LND could be safely performed without the energy device interfering with the pancreas.\nIn this operation, there were two problems that could not be solved by performing the operation symmetrically. One of the problems was the method of retracting the lateral segment of the liver. We usually use the Nathanson liver retractor in laparoscopic gastrectomy (LG), which was also used in this case. However, the tip of the liver retractor was oriented toward the hepatic hilar side due to its asymmetrical hook shape. Therefore, the retraction of the lateral segment of the liver was somewhat insufficient, and special care was required not to damage the liver . The second problem was intracorporeal suturing. We usually perform intracorporeal suturing with the surgeon in the paraxial position; however, in this operation, the surgeon performed the suturing in the co-axial position between the patient’s legs. By shifting to this standing position, the surgeon was able to suture with the dominant hand and the normal needle direction.\nOperation time, including intraoperative frozen section histological analysis for the proximal resection margin, was 323 min, and blood loss was 10 ml. After an uneventful postoperative course, the patient was discharged on postoperative day 10. Postoperative staging of GC was pathological Stage IIIB (pT4aN3aM0) according to the TNM classification of malignant tumors 8th edition. The patient received S − 1 + docetaxel adjuvant chemotherapy for 1 year after surgery without any signs of recurrence.", "summary": "The patient was a 72-year-old man diagnosed with GC. Upper endoscopy revealed a type 3 tumor in the anterior wall of the stomach body. Multidetector computed tomography showed no obvious GC metastasis or inverted organs. The preoperative diagnosis was cStage IIB (i.e., cT3, cN0, and cM0) GC with SI. Although liver retracting and intracorporeal suturing required special attention, LDG with D2 LND and Billroth-I reconstruction were safely performed by reversing the usual procedure. The patient was discharged 10 days after the surgery.", "subclaim_evaluations": [ { "subclaim": "The patient was a 72-year-old man.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with gastric cancer.", "support_label": "supported" }, { "subclaim": "Upper endoscopy revealed a type 3 tumor.", "support_label": "not_supported" }, { "subclaim": "The tumor was located in the anterior wall of the stomach body.", "support_label": "supported" }, { "subclaim": "Multidetector computed tomography showed no obvious gastric cancer metastasis.", "support_label": "supported" }, { "subclaim": "The preoperative diagnosis was cStage IIB gastric cancer.", "support_label": "supported" }, { "subclaim": "The preoperative diagnosis included cT3, cN0, and cM0.", "support_label": "supported" }, { "subclaim": "The patient had a small intestinal stenosis.", "support_label": "not_supported" }, { "subclaim": "Laparoscopic distal gastrectomy with D2 lymph node dissection was performed.", "support_label": "supported" }, { "subclaim": "Billroth-I reconstruction was performed.", "support_label": "supported" }, { "subclaim": "The patient was discharged 10 days after the surgery.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2782_en.txt", "fulltext": "Our patient is a 70-year-old male, right-hand dominant farmer who presented at the outpatient clinic after falling on the concrete and landing on his left hand. The patient complained of pain on the ulnar side of his hand and swelling was noted on examination. No apparent deformity of the little finger was noted, finger cascade was normal, and full range of motion was elicited but with pain on motion. Ulnar nerve function was intact. Radiographs of the left hand were performed and showed no fractures or dislocations .\nThe patient denied any interval injuries but had persistent pain on the ulnar side of his left hand, prompting him to come back to the clinic 9 weeks later.\nRepeat radiographs showed complete ulno-palmar dislocation of the 5th CMCJ. A CT scan with 3-D reconstruction was also done, confirming said injury, and no associated fractures were noted .\nManual closed reduction was done under fluoroscopic guidance, but the joint was noted to be unstable when traction was removed. The patient was then indicated for open reduction of the 5th CMCJ.\nThe dislocated joint was approached from the dorsoulnar side and scar tissue was carefully removed from the 5th CMCJ . All ligaments of the 5th CMCJ were torn including the pisometacarpal ligament. Using manual longitudinal traction and dorsally directed force to the 5th metacarpal base, the 5th CMCJ was repositioned to its anatomic location. A K-wire was inserted perpendicular to the long axis of the 5th through 4th metacarpals as a temporary fixation. Thereafter, intermetacarpal fixation was performed between the 4th and 5th metacarpals using Mini TightRope® (Arthrex, FL, USA) .\nUnder C-arm guidance, 1.2-mm holes were drilled with a trajectory about 1 cm distal from and parallel to the articular surfaces of the 5th metacarpal base to the 4th metacarpal base, approximating the original location of the intermetacarpal ligament. Together with one of the stainless-steel metal buttons, a loop of the Mini TightRope® construct is passed from the ulnar to the radial hole of the 4th metacarpal. Mini TightRope® construct was then pulled to tension until the button was flush on the radial cortex of the 4th metacarpal base. The two strands of Mini TightRope® FiberWire were then passed through the radial to ulnar holes of the 5th metacarpal, and second button was then loaded into the sutures and pushed until it was flush against the ulnar cortex of the 5th metacarpal. While maintaining tension, a provisional knot is created, and range of motion and finger cascade are then checked. Once deemed acceptable, sutures were then tied for up to 5 knots over the ulnar button. Remaining strands are then cut using a blade 11 scalpel. Capsule, fascia, and skin were then closed. Immediately after surgery, the patient was allowed to use his fingers freely with unrestricted range of motion.\nK-wires were removed at 2 weeks postoperatively. Follow-up radiograph at 1 year postoperatively showed maintained proper alignment of the 5th CMCJ and the little finger had no limitation of motion. There are no plans to remove the Mini TightRope®, unless the patient begins to complain of pain related to the aforementioned hardware.", "summary": "A 70-year-old, right-hand dominant, male farmer injured his left hand when he slipped and fell on a concrete surface, landing on the ulnar side of his left hand. He was immediately seen in the clinic, just with a swollen left hand but no obvious deformity and with apparently normal PA and oblique radiographs of the hand. Nine weeks later, he came back due to persistent ulnar-sided hand pain; repeat radiographs and a CT scan of the left hand showed ulno-palmar dislocation of the fifth CMCJ. He then underwent trial closed reduction of the 5th CMCJ dislocation but failed. Open reduction, temporary K-wire fixation, and fixation using Mini TightRope® through the 4th and 5th metacarpals were done. A full range of motion of the hand was allowed immediately post-operative. Reduction was maintained and no complications were noted on subsequent follow-up visits.", "subclaim_evaluations": [ { "subclaim": "The patient is a 70-year-old male.", "support_label": "supported" }, { "subclaim": "The patient is right-hand dominant.", "support_label": "supported" }, { "subclaim": "The patient is a farmer.", "support_label": "supported" }, { "subclaim": "The injury occurred when the patient slipped and fell on a concrete surface.", "support_label": "supported" }, { "subclaim": "The patient landed on the ulnar side of his left hand.", "support_label": "supported" }, { "subclaim": "The patient was seen in the clinic immediately after the injury.", "support_label": "not_supported" }, { "subclaim": "The patient had a swollen left hand.", "support_label": "supported" }, { "subclaim": "There was no obvious deformity of the left hand.", "support_label": "supported" }, { "subclaim": "PA and oblique radiographs of the hand were apparently normal.", "support_label": "supported" }, { "subclaim": "Nine weeks after the injury, the patient returned due to persistent ulnar-sided hand pain.", "support_label": "supported" }, { "subclaim": "Repeat radiographs and a CT scan showed ulno-palmar dislocation of the fifth CMCJ.", "support_label": "supported" }, { "subclaim": "A trial of closed reduction of the 5th CMCJ dislocation was attempted.", "support_label": "supported" }, { "subclaim": "The closed reduction failed.", "support_label": "supported" }, { "subclaim": "Open reduction was performed.", "support_label": "supported" }, { "subclaim": "Temporary K-wire fixation was used.", "support_label": "supported" }, { "subclaim": "Fixation using Mini TightRope® through the 4th and 5th metacarpals was performed.", "support_label": "supported" }, { "subclaim": "A full range of motion of the hand was allowed immediately post-operative.", "support_label": "supported" }, { "subclaim": "Reduction was maintained on subsequent follow-up visits.", "support_label": "supported" }, { "subclaim": "No complications were noted on subsequent follow-up visits.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3135_en.txt", "fulltext": "A 47-year-old Chinese male farmer, with history of contact with soil during farm work 2 days before the onset of illness, was admitted to our hospital with a 2-week history of a high fever, productive cough with purulent sputum, shortness of breath on exertion, and nausea and vomiting. Chest computed tomography (CT) performed at a local hospital before admission to our hospital had shown irregular patchy opacities in the lower lobe of the left lung. He had been treated with levofloxacin for 4 days and then switched to moxifloxacin and meropenem for 10 days at the local hospital. However, as his fever, expectoration, and shortness of breath had not improved, he was transferred to our hospital for further investigation and treatment.\n\nThe patient had a 7-year history of dry mouth and dry eyes which had not previously been medically evaluated or treated, but had no history of other possible autoimmune disease such as recurrent oral ulcers, Raynaud’s phenomenon, rash, or arthritis. He was a smoker with a 30 pack-year smoking history. He denied a history of pulmonary disease. He didn’t undergo any previous chest X-ray examination and reported no symptoms and signs of previous interstitial lung disease such as gradually progressive dyspnea on exertion, dry cough, fatigue of unknown origin. He also denied a history of occupational dust exposure, keeping pets and drug abuse. He had no family history of pulmonary disease and cancer.\n\nOn admission, he had a temperature of 37.6 °C, pulse of 82 beats/min, respiratory rate of 16 breaths/min, and blood pressure of 123/71 mmHg. The skin on both his legs was dry and rough, but there was no rash or bruising. There were no rales in the lungs on auscultation, and no other obvious abnormalities were noted on physical examination.\n\nThe chest CT images on admission at our hospital showed that the patchy opacities in the left lower lobe had extended since the previous chest CT, and there were new small patches in the right middle lobe. Laboratory tests revealed an elevated white blood cell count and neutrophil percentage, elevated levels of procalcitonin and C-reactive protein, an increased erythrocyte sedimentation rate, mild hyponatremia, and elevated levels of liver enzymes. The serum human immunodeficiency virus antibody was negative. No infectious agents were detected in the patient’s blood culture and sputum microbiological examination.\n\n\nMain Laboratory test\n\nTest\tDay 1 (admission)\tDay 8\tDischarge\tReference result/range\nHematology\t\t\t\t\nWhite blood cell count (× 109 cells/L)\t20.59\t11.53\t5.78\t3.5–9.5\nNeutrophil percentage (%)\t87\t81.7\t57\t42.5–71.5\nProcalcitonin (ng/mL)\t0.117\t\t\t< 0.05\nC-reactive protein (mg/L)\t103\t43.1\t12\t0–8\nErythrocyte sedimentation (mm/hr)\t100\t\t\t0–15\nLiver enzymes\t\t\t\t\nAlanine transaminase (U/L)\t101\t\t\t0–40\nAspartate transaminase (U/L)\t60\t\t\t5–34\nAlkaline phosphatase (U/L)\t463\t\t\t40–150\nGama-glutamyl transferase (U/L)\t209\t\t\t9–64\nSerum sodium (mmol/L)\t132\t\t\t136–145\nInfections\t\t\t\t\nLegionella urine antigen\tPositive\t\t\tNegative\nStreptococcus pneumoniae Urine antigen\tNegative\t\t\tNegative\nBlood culture\tNo growth\t\t\tNo growth\nSputum microbiological examination\tNegative\t\t\tNegative\nSerum anti-Mycoplasma IgM\tNegative\t\t\tNegative\nSerum anti-Chlamydia IgM\tNegative\t\t\tNegative\nSerum anti-Legionella IgG\tNegative\t\t\tNegative\nSerum HIV antibody\tNegative\t\t\tNegative\nImmunological test\t\t\t\t\nTear secretion test (mm/5 min)\tLeft eye: 3; right eye: 9\t\t\t10–15\nAntinuclear antibodies\tPositive, titer 1:160\t\t\tNegative, < 1:80\nAnti-SSA/Ro60\t5.2 (positive)\t\t\t< 0.8 negative\nAnti-SSA/Ro52\t5.5 (positive)\t\t\t< 0.8 negative\nAnti-SSB/La\t0.8 (weak positive)\t\t\t< 0.8 negative\nAnti-histone\t0.9 (weak positive)\t\t\t< 0.8 negative\nRheumatoid factor (IU/mL)\t94.5\t\t\t0–30\n\n\nBecause the patient had symptoms and signs of extrapulmonary system involvement, including gastrointestinal symptoms, hyponatremia, and signs of liver damage, we could not rule out Legionella pneumonia and thus we performed a Legionella urine antigen test, which was positive. The patient was treated with moxifloxacin 0.4 g once a day and piperacillin sodium and tazobactam sodium 4.5 g three times a day for 8 days. His white blood cell count, neutrophil percentage and C-reactive protein level had decreased since admission. However, his symptoms of fever, expectoration, and shortness of breath persisted. Thus, the antibiotic treatment was switched to intravenous tigecycline 50 mg twice a day for 5 days after an initial dose of 100 mg. However, his symptoms still did not improve. To confirm the diagnosis, we performed an ultrasound-guided percutaneous needle lung biopsy and tested for markers of autoimmune disease.\n\nThe result of a tear secretion test was positive. Salivary gland emission computed tomography dynamic imaging showed impaired uptake in both submandibular glands and parotid glands. Immunological index testing gave positive results for antinuclear antibodies, anti-SSA/Ro60, anti-SSA/Ro52, anti-SSB/La and anti-histone antibody, and the serum rheumatoid factor level was increased. Test for autoimmune liver disease-related antibodies, antineutrophil cytoplasmic antibodies, were all negative, and the serum complement C3 and C4 levels were normal.\n\nLung histology showed formation of fibrin balls in the alveolar cavities accompanied by changes associated with OP (Fig. 2). No pathogens were detected in the lung tissue using metagenomic next generation sequencing (mNGS). Based on the results of the lung biopsy, antibiotics were stopped and intravenous methylprednisolone 40 mg daily was initiated. The patient’s symptoms improved rapidly, and his body temperature returned to normal on the first day of corticosteroid therapy. He was discharged home 4 days later, and continued oral prednisone 10 mg daily for 20 days followed by 5 mg daily for 5 days. At the follow-up visit one month after discharge, his chest CT showed almost complete resolution of the pulmonary lesions.", "summary": "A 47-year-old man was admitted to the hospital because of fever, expectoration, and shortness of breath. Lung imaging showed irregular patchy consolidation. A diagnosis of Legionella pneumonia was initially considered on the basis of the patient’s history of exposure to soil before disease onset, signs of extrapulmonary involvement, and a positive Legionella urine antigen test result. However, the patient’s symptoms and lung imaging did not improve after treatment with levofloxacin, moxifloxacin, and tigecycline for Legionella infection. In addition, Sjögren’s syndrome was diagnosed on the basis of clinical manifestations and immunological indicators. Pathological changes associated with AFOP were confirmed from the results of ultrasound-guided percutaneous lung biopsy. The patient’s clinical symptoms improved rapidly after a short course of low-dose corticosteroid therapy, and lung imaging showed significant improvement.", "subclaim_evaluations": [ { "subclaim": "The patient is a 47-year-old man.", "support_label": "supported" }, { "subclaim": "The patient was admitted to the hospital.", "support_label": "supported" }, { "subclaim": "The patient had fever.", "support_label": "supported" }, { "subclaim": "The patient had expectoration.", "support_label": "supported" }, { "subclaim": "The patient had shortness of breath.", "support_label": "supported" }, { "subclaim": "Lung imaging showed irregular patchy consolidation.", "support_label": "supported" }, { "subclaim": "A diagnosis of Legionella pneumonia was initially considered.", "support_label": "supported" }, { "subclaim": "The patient had a history of exposure to soil before disease onset.", "support_label": "supported" }, { "subclaim": "The patient had signs of extrapulmonary involvement.", "support_label": "supported" }, { "subclaim": "The Legionella urine antigen test result was positive.", "support_label": "supported" }, { "subclaim": "The patient was treated with levofloxacin.", "support_label": "supported" }, { "subclaim": "The patient was treated with moxifloxacin.", "support_label": "supported" }, { "subclaim": "The patient was treated with tigecycline.", "support_label": "supported" }, { "subclaim": "The patient’s symptoms did not improve after treatment.", "support_label": "not_supported" }, { "subclaim": "Lung imaging did not improve after treatment.", "support_label": "not_supported" }, { "subclaim": "Sjögren’s syndrome was diagnosed.", "support_label": "supported" }, { "subclaim": "Pathological changes associated with AFOP were confirmed.", "support_label": "not_supported" }, { "subclaim": "The confirmation was based on ultrasound-guided percutaneous lung biopsy.", "support_label": "supported" }, { "subclaim": "The patient received a short course of low-dose corticosteroid therapy.", "support_label": "supported" }, { "subclaim": "The patient’s clinical symptoms improved rapidly.", "support_label": "supported" }, { "subclaim": "Lung imaging showed significant improvement.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1945_en.txt", "fulltext": "A 45-year-old man previously injured by a chest shotgun was referred to our Institution for a retained bullet in the left ventricle. The patient’s medical history included hypertension, diabetes, and thyroid dysfunction.\nOne month before the admission, the patient underwent an emergency cardiorrhaphy through a left thoracotomy. At that time, the patient was in a war zone, and the previous emergent operation was performed by a general surgeon with the aim to stop the bleeding. At the time of hospitalization, the patient was in stable clinical conditions with sporadic atypical chest pains and rate-dependant left bundle branch block (LBBB). At presentation, the physical examination did not showed pathological signs, except for a left thoracic wound. Blood tests, including markers of cardiac injury, were all within normal limits. Transthoracic echocardiography showed the bullet retained within the left ventricular chamber localized into the posterior wall underneath the posterior mitral leaflet without signs of valve dysfunction or systolic dysfunction . Chest X-ray and angio-computed tomography (CT) scan confirmed the presence of the missile in the left ventricle wedged within the tendineal chordae underneath the posterior mitral leaflet .\nPreoperative workup included a coronary angiogram showing unobstructed coronary arteries. After multidisciplinary discussion at the Heart Team, we decided to proceed with the surgical removal of the RCM. The operation was performed through median sternotomy with routine cardiopulmonary bypass. After aortic cross-clamping and cardioplegia delivery, the left atrium was opened, the posterior mitral leaflet was incised just above the RCM, and the bullet was removed . The edges were then sutured to re-establish continuity of P2 with a 4/0 braided suture. Posterior ring annuloplasty was then performed using a flexible Gore-tex band. The post-operative course was uneventful and the patient was discharged on the seventh post-operative day. Echocardiography performed at discharge did not revealed any residual mitral regurgitation.", "summary": "We describe the case of successful surgical treatment of a retained missile localized within the left ventricle in close proximity of the posterior mitral leaflet. The operation was performed through a transatrial approach, detaching the posterior mitral leaflet. The post-operative course was uneventful. The patient was discharged on the seventh post-operative day. At 30-day follow-up visit, the patient was in good conditions, with normal mitral valve function.", "subclaim_evaluations": [ { "subclaim": "The missile was retained within the left ventricle.", "support_label": "supported" }, { "subclaim": "The missile was in close proximity to the posterior mitral leaflet.", "support_label": "supported" }, { "subclaim": "The operation was performed through a transatrial approach.", "support_label": "supported" }, { "subclaim": "The posterior mitral leaflet was detached during the operation.", "support_label": "supported" }, { "subclaim": "The post-operative course was uneventful.", "support_label": "supported" }, { "subclaim": "The patient was discharged on the seventh post-operative day.", "support_label": "supported" }, { "subclaim": "At 30-day follow-up, the patient was in good condition.", "support_label": "not_supported" }, { "subclaim": "At 30-day follow-up, mitral valve function was normal.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2873_en.txt", "fulltext": "A 48-year-old man returned to Weihai from Wuhan on January 10, 2020. He developed recurrent fever on January 20, 2020 with a maximum temperature of 38.2 °C with mild cough, without sputum, expectoration or chest tightness. Only oral antipyretics were taken. He went to the clinic on January 23, 2020 where real-time reverse-transcription polymerase chain reaction of pharyngeal swab specimens confirmed COVID-19. He was admitted to the hospital.\nThe patient had asthma for 10 years that was stable in normal circumstances, without affecting daily life and activity. He inhaled salmeterol/fluticasone powder (Xeretide, 50/500 μg) twice daily. Smoking or other medical history was denied.\nOn admission, temperature was 37.3 °C, respiratory rate was 23 breaths/min, and a few wheezing rales were heard in both lungs. Arterial blood gases at 21% fraction of inspiration O2 (FiO2) showed partial pressure of oxygen (PaO2) 97 mmHg, partial arterial pressure of carbon dioxide (PaCO2) 39.5 mmHg, pH 7.393, and oxygenation index (OI, PaO2/FiO2) was 465 mmHg [normal range (NR) 400-500 mmHg].\nLaboratory parameters were as follows: White blood cell count 4.66 × 109/L (NR, 3.3 × 109–9.5 × 109/L), neutrophil count 3.0 × 109/L (NR, 2 × 109–7.7 × 109/L), lymphocyte count 1.27 × 109/L (NR, 0.8 × 109–4 × 109/L), CD4 T lymphocyte count 542/μL (NR, 500–1440/μL), monocyte count 0.35×109/L (NR, 0.12 × 109–0.8 × 109/L), eosinophil count 0.03 × 109/L (NR, 0.05 × 109–0.5 × 109/L), platelet count 135 × 109/L (NR, 125 × 109–350 × 109/L), lactate dehydrogenase (LDH) 166 U/L (NR, 100–190 U/L), alanine transaminase (ALT) 15 U/L (NR, 0–50 U/L), aspartate transaminase (AST) 20 U/L (NR, 5–35U/L), albumin 39.8 g/L(NR, 38–55 g/L), C-reactive protein (CRP) 10.94 mg/L (NR, < 4 mg/L). Procalcitonin, myocardial enzymes, serum electrolytes and renal and liver function tests were normal. Detection of antigen and antibody of respiratory tract pathogenic spectrum (including influenza virus A/B) was negative. Chest X-ray showed increased lung markings in both lungs.", "summary": "We report a patient with confirmed COVID-19 combined with asthma. It took 41 d from disease onset to discharge to obtain two negative tests for this coronavirus.", "subclaim_evaluations": [ { "subclaim": "The patient had confirmed COVID-19.", "support_label": "supported" }, { "subclaim": "The patient had asthma.", "support_label": "supported" }, { "subclaim": "It took 41 days from disease onset to discharge.", "support_label": "not_supported" }, { "subclaim": "The patient obtained two negative tests for the coronavirus.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_795_en.txt", "fulltext": "A 57-year-old lady with a history of diabetes, thyroid disease, dyslipidemia, and an episode of atrial fibrillation, resolved with pharmacological cardioversion several years before, presented to the Emergency Department for worsening dyspnea (New York Heart Association Classification—NYHA: IV). Her medical therapy included levothyroxine once daily, dapagliflozin 10 mg once daily, metformin 1,000 mg twice daily, rosuvastatin 5 mg, and ezetimibe 10 mg every night. She had no prior heart failure admissions. Other symptoms included orthopnea and paroxysmal nocturnal dyspnea but no chest pain or syncopal episodes. Physical examination showed a pulse rate of 95 bpm, blood pressure of 140/70 mmHg, and 97% of peripheral oxygen saturation. Cardiac auscultation revealed a pansystolic murmur of 3/6 Levine grade over the apex as well as an ejection systolic murmur over the second intercostal space at the left sternal border. There were moderate bibasal lung crepitations and mild ankles edema. Intravenous furosemide was given with resolution of the lungs and ankles edema. Her electrocardiogram showed ectopic atrial rhythm, left anterior hemiblock as well as LV hypertrophy . Laboratory tests showed troponine T of 20 pg/ml (URL of 14 pg/ml), N-terminal pro B-type natriuretic peptide (NT-proBNP) of 582 pg/ml (URL <150 pg/ml).\nA trans-thoracic echocardiogram showed a significant septal, asymmetric LV hypertrophy (basal anteroseptal wall diastolic thickness of 19 mm). Left and right ventricular systolic functions were normal. There was a clear SAM of the AML and an LVOT gradient of 56 mmHg at rest rising to 136 mmHg during the Valsalva maneuver ( and ). In addition, there was evidence of moderate to severe MR with a significant anteriorly directed jet, not very typical of SAM-related MR. A large calcification at PML-base was noted. 2D-3D trans-esophageal echocardiogram (2D-3D TEE) revealed the true MR mechanism. There was an MR combined mechanism based on: (1) PML degenerative prolapse with P2-flail from ruptured chordae with an eccentric anteriorly directed regurgitant jet and (2) a second posteriorly directed jet, related to SAM of AML ( and –). The pre-operative end-systolic mitral annular diameter was 39 mm while the end-diastolic diameter was 34 mm. There were no signs of infective endocarditis. We added beta-blockers and intravenous diuretics to pre-existing therapy and her clinical condition improved together with a significant LVOT gradient reduction (from 56 to 30 at rest). She underwent coronary-computed tomography angiography that excluded the presence of significant coronary stenoses. She was discharged and, one month later, she underwent MV surgical repair (artificial ring annuloplasty plus artificial chordae implantation) together with septal myectomy. Septal myectomy was performed according to modified Morrow’s procedure. The ruptured chorda was resected during the operation. Regarding annuloplasty, a Carpentier-Edwards Physio II ring N. 32 (Edwards Lifesciences, Irvine, CA, USA) was used. Chordal reconstruction was performed using n. 2 ePTFE Goretex neo-chordae (W.L. Gore & Associates, Flagstaff, AZ, USA). Gore-Tex chords were anchored at the papillary muscle and individually sutured to the free posterior leaflet margin. This intervention shifted the coaptation line posteriorly and contributed to fully resolving AML-SAM. The final outcome was good.", "summary": "A 57-year-old lady with a history of diabetes, dyslipidemia, and a previous single episode of atrial fibrillation (treated with pharmacological cardioversion), presented to the Emergency Department for worsening dyspnea (New York Heart Association Classification class IV). A trans-thoracic echocardiogram (TTE) showed a significant, septal, and asymmetric left ventricular hypertrophy (basal anteroseptal wall diastolic thickness of 19 mm) with normal left ventricle systolic function. A SAM of AML was evident together with a left ventricular outflow tract gradient of 56 mmHg at rest, rising to 136 mmHg during the Valsalva maneuver. In addition, there was evidence of moderate to severe mitral regurgitation (MR) with an anteriorly directed jet, not very typical of MR related to SAM. A 2D-3D trans-esophageal echocardiogram (2D-3D TEE) revealed a combined MR mechanism based on PML degenerative prolapse with P2-flail from ruptured chordae with related eccentric anteriorly directed regurgitant jet, together with a second regurgitant posteriorly directed jet, related to SAM of AML. The patient underwent MV repair together with septal myectomy, with a good final outcome.", "subclaim_evaluations": [ { "subclaim": "The patient is a 57-year-old lady.", "support_label": "supported" }, { "subclaim": "She has a history of diabetes.", "support_label": "supported" }, { "subclaim": "She has a history of dyslipidemia.", "support_label": "supported" }, { "subclaim": "She had a previous single episode of atrial fibrillation.", "support_label": "supported" }, { "subclaim": "The atrial fibrillation was treated with pharmacological cardioversion.", "support_label": "supported" }, { "subclaim": "She presented to the Emergency Department for worsening dyspnea.", "support_label": "supported" }, { "subclaim": "Her dyspnea was classified as New York Heart Association Class IV.", "support_label": "supported" }, { "subclaim": "A trans-thoracic echocardiogram showed significant, septal, and asymmetric left ventricular hypertrophy.", "support_label": "supported" }, { "subclaim": "The basal anteroseptal wall diastolic thickness was 19 mm.", "support_label": "supported" }, { "subclaim": "Left ventricular systolic function was normal.", "support_label": "supported" }, { "subclaim": "A SAM of AML was evident.", "support_label": "supported" }, { "subclaim": "The left ventricular outflow tract gradient at rest was 56 mmHg.", "support_label": "supported" }, { "subclaim": "The left ventricular outflow tract gradient rose to 136 mmHg during the Valsalva maneuver.", "support_label": "supported" }, { "subclaim": "There was evidence of moderate to severe mitral regurgitation.", "support_label": "supported" }, { "subclaim": "The mitral regurgitation jet was anteriorly directed.", "support_label": "supported" }, { "subclaim": "A 2D-3D trans-esophageal echocardiogram revealed a combined MR mechanism.", "support_label": "supported" }, { "subclaim": "The combined MR mechanism included PML degenerative prolapse with P2-flail from ruptured chordae.", "support_label": "supported" }, { "subclaim": "The combined MR mechanism included a second regurgitant posteriorly directed jet related to SAM of AML.", "support_label": "supported" }, { "subclaim": "The patient underwent MV repair.", "support_label": "supported" }, { "subclaim": "The patient underwent septal myectomy.", "support_label": "supported" }, { "subclaim": "The patient had a good final outcome.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_604_en.txt", "fulltext": "This case report has been written in accordance with the SCARE 2018 criteria .\nA 64-year-old female presented to the Emergency Department of our hospital with acute onset of a right-sided groin bulge that occurred earlier that day after doing heavy lifting. She had no significant past medical or surgical history. Her baseline functional status was exceedingly well. Her laboratory studies showed no leukocytosis or any electrolyte abnormalities. Initial radiologic studies included a transabdominal and transvaginal pelvic ultrasound, which showed a 2.4 × 2.6 cm fluid collection with some septations and absent visualized adnexal structures. A subsequent CT demonstrated a well-circumscribed 2.7 × 3.2 × 2.6 cm fluid collection containing echogenic debris. It did not have significant rim enhancement yet was noted to be most consistent with an abscess, complex seroma, or necrotic lymph node; its depth was amenable to percutaneous drainage. On further review with the radiologist, it was noted to contain the appendix, the tip of which was dilated and radiographically concerning for a cystic process, with mucocele remaining within the differential diagnosis.\nThe patient was kept nil per os, intravenous fluid resuscitation was initiated, and antibiotic therapy was begun. She was brought to the operating room for emergent surgical intervention. The patient underwent laparoscopic appendectomy with open femoral hernia repair. Intraoperatively, the appendiceal tip was incarcerated within the hernia sac . Due to the preoperative radiographic appearance and the suspicion for mucocele, extreme caution was exercised to avoid rupture and not to provide excess tension in an attempt to reduce it laparoscopically. It was easily removed through the open inguinal incision after the appendix base was divided laparoscopically . The femoral hernia was repaired in standard McVay fashion. Final pathology showed inflamed non-perforated acute appendicitis without evidence for neoplasm. The patient recovered well without notable complications and was discharged on postoperative day number two without antibiotics.", "summary": "A 64-year-old female presented to the Emergency Department of our hospital with acute onset of a right-sided groin bulge that occurred earlier that day after doing heavy lifting. Her workup revealed acute appendicitis contained within an incarcerated right femoral hernia. The patient underwent laparoscopic appendectomy with open femoral hernia repair. Intraoperatively, the appendiceal tip was incarcerated within the hernia sac. It was removed through the open inguinal incision after the appendix base was divided laparoscopically. Final pathology showed inflamed acute appendicitis without evidence for neoplasm.", "subclaim_evaluations": [ { "subclaim": "The patient is a 64-year-old female.", "support_label": "supported" }, { "subclaim": "She presented to the Emergency Department with a right-sided groin bulge.", "support_label": "supported" }, { "subclaim": "The bulge occurred after doing heavy lifting.", "support_label": "supported" }, { "subclaim": "The workup revealed acute appendicitis.", "support_label": "supported" }, { "subclaim": "The acute appendicitis was contained within an incarcerated right femoral hernia.", "support_label": "supported" }, { "subclaim": "The patient underwent laparoscopic appendectomy.", "support_label": "supported" }, { "subclaim": "The patient also had open femoral hernia repair.", "support_label": "supported" }, { "subclaim": "Intraoperatively, the appendiceal tip was incarcerated within the hernia sac.", "support_label": "supported" }, { "subclaim": "The appendix base was divided laparoscopically.", "support_label": "supported" }, { "subclaim": "The appendiceal tip was removed through the open inguinal incision.", "support_label": "supported" }, { "subclaim": "Final pathology showed inflamed acute appendicitis.", "support_label": "supported" }, { "subclaim": "There was no evidence for neoplasm.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1607_en.txt", "fulltext": "A previously healthy 54-year-old Caucasian man presented to the emergency department of our internal medicine ward with a medical history of aggravation of general health related to dizziness, weight gain, and two syncopal attacks. A physical examination was conducted which showed his blood pressure to be normotensive and his measured pulse rate and body temperature to be within normal limits. His initial laboratory results showed an increased hematocrit level of 69%, a hemoglobin level of 23g/dl, and a white blood cell count of 15.5×1000/μL. Initially he seemed to be hemodynamically stable with no signs of dyspnea. He experienced a rapid decrease of total proteins (5.67g/dl decreasing to 2.02g/dl within 72 hours) and began to exhibit hemodynamic instability, at which point he was admitted to our intensive care unit (ICU) and treated with catecholamines. Due to an increasing pulmonary insufficiency an endotracheal intubation was performed immediately. A massive emission of fluids and proteins from the intravascular to the extracellular compartments caused a generalized compartment syndrome to develop. Over 24 hours after admission to the ICU our patient developed compartment syndromes in both his upper and lower limbs and the abdominal compartment. The abdominal compartment syndrome was diagnosed by measuring the intra-abdominal pressure through a urinary catheter. The highest measured intra-abdominal pressure (IAP) was 26mm/Hg and therefore a diagnosis of abdominal compartment syndrome Grade IV was made. His abdomen and all four limbs required decompression by a fasciotomy of both forearms, both thighs, both lower legs, and the abdomen. The surgeries were performed 24 hours after admission to the clinic. Vacuum-assisted dressings were placed first on his lower limbs. During a second revision operation vacuum-assisted dressings were placed on his upper limbs to assist with monitoring the edema and in preparation for the definite closure of the fasciotomy wounds. The dressing of his abdomen included putting the intestine into a sac and covering it with a transparency dressing. Continuous renal replacement therapy (CRRT) was required three days after admission due to acute renal failure. Continuous venovenous hemodiafiltration (CVVHD) was applied for a total of four days. The blood levels of creatinine and urea returned to normal after three days of CVVHD and he gained back full renal function. Before CVVHD the highest creatinine level amounted to 1.4mg/dl and after renal replacement therapy (before discharge from the hospital) it decreased to 0.6mg/dl. The urea levels also decreased from 80mg/dl to 17mg/dl. The hematological parameters returned to their normal limits by the fourth day of admission . The clinical diagnostics included cultures of the blood, urine, stool, sputum, and intra-operative tissue samples which were all analyzed for aerobic and anaerobic bacteria, as well as for fungus. The results of the samples were all negative. After ruling out the differential diagnoses the diagnosis of a SCLS was confirmed, with secondary abdominal compartment and compartment syndromes in all four limbs. The secondary closure of the abdomen had been performed 16 days after admission and 23 days after admission we were able to remove the vacuum-assisted pumps and proceed in closing all wounds . His upper limbs required skin grafting . His lower limbs showed weakness in the dorsal flexion of the feet and toes, therefore peroneal splints were adjusted to his feet. His upper limbs showed residual deficits of fine motor skills, especially the left upper limb. These deficits had been improved with hand therapy. Our patient was moved to the rheumatology ward after 23 days in our ICU. He was started on medical prophylactic treatment with theophylline and terbutaline in combination with steroid therapy (prednisolone). During remission induction therapy the dose of theophylline ranged between 1200 and 1600mg per day in order to achieve serum concentrations between 20 and 25mg/dl. Before discharging him the theophylline dose was reduced to 1000mg/day. In order to obtain the remission advised to achieve peak serum concentrations between 10 and 20mg/dl, terbutaline was first given at a total dose of 20mg per day in divided doses. Before he was discharged the dose was reduced to 10mg per day. We recommended that he should continue to take theophylline and terbutaline for the rest of his life. Methylprednisolone was applied intravenously while in remission induction therapy at a dose of 40mg per day. After remission was induced the prednisolone was gradually reduced to 15mg/day. We recommended maintaining the gradual reduction of that dose.\nAfter 60 days of treatment he was discharged from the clinic. He was able to return to his previous place of work and reached the same level of athletic activity as before the illness.", "summary": "A previously healthy 54-year-old Caucasian man presented to the emergency department of our internal medicine ward with a medical history of aggravation of general health related to dizziness, weight gain, and two syncopal attacks. Due to a massive emission of fluids and proteins from the intravascular to the extracellular compartments, he developed compartment syndromes in his upper and lower limbs and the abdominal compartment. The abdomen and all four limbs required decompression by a fasciotomy of both forearms, both thighs, both lower legs, and the abdomen within 24 hours after admission. After 60 days of treatment he was dismissed from the clinic. He was able to return to his previous occupation and reached the same level of athletic activity as before the illness.", "subclaim_evaluations": [ { "subclaim": "The patient is a 54-year-old man.", "support_label": "supported" }, { "subclaim": "The patient is Caucasian.", "support_label": "supported" }, { "subclaim": "The patient had two syncopal attacks.", "support_label": "supported" }, { "subclaim": "The patient developed compartment syndromes in his upper and lower limbs.", "support_label": "supported" }, { "subclaim": "The patient developed an abdominal compartment syndrome.", "support_label": "supported" }, { "subclaim": "The abdomen required decompression by fasciotomy.", "support_label": "supported" }, { "subclaim": "Both forearms required decompression by fasciotomy.", "support_label": "supported" }, { "subclaim": "Both thighs required decompression by fasciotomy.", "support_label": "supported" }, { "subclaim": "Both lower legs required decompression by fasciotomy.", "support_label": "supported" }, { "subclaim": "The fasciotomies were performed within 24 hours after admission.", "support_label": "supported" }, { "subclaim": "The patient was dismissed from the clinic after 60 days of treatment.", "support_label": "supported" }, { "subclaim": "The patient was able to return to his previous occupation.", "support_label": "supported" }, { "subclaim": "The patient reached the same level of athletic activity as before the illness.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1368_en.txt", "fulltext": "A 10-year-old Tunisian girl presented to our department with fever, vomiting, and asthenia. She had neither family history of hematological diseases nor other illness before the disease onset. During her admission, a physical examination showed a child of normal stature with pallor and fever (body temperature of 39 °C). She was tachycardic at 141 beats/minute and her blood pressure was at 107/51 mmHg. She had tachypnea at 52 breaths/minute with oxygen saturation in air at 95% and no heart murmur. An abdominal examination found an isolated splenomegaly. Biochemical analysis showed signs of hemolysis: total bilirubin, 51 microml/L with a direct fraction of 9 microml/L; haptoglobin < 58 mg/L; and D-lactate dehydrogenase, 2051 U/L. Her complete blood count showed severe anemia with hemoglobin (Hb), 2.6 g/dl; RBCs, 90 × 104/mm3; hematocrit (Ht), 6.6%; mean corpuscular volume (MCV), 91.3 fL; mean corpuscular hemoglobin (MCH), 31 pg; mean corpuscular hemoglobin concentration (MCHC), 33 g/dL; reticulocytosis, 239,400/mm3; white blood cells, 40,500/mm3; and platelets, 540,000/mm3. The blood smear did not reveal schistocytes. A DAT identified autoantibodies of the immunoglobulin M (IgM), immunoglobulin A (IgA), immunoglobulin G (IgG) isotypes, and C3d that reacted strongly (3+) at 37 °C with all tested cells. This confirmed the diagnosis of AIHA.\nBacteriological analysis performed to access the etiology of the fever showed urinary infection (the urine analysis showed leukocytes of 2000/mm3 and erythrocytes of 1000/mm3) with C-reactive protein at 206 mg/L. The urine culture was negative because the child had already received amoxicillin. Then, antibiotherapy was continued with intravenously administered cefotaxime and amikacin. For AIHA, she had intravenously administered immunoglobulin (IVIG) at a dose of 1 g/kg per day twice during 48 hours. She also received repetitive RBCs transfusion. After controlling the infectious process, she was given a high-dose pulse of methylprednisolone (30 mg/kg per day for 3 days) followed by orally administered prednisone at a dose of 2 mg/kg per day. Due to the persistence of altered neurological status and severe hemolysis, she was again given IVIG and high-dose pulse methylprednisolone but without any benefit. Therefore, it was urgent to use a second-line therapy. In view of severe life-threatening hemolysis and her age, rituximab was deemed a better option than plasmapheresis, splenectomy, and/or cytotoxic drugs. Rituximab was given at a dose of 375 mg/m2 per week for 4 weeks. Afterward, prednisone was continued. After the second dose of rituximab our patient no longer required blood transfusions and there was a slow rise in her Hb level until day 15 at which point it stabilized . At the last out-patient follow up (4 months after her hospitalization), her Hb and hemolytic markers were still within a normal range: Hb, 13 g/dl; RBCs, 4.31 × 106/mm3; Ht, 37.5%; and reticulocytosis of 69,000/mm3. Biological investigations (serological tests, antinuclear antibodies screening, and immunity exploration) done to search for an underlying condition such as infection, lupus, or immune deficiency disease were all negative.", "summary": "Here, we report the case of a 10-year-old Tunisian girl with refractory acute autoimmune hemolytic anemia caused by warm-reactive immunoglobulin A, immunoglobulin G, immunoglobulin M, and C3d autoantibodies. First-line treatments using corticosteroids and intravenously administered immunoglobulin were ineffective in controlling her severe disease. On the other hand, she was successfully treated with rituximab. In fact, her hemolytic anemia improved rapidly and no adverse effects were observed.", "subclaim_evaluations": [ { "subclaim": "The patient is a 10-year-old Tunisian girl.", "support_label": "supported" }, { "subclaim": "She has refractory acute autoimmune hemolytic anemia.", "support_label": "supported" }, { "subclaim": "The anemia was caused by warm-reactive immunoglobulin A autoantibodies.", "support_label": "supported" }, { "subclaim": "The anemia was caused by warm-reactive immunoglobulin G autoantibodies.", "support_label": "supported" }, { "subclaim": "The anemia was caused by warm-reactive immunoglobulin M autoantibodies.", "support_label": "supported" }, { "subclaim": "The anemia was caused by warm-reactive C3d autoantibodies.", "support_label": "supported" }, { "subclaim": "First-line treatment included corticosteroids.", "support_label": "supported" }, { "subclaim": "First-line treatment included intravenously administered immunoglobulin.", "support_label": "supported" }, { "subclaim": "The first-line treatments were ineffective in controlling her severe disease.", "support_label": "supported" }, { "subclaim": "She was treated with rituximab.", "support_label": "supported" }, { "subclaim": "Her hemolytic anemia improved rapidly.", "support_label": "not_supported" }, { "subclaim": "No adverse effects were observed.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1993_en.txt", "fulltext": "A 14-year-old girl had pain in the left epigastrium for more than 10 d, with no tarry stool, hematemesis, or coma history. She normally liked squatting, and her activity tolerance was low. She was normally developed without positive signs.\nThe results of laboratory examinations were as follows: routine blood examination: red blood cell 4.64 × 109/L, white blood cell 4.83 × 109/L, blood platelet 218 × 109/L; blood biochemistry: alanine aminotransferase 36.9 μ/L, aspartate aminotransferase 30.6 μ/L, serum albumin 41.9 g/L, total bilirubin 21.7 μmol/L, direct bilirubin 8.0 μmol/L, PT 12.8 s, international normalized ratio 1.13. Blood ammonia 22.4 μmol/L, lactic acid 3.28 mmol/L. No abnormality was observed in arterial blood gas parameters at resting state.\nCT suggested congenital extrahepatic portacaval diversion (Type Ib Abernethy deformation). The superior mesenteric vein and splenic vein joined to form a short extra-hepatic portal vein that drained into a postcava with left hepatic vein, associated with double pulmonary congestion and pulmonary arterial hypertension. There were multiple space-occupying lesions in the liver, and the size of the relatively large tumor was approximately 50 mm. To exclude malignant tumor transformation, positron emission tomography-CT examination was performed . The results indicated nodules and mass imaging with multiple increased glycometabolism in the liver parenchyma and increased 11C-choline metabolism in some lesions. Multiple focal nodular hyperplasia combined with partial malignant transformation was highly possible. Echocardiography suggested the mean pressure of pulmonary artery at 36 mmHg and light pulmonary arterial hypertension. Pulmonary function examination indicated severe diffusion impairment.", "summary": "The patient was a 14-year-old girl, diagnosed preoperatively as type Ib Abernethy deformation, intrahepatic multiple space-occupying lesion, and hepatopulmonary syndrome. The patient recovered well after undergoing classic orthotopic liver transplantation. Liver function, pulmonary function, and portal vein computed tomography angiography imaging were reexamined 20 mo postoperatively, and no abnormality was observed.", "subclaim_evaluations": [ { "subclaim": "The patient was a 14-year-old girl.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed preoperatively as type Ib Abernethy deformation.", "support_label": "supported" }, { "subclaim": "The patient had intrahepatic multiple space-occupying lesions.", "support_label": "supported" }, { "subclaim": "The patient had hepatopulmonary syndrome.", "support_label": "not_supported" }, { "subclaim": "The patient underwent classic orthotopic liver transplantation.", "support_label": "not_supported" }, { "subclaim": "The patient recovered well after the liver transplantation.", "support_label": "not_supported" }, { "subclaim": "Liver function was reexamined 20 months postoperatively.", "support_label": "not_supported" }, { "subclaim": "Pulmonary function was reexamined 20 months postoperatively.", "support_label": "not_supported" }, { "subclaim": "Portal vein computed tomography angiography imaging was reexamined 20 months postoperatively.", "support_label": "not_supported" }, { "subclaim": "No abnormality was observed in the 20-month postoperative reexaminations.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2831_en.txt", "fulltext": "A 44-year-old woman had undergone first allogeneic cord blood transplantation (CBT, 2.35 × 106/kg nucleated cells, two locus mismatch) for acute myeloid leukemia after two courses of induction therapy that led to hematologic complete remission. The patient was pre-treated with cytarabine, cyclophosphamide, and total body irradiation conditioning. Graft-versus-host disease prophylaxis consisted of cyclosporine and methotrexate. Her medical, family, and social histories were unremarkable. The patient underwent a second CBT (2.0 × 107/kg nucleated cells) 32 days after the first due to graft failure.\nSeven days after the second CBT, she presented with high fever and shaking chills. Upon physical examination, painful induration with linear erythema along the superficial veins was observed in the peripherally inserted central catheter (PICC) site, which was inserted on the day after the second CBT. Two sets of blood samples were drawn for culture and meropenem treatment was started. The blood culture was positive on the third day of incubation (10 days after the second CBT). Gram staining of a positive blood culture revealed GPR , and vancomycin was added thereafter. Fever persisted and PICC was removed on day 11 after the second CBT (PICC was maintained for 10 days). The VITEK® 2 system (bioMérieux, Durham, NC, USA) was not able to identify the organism. Blood cultures drawn on days 10, 11, 15, and 22 after CBT were also positive for GPR. On the 14th day after the second CBT, Ziehl–Neelsen staining was performed and was found to be positive for acid-fast bacilli .\nThe nucleotide sequences were analyzed using the National Center for Biotechnology Information BLAST . The almost full-length (1442-bp) 16S rDNA gene sequence of the isolate shared 100% similarity to M. wolinskyi type strain ATCC 700010.\nIn addition to PICC removal, imipenem/cilastatin (IPM/CS), amikacin (AMK), levofloxacin (LVX), and azithromycin (AZM) were started empirically. Antibiotic susceptibilities were determined using the broth microdilution method (BrothMIC RGM®; Kyokuto, Tokyo, Japan) based on the Clinical and Laboratory Standards Institute M24 recommendations .\nAccording to the susceptibilities, IPM/CS and AZM were discontinued, and minocycline (MIN) was added. LVX was changed to moxifloxacin (MFX) based on previous case series . After 1 month of intravenous administration of AMK, the patient was discharged on an oral regimen of MFX and MIN. Although MXF had to be discontinued after 4 months due to nausea, MIN was continued for 6 months.\nAfter 3 weeks of combination antimicrobial therapy, blood cultures became negative. She showed successful engraftment by day 28. The patient responded well to therapy and no recurrence of infection was identified at 1-year follow-up.", "summary": "We present a case of CRBSI caused by Mycobacterium wolinskyi, a rare RGM, in a 44-year-old female patient who received an umbilical cord blood transplant.", "subclaim_evaluations": [ { "subclaim": "The case involves a 44-year-old female patient.", "support_label": "supported" }, { "subclaim": "The patient received an umbilical cord blood transplant.", "support_label": "supported" }, { "subclaim": "The patient developed a catheter-related bloodstream infection (CRBSI).", "support_label": "supported" }, { "subclaim": "The infection was caused by Mycobacterium wolinskyi.", "support_label": "supported" }, { "subclaim": "Mycobacterium wolinskyi is a rare rapidly growing mycobacterium (RGM).", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2546_en.txt", "fulltext": "A 73-year-old woman with pancreatic head adenocarcinoma underwent pancreatoduodenectomy (PD) at the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan, in July 2005. The patient’s height, body weight, and body mass index were 154 cm, 56 kg, and 23.6 kg/m2, respectively. The patient was discharged 40 days postoperatively; however, approximately 1 month after discharge, she visited the hospital’s Division of Dentistry and Oral Surgery with a chief complaint of tongue pain with dysgeusia. The first examination revealed glossitis characterized by complete atrophy of the lingual papillae, which became erythematous; this is a symptom of glossitis . Furthermore, remarkable taste disorder (hypogeusia) and oral pain were reported. The angle of the mouth had stomatitis with erosive changes. The extremities showed acrodermatitis enteropathica-like eruption and abnormal keratinization . Blood test results showed hypoproteinemia and hypoalbuminemia (total protein (TP) 5.1 g/dL, albumin (ALB) 2.4 g/dL) . Examination of trace elements showed remarkably lower serum zinc and copper levels (30 μg/dL and 40 μg/dL, respectively) . We diagnosed malnutrition, dysgeusia, glossitis, angular cheilitis, and acrodermatitis enteropathica due to zinc deficiency. However, she had no obvious frequent diarrhea or steatorrhea.\nInitially, we orally administered 150 mg of Promac® granules 15% (polaprezinc, ZERIA Pharmaceutical Co., Ltd, Japan) per day (total zinc dose, 34 mg/day) to treat the zinc deficiency. However, due to the insufficient effectiveness of the replacement therapy, we additionally administered multi-trace elements (MTEs) for high-calorie infusions. Elemenmic® (Ajinomoto Co Inc, Japan) was administered intravenously, one ampule of which contained elemental iron (Fe) 35 μmol, manganese (Mn) 1 μmol, zinc (Zn) 60 μmol (= 4 mg), copper (Cu) 5 μmol, and iodine (I) 1 μmol; this was administered twice a week for 2 weeks as an outpatient treatment. However, the intravenous replacement therapy was similarly inadequate at this dosing interval and did not provide sufficient improvement in the serum copper and zinc values. The blood test results 4 months after PD were as follows: TP, 4.4 g/dL; ALB, 2.0 g/dL; Zn, 34 μg/dL; and Cu, 28 μg/dL; the patient required nutritional management during hospitalization with total parenteral nutrition (TPN) . An improvement was observed in the zinc level (99 μg/dL) and copper level (204 μg/dL) after 20 days of administering one ampule of Elemenmic® per day. Concurrently, her tongue pain and dysgeusia gradually improved. Because of a similar improvement in her nutritional status, she completed TPN (TP 5.1 g/dL, ALB 2.5 g/dL, Zn 99 μg/dL, Cu 204 μg/dL). A central venous catheter (CVC) inserted after admission was removed, and she was discharged 20 days after the second admission. On this occasion, intravenous zinc replacement therapy was discontinued.\nOne month after discharge, the serum zinc level decreased sharply, her oral pain increased again, and she had reduced food intake (Zn 35 μg/dL, Cu 44 μg/dL) . The patient was readmitted at the end of December 2005. To improve malnutrition, a CVC was re-inserted through the external jugular vein and injected with the MTE formulation and high-calorie infusions on consecutive days for 4 weeks (TP 5.9 g/dL, ALB 3.4 g/dL, Zn 75 μg/dL, Cu 47 μg/dL). In January 2006, since her oral pain and diet had improved, she was discharged from the hospital after receiving an implant of a central venous port, and she continued home self-injection of MTEs to maintain zinc levels. In February 2006, her taste function tended to improve, and in April 2006, the taste almost improved. When MTEs were self-injected daily, the serum zinc level gradually exceeded the normal range and reached 167 μg/dL in August 2006 ; therefore, the administration was switched to every other day. Subsequently, we had to confirm the blood test data repeatedly to monitor serum zinc levels to ensure that they were within the normal range . Despite continuing intravenous zinc replacement therapy, serum zinc levels decreased when additional oral zinc was discontinued in May 2007. After resuming the oral administration of Promac® due to the recurrence of dysgeusia, both the serum zinc level and dysgeusia improved. Since 2008, Pancreatin® (pancreatic enzyme, Mylan Co Inc, USA) 3 g/day had been administered alongside conventional zinc administration for this patient .\nAs of January 2012, she continued using MTEs intermittently while her serum zinc values were monitored; however, slight angular cheilitis was observed, and she exhibited no signs of glossitis and dysgeusia . Moreover, recurrence and metastasis of the primary tumor were not observed. She subsequently died of lung cancer in May 2020.", "summary": "A 73-year-old woman with glossitis, taste disorder, and acrodermatitis enteropathica-like eruption on her fingers presented to the Division of Dentistry and Oral Surgery 69 days after PD. Her serum zinc level markedly decreased to 30 μg/dL. Oral zinc administration was inadequate to treat hypozincemia after PD; therefore, multi-trace elements were injected intravenously during readmission. Her serum zinc levels recovered, and her lesions gradually improved. Furthermore, a central venous port was implanted to maintain normal serum zinc levels, and she continued self-injecting zinc at home.", "subclaim_evaluations": [ { "subclaim": "The patient is a 73-year-old woman.", "support_label": "supported" }, { "subclaim": "She had glossitis.", "support_label": "supported" }, { "subclaim": "She had a taste disorder.", "support_label": "supported" }, { "subclaim": "She had an acrodermatitis enteropathica-like eruption on her fingers.", "support_label": "supported" }, { "subclaim": "She presented to the Division of Dentistry and Oral Surgery.", "support_label": "supported" }, { "subclaim": "She presented 69 days after PD.", "support_label": "supported" }, { "subclaim": "Her serum zinc level was 30 μg/dL.", "support_label": "supported" }, { "subclaim": "Oral zinc administration was inadequate to treat hypozincemia after PD.", "support_label": "supported" }, { "subclaim": "Multi-trace elements were injected intravenously during readmission.", "support_label": "supported" }, { "subclaim": "Her serum zinc levels recovered.", "support_label": "supported" }, { "subclaim": "Her lesions gradually improved.", "support_label": "supported" }, { "subclaim": "A central venous port was implanted.", "support_label": "supported" }, { "subclaim": "She continued self-injecting zinc at home.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_884_en.txt", "fulltext": "An 83-year-old Taiwanese woman found a palpable mass in her right breast for 1 year. The lesion was approximately 1cm in greatest dimension last year and had got larger in the past 6 months. She had a history of type AB thymoma and was treated with complete tumor resection 10 years ago. The thymoma was 15cm in greatest dimension, encapsulated with focal pericardial adhesion and without pericapsular invasion . A mammography revealed a well-defined hypoechoic oval mass in 10 o'clock direction and 3.0cm away from her nipple, occupying the whole thickness of her breast, and measuring 4.0×3.2×2.6cm in size . A tumor excision was performed.\nThe specimen consisted of a piece of breast tissue partially occupied by an oval encapsulated mass that measured 5.0×3.8×3.5cm in size, with focal artificial disruption. The cut surface of the tumor was tan red and the focal was light yellowish. The tumor consistency was soft and fragile. On microscopic examination, the well-encapsulated tumor was composed of neoplastic cells arranged in solid sheets, vague fascicles or ribbons and few rosettes without lumen, and admixed with variable amounts of lymphocytes . The neoplastic cells set in the lymphocyte-rich background were oval, polygonal or short fusiform, and had small round-to-oval nuclei with inconspicuous nucleoli . The spindle tumor cells were mainly seen in the lymphocyte-poor area. The two groups of neoplastic cells either separated with a discrete border or were intermixed together. Mild nuclear atypia was occasionally seen. Mitoses were scanty. Some aggregates of histiocytes and few dilating and mildly branching thin-walled vessels were also found. The neoplastic cells were diffusely positive for cytokeratin , partially positive for vimentin and smooth muscle actin, mostly positive for p63, and focally immunoreactive with epithelial membrane antigen. A few tumor cells were also positive for CD20 . Some spindle neoplastic cells were surrounded by collagen IV deposition. The tumor cells were negative for CD21 and CD34. The lymphocytes were positive for CD3, CD5, CD1a, and CD99 . Few scattered individual and small groups of interdigitating reticulum cells were seen by S-100 protein staining. From these features and past history, we diagnosed this tumor as a metastatic type AB thymoma to the breast.", "summary": "We describe an 83-year-old Taiwanese woman with a metastatic thymoma to the breast 10 years after complete resection of noninvasive and encapsulated primary tumor, and analyze the possible factors to explain the recurrence and metastasis of the stage I thymomas.", "subclaim_evaluations": [ { "subclaim": "The patient is an 83-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient is of Taiwanese ethnicity.", "support_label": "supported" }, { "subclaim": "The patient had a primary thymoma.", "support_label": "supported" }, { "subclaim": "The primary thymoma was noninvasive.", "support_label": "supported" }, { "subclaim": "The primary thymoma was encapsulated.", "support_label": "supported" }, { "subclaim": "The primary thymoma was completely resected.", "support_label": "supported" }, { "subclaim": "The metastasis occurred 10 years after the primary tumor resection.", "support_label": "supported" }, { "subclaim": "The thymoma metastasized to the breast.", "support_label": "supported" }, { "subclaim": "The primary tumor was stage I.", "support_label": "not_supported" }, { "subclaim": "The case analyzes possible factors for the recurrence and metastasis of stage I thymomas.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2202_en.txt", "fulltext": "A healthy 79-year-old Caucasian woman was referred to our hospital with a diagnosis of stage III immunoglobulin A-lambda MM with numerous osteolytic areas (bilateral iliac wings, T3 to T4) and cardiologic symptoms of pulmonary embolism. Computed tomography (CT) of her chest documented the presence of a right atrial mass (42mm × 53mm), confirmed by subsequent magnetic resonance imaging (MRI) and fluorine-18-fluorodeoxyglucose positron emission tomography (F18-FDG PET). A transesophageal echocardiogram revealed a large pericardial effusion with evidence of cardiac tamponade and a large right atrial mass encasing her interatrial septum and extending into her left atrium. Histologic specimens of a bone marrow biopsy demonstrated the presence of tiny aggregates of atypical plasma cells with asynchronous morphology, positive for cluster of differentiation 138.\nOur patient was treated with four cycles of bortezomib, four cycles of melphalan and prednisone and another four cycles of bortezomib, achieving a lessening of the symptoms and a stability of the cardiac disease. Pharmacological toxicity was not significant.\nNine months later, our patient developed a painful bone relapse. The pain was severe, constant and localized primarily in her sacrum and the right iliac wing. The pain increased to some extent with movement. Our patient received local radiotherapy on both sites (2000cGy/5 fractions), achieving a reduction in symptoms and an improvement of her performance status.\nOne year after the initial diagnosis, our patient presented to our emergency department because of the new appearance of signs and symptoms of congestive heart failure: dyspnea, hypotension, cyanosis and facial edema.\nCT of her chest revealed an increase in the size of the mass (78mm × 84mm), which appeared to infiltrate her right pulmonary vein and superior vena cava for approximately 21mm, causing neoplastic thrombosis of her right subclavian vein . These findings were confirmed by echocardiography and F18-FDG PET .\nRestaging examinations documented stable bone disease.\nOur patient was evaluated by a surgeon for possible surgery on her right atrium, but she was considered inoperable due to the extent of the disease. The diagnosis of atrial localization of malignant plasmacytoma was confirmed via examination of a biopsy specimen. In order to obtain rapid control of the intracardiac disease, radiation to the cardiac mass was started.\nExternal-beam radiation, totaling 3000cGy in 10 daily fractions of 300cGy, each with 6mV photons, was delivered using the intensity modulated radiation therapy (IMRT) technique.\nOur patient was immobilized in the supine position with a wing board and target localization was accomplished using CT simulation. The volumes of interest were identified on each axial CT slice. The gross tumor volume was defined as the gross extent of the tumor shown by imaging (CT, MRI and PET); the clinical target volume was defined as the gross tumor volume plus a margin for potential microscopic spread (5mm); and, in order to account for organ motion and patient setup errors, the planning target volume was defined by adding a 1 cm margin to the clinical target volume. Treatment planning was performed using an inverse planning algorithm in a tomotherapy planning system and our patient was treated with an IMRT delivered with tomotherapy.\nThe treatment was generally well tolerated; our patient showed no symptoms suggestive of radiation-induced toxicity. Her symptoms immediately improved with a decrease in generalized edema and improved performance status. A transesophageal echocardiogram performed three weeks from the end of the radiotherapy confirmed a significant decrease in tumor size in her right atrium.\nDue to our patient’s age and good condition, the medical staff chose a ‘wait and see’ approach. Three months later, repeat chest and abdominal CT scans showed complete remission of the cardiac disease, but progressive bone disease.\nThe worsening of the general conditions of our patient, due to other causes, meant that she was subjected to supportive care for two months. After the improvement of her health status, our patient started maintenance chemotherapy with lenalidomide and she is currently tolerating it well.\nIn a new CT scan of her chest done eighteen months after the end of the radiotherapy , complete remission of the cardiac disease was confirmed.\nCurrently, our patient is generally in good condition and shows no significant cardiac symptoms. Recently performed chest and abdominal CT documented stability of the disease in known locations, but highlighted the emergence of an axillary mass, for which we are programming a new radiation treatment in view of her good response to previous radiotherapy.", "summary": "A 79-year-old Caucasian woman was treated at our hospital for right atrial myeloma localization. Our patient showed the following signs and symptoms of congestive heart failure: dyspnea, hypotension, cyanosis and facial edema. Surgery was not considered feasible due to the extent of the disease. Our patient underwent external-beam radiation therapy using an intensity modulated technique, thus obtaining a persistent complete remission. Our patient has been in continuous complete local remission for 25 months since the end of radiotherapy.", "subclaim_evaluations": [ { "subclaim": "The patient is a 79-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient is Caucasian.", "support_label": "supported" }, { "subclaim": "The patient had right atrial myeloma localization.", "support_label": "supported" }, { "subclaim": "The patient had dyspnea.", "support_label": "supported" }, { "subclaim": "The patient had hypotension.", "support_label": "supported" }, { "subclaim": "The patient had cyanosis.", "support_label": "supported" }, { "subclaim": "The patient had facial edema.", "support_label": "supported" }, { "subclaim": "Surgery was not considered feasible.", "support_label": "supported" }, { "subclaim": "The patient underwent external-beam radiation therapy.", "support_label": "supported" }, { "subclaim": "The radiation therapy used an intensity modulated technique.", "support_label": "supported" }, { "subclaim": "The patient achieved a persistent complete remission.", "support_label": "not_supported" }, { "subclaim": "The patient has been in continuous complete local remission for 25 months.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_3049_en.txt", "fulltext": "A 59 year old Chinese woman underwent routine mammographic screening that revealed scattered areas of fibroglandular densities with microcalcifications developing in the lower inner quadrant of the left breast and prominent lymph nodes. Magnification mammographic views of the left breast demonstrated amorphous heterogeneous calcifications in a segmental distribution, spanning an area approximately 70 mm in maximal anterior–posterior dimension. No associated mass was identified on mammography or ultrasound. A 14 gauge (G) ultrasound-guided, spring-loaded core biopsy of the left breast lesion revealed low-to-intermediate grade ductal carcinoma in situ (DCIS) (with associated microcalcifications).\n\nThe patient was gravida 3 para 3, postmenopausal approximately 1 year previously, with no family history of breast cancer and in good health. She had no history of malignancy and was a lifetime nonsmoker.\n\nUltrasound of the left axilla showed normal morphology level I lymph nodes and one to two abnormal level II lymph nodes with focally increased cortical thickness measuring up to 5 mm and an eccentrically displaced and partially flattened fatty hilum. This clinical scenario raised the question of why this patient had enlarged nodes in the apparent presence of only DCIS.\n\nIn addition, 10 months prior to presentation, she had acute upper respiratory tract symptoms consistent with a viral illness, with a negative nasopharyngeal swab reverse transcription polymerase chain reaction test for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). This patient had sought medical attention after she detected swelling in her left supraclavicular fossa 7 months earlier. In addition, 7 days prior to presenting with left supraclavicular fossa swelling, she had received the first dose of the Pfizer COVID-19 vaccine in the left deltoid muscle. Just prior to her vaccination, serologic testing for total antibodies to SARS-CoV-2 nucleocapsid and spike proteins were negative.\n\nPhysical examination at the time of her presentation revealed a cluster of three soft nontender lymph nodes in the left supraclavicular fossa, each approximately 1–1.5 cm in diameter. There was no detectable cervical or axillary lymphadenopathy. Breast exam was normal, with no palpable masses. A chest X-ray revealed no abnormalities. The enlarged lymph nodes were attributed to the COVID-19 vaccine. Over the next 4 weeks, the left supraclavicular lymph nodes decreased in size and became barely palpable.\n\nInitial ultrasound-guided 25G and 22G fine needle aspiration of the level II axillary lymph node yielded insufficient lymphoid sample and was unsatisfactory for evaluation.\n\nDynamic contrast enhanced magnetic resonance imaging (MRI) was performed to further assess the breasts and lymph nodes. There was corresponding focally increased non-mass enhancement at the site of the left breast biopsy proving DCIS but no MRI evidence of grossly invasive disease. In the left axilla, there was an enhancing mass measuring 1.3 cm in diameter, deep to the pectoralis major muscle. An ultrasound-guided core biopsy of this mass was performed. Pathology revealed lymphoid tissue with interfollicular areas containing small lymphocytes, plasma cells, and rare eosinophils. No aberrant expression of CD20, CD3, BCL2, BCL6, kappa, lambda, or AE1/AE3 was identified. These histologic findings and the immunophenotype were consistent with lymphoid hyperplasia.\n\nLymphadenopathy can be caused by various etiologies, including malignancies, infections, autoimmune disorders, or miscellaneous conditions such as certain medications, foreign bodies, or vaccinations. In this case, many etiologies could be eliminated from consideration on the basis of the patient’s history, physical exam, and investigations. The patient had no known infections and no findings suggestive of an infection. She had no history of or symptoms suggestive of an autoimmune disorder. The patient was only taking hormone replacement therapy, steroid inhaler, and chronic antihypertensive medications in the 7-month period between vaccination and diagnosis of DCIS, none of which are associated with lymphadenopathy. There was no history of any implanted device or foreign body. After reviewing imaging and pathology, the clinical team concluded that the enlarged left axillary lymph nodes with reactive histology were not due to a malignancy or benign tumor. Thus the team determined by diagnosis of exclusion that the lymphadenopathy was most likely due to the prior ipsilateral upper extremity COVID-19 vaccine administration.\n\nBecause of the extent of the DCIS, the final recommendation was to do a total mastectomy of the left breast with sentinel node removal and immediate reconstruction with a deep inferior epigastric artery perforator (DIEP) flap.\n\nSurgical pathology revealed multifocal intermediate grade DCIS that was positive for estrogen receptor protein and progesterone receptor protein, with the largest area spanning 59 mm on histology. The left axilla sentinel lymph node was negative for malignancy. The patient had an uneventful recovery and received no additional treatment.", "summary": "A 59 year old Chinese woman underwent routine mammographic screening that revealed scattered areas of fibroglandular densities in the lower-inner quadrant of the left breast and abnormal lymph nodes. A core biopsy of the breast identified ductal carcinoma in situ. A biopsy of the lymph nodes was performed, and histological findings and immunophenotype were consistent with lymphoid hyperplasia. This patient had sought medical attention after she detected swelling in her left supraclavicular fossa 7 months earlier. She had received the first dose of the Pfizer coronavirus disease-2019 vaccine in the left deltoid muscle 7 days prior to presenting with left supraclavicular fossa swelling.", "subclaim_evaluations": [ { "subclaim": "The patient is a 59 year old Chinese woman.", "support_label": "supported" }, { "subclaim": "The patient underwent routine mammographic screening.", "support_label": "supported" }, { "subclaim": "Mammography revealed scattered areas of fibroglandular densities in the lower-inner quadrant of the left breast.", "support_label": "supported" }, { "subclaim": "Mammography revealed abnormal lymph nodes.", "support_label": "supported" }, { "subclaim": "A core biopsy of the breast identified ductal carcinoma in situ.", "support_label": "supported" }, { "subclaim": "A biopsy of the lymph nodes was performed.", "support_label": "supported" }, { "subclaim": "Histological findings of the lymph nodes were consistent with lymphoid hyperplasia.", "support_label": "supported" }, { "subclaim": "The patient had sought medical attention after she detected swelling in her left supraclavicular fossa 7 months earlier.", "support_label": "supported" }, { "subclaim": "The patient had received the first dose of the Pfizer coronavirus disease-2019 vaccine in the left deltoid muscle.", "support_label": "supported" }, { "subclaim": "The vaccine was administered 7 days prior to presenting with left supraclavicular fossa swelling.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_965_en.txt", "fulltext": "A 52-year-old man arrived at the emergency department with a chief complaint of right-sided weakness since 3 h. He had a history of hypertension. Neurological examination revealed right-sided hemiparesis (manual muscle test grade of 3 in the right arm and 4 in the right leg; grade 0 meaning no strength, grade 5 full strength) and hypoesthesia. The National Institutes of Health Stroke Scale score was 4. His blood pressure was 166/109 mm Hg. To avoid delaying thrombolysis, we first chose non-contrast CT to exclude intracranial hemorrhage. Initial head CT revealed no intracranial hemorrhage and no early ischemic changes and an old lacunar cerebral infarction in the left putamen . The prothrombin time/international normalized ratio and the activated partial thromboplastin time were normal. Intravenous treatment with tenecteplase of 16 mg (0.25 mg/kg) was started 3.8 h after stroke onset. CTA of the head and neck was performed using 50 ml of intravenous iopamidol-370 and flow rate of 4.0 ml/s 0.5 h after IVT. The CTA showed bilateral mild to moderate atherosclerosis of the carotid and fenestration of the left proximal middle cerebral artery without any hemodynamically significant stenosis or occlusion of the carotid and major intracranial arteries . Then, he was transferred to the stroke unit for further evaluation.\nAt about 1.5 h after CTA, the right-sided hemiparesis deteriorated with a manual muscle test grade of 1 in the right arm and 2 in the right leg, accompanied by drowsiness, aphasia, and urinary incontinence. Immediate head CT showed hyperdense lesions with mild space-occupying effect in the left basal ganglia and both lateral ventricles, which.\nhad a mean Hounsfield unit (HU) of 55 (range from 24 HU to 79 HU) . He was transferred to our department for further treatment. The follow-up CT after 5 h showed that the hyperdensity in the left basal ganglia and lateral ventricles was reduced in size. A mild hyperdensity of the right posterior insular cortex was found . Two days later, CT showed that the hyperdense lesions in the lateral ventricles had almost completely disappeared and only a small amount remained in the basal ganglia and insular, without obvious surrounding edema and mass effect . The hyperdensity in the right posterior insular cortex remained, probably representing a mild HT . Only some scattered small petechiae could be seen in the left infarcted area on CT eight days after intravenous thrombolytic treatment . The patient was improving with physical, occupational and speech therapies during hospitalization and was eventually discharged to a rehabilitation center.", "summary": "A 52-year-old man presented with right-sided hemiparesis and hypoesthesia. Initial non-contrast head CT was negative for intracranial hemorrhage and acute ischemic changes. He received intravenous treatment with tenecteplase 3.8 h after the onset of stroke. CTA of the head and neck was performed at 4.3 h after stroke onset. It showed no stenosis or occlusion of the carotid and major intracranial arteries. At about 1.5 h after CTA, the right-sided hemiparesis deteriorated, accompanied by drowsiness, aphasia, and urinary incontinence. Immediate head CT showed hyperdense lesions with mild space-occupying effect in the left basal ganglia and both lateral ventricles. The hyperdense lesions were reduced in size on follow-up CT after 5 h. Two days later, CT showed that the hyperdense lesions in the lateral ventricles almost completely disappeared and only a small amount remained in the infarcted area.", "subclaim_evaluations": [ { "subclaim": "The patient is a 52-year-old man.", "support_label": "supported" }, { "subclaim": "He presented with right-sided hemiparesis.", "support_label": "supported" }, { "subclaim": "He had right-sided hypoesthesia.", "support_label": "supported" }, { "subclaim": "Initial non-contrast head CT was negative for intracranial hemorrhage.", "support_label": "supported" }, { "subclaim": "Initial non-contrast head CT was negative for acute ischemic changes.", "support_label": "supported" }, { "subclaim": "He received intravenous tenecteplase.", "support_label": "supported" }, { "subclaim": "Tenecteplase was administered 3.8 hours after stroke onset.", "support_label": "supported" }, { "subclaim": "CTA of the head and neck was performed 4.3 hours after stroke onset.", "support_label": "not_supported" }, { "subclaim": "CTA showed no stenosis of the carotid arteries.", "support_label": "not_supported" }, { "subclaim": "CTA showed no occlusion of the major intracranial arteries.", "support_label": "supported" }, { "subclaim": "Right-sided hemiparesis deteriorated 1.5 hours after CTA.", "support_label": "supported" }, { "subclaim": "Drowsiness occurred 1.5 hours after CTA.", "support_label": "supported" }, { "subclaim": "Aphasia occurred 1.5 hours after CTA.", "support_label": "supported" }, { "subclaim": "Urinary incontinence occurred 1.5 hours after CTA.", "support_label": "supported" }, { "subclaim": "Immediate head CT showed hyperdense lesions in the left basal ganglia.", "support_label": "supported" }, { "subclaim": "Immediate head CT showed hyperdense lesions in both lateral ventricles.", "support_label": "supported" }, { "subclaim": "The hyperdense lesions had a mild space-occupying effect.", "support_label": "supported" }, { "subclaim": "Follow-up CT after 5 hours showed reduced size of the hyperdense lesions.", "support_label": "supported" }, { "subclaim": "Two days later, CT showed the hyperdense lesions in the lateral ventricles almost completely disappeared.", "support_label": "supported" }, { "subclaim": "Two days later, CT showed a small amount of hyperdense lesion remained in the infarcted area.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2111_en.txt", "fulltext": "A 67-year-old man presented with a 2-wk history of progressively worsening polyarthralgia and nail dystrophy.\nThe patient was diagnosed with advanced gastric adenocarcinoma with distant lymph nodes (LNs) metastases was referred to our department in March 2020. Esophagogastroduodenoscopy revealed a 3-cm sized ulcerofungating mass in the pre-pyloric antrum. Histopathological examination of the endoscopic biopsy specimen revealed moderately differentiated adenocarcinoma, negative results for human epidermal growth factor receptor 2 (immunohistochemistry 1+), Epstein-Barr virus, and deficient DNA mismatch repair (dMMR) (retained nuclear expression of MSH2 and MSH6 and loss of MLH-1 and PMS-1). Abdominal computed tomography showed multiple enlarged LNs in the para-aortic and aortocaval areas. The patient was treated with capecitabine and oxaliplatin as the first-line palliative chemotherapy for 11 mo, followed by ramucirumab and paclitaxel as second-line palliative chemotherapy. After 2 mo of treatment with ramucirumab and paclitaxel, the tumor response indicated progressive disease. In June 2021, pembrolizumab (200 mg in a 3-wk cycle) was initiated as third-line palliative chemotherapy, given that the tumors showed dMMR.\nHe had a history of foot psoriasis, which was well controlled without treatment.\nHe had no personal and family history.\nThe patient was afebrile with stable vital signs. Physical examination revealed erythematous swelling in the distal interphalangeal joints, left shoulder, and both knees . He had plaque psoriasis with psoriatic nail dystrophy and dactylitis in the distal joints of the fingers and toes .\nBefore pembrolizumab administration, the neutrophil-to-lymphocyte ratio (NLR, absolute neutrophil count divided by absolute lymphocyte count) and prognostic nutritional index (PNI, 10 × serum albumin value, g/dL + 0.005 × total lymphocyte count/mm3) were 1.1 and 50.5, respectively. Two months after the initiation of pembrolizumab, laboratory testing revealed a normal white blood cell count of 7970/µL with 72.6% neutrophils and 17.9% lymphocytes, an elevated erythrocyte sedimentation rate (ESR) of 89.0 mm/h, and a serum high-sensitivity C-reactive protein (hs-CRP) level of 2.3 mg/L. Immunological serum tests were negative for rheumatoid factor (RF) and anticyclic citrullinated peptide antibody. Synovial fluid analysis of knee joint revealed a yellow appearance, decreased viscosity, and a cell count of 26,678 cells/mm3 with 81.2% neutrophils, indicating inflammatory arthritis. Gram staining was negative, no crystals were detected by microscopy, and cultures for common pathogens and mycobacteria were negative.\nMagnetic resonance imaging of the right knee and left shoulder showed joint effusion and synovial enhancement.", "summary": "The patient was a 67-year-old man with a history of well-controlled foot psoriasis who presented with polyarthralgia. He had received pembrolizumab for metastatic gastric adenocarcinoma 2 mo previously. Physical examination revealed erythematous swelling in the distal interphalangeal joints, left shoulder, and both knees. He had plaque psoriasis with psoriatic nail dystrophy and dactylitis in the distal joints of the fingers and toes. Inflammatory markers including C-reactive protein and erythrocyte sedimentation rate were elevated but rheumatoid factor and anticyclic citrullinated peptide antibody were negative. The patient was diagnosed with psoriatic arthritis (PsA) and started on methylprednisolone 1 mg/kg/day after pembrolizumab discontinuation. However, despite 1 wk of methylprednisolone treatment, PsA worsened; hence, leflunomide and methotrexate were started. After 4 wk of steroid treatment, PsA worsened and improved repeatedly with steroid tapering. Therefore, the therapy was intensified to include etanercept, a tumor necrosis factor inhibitor, which ultimately resulted in adequate PsA control.", "subclaim_evaluations": [ { "subclaim": "The patient was a 67-year-old man.", "support_label": "supported" }, { "subclaim": "He had a history of well-controlled foot psoriasis.", "support_label": "supported" }, { "subclaim": "He presented with polyarthralgia.", "support_label": "supported" }, { "subclaim": "He had received pembrolizumab for metastatic gastric adenocarcinoma 2 months previously.", "support_label": "supported" }, { "subclaim": "Physical examination revealed erythematous swelling in the distal interphalangeal joints.", "support_label": "supported" }, { "subclaim": "He had plaque psoriasis with psoriatic nail dystrophy.", "support_label": "supported" }, { "subclaim": "He had dactylitis in the distal joints of the fingers and toes.", "support_label": "supported" }, { "subclaim": "Inflammatory markers including C-reactive protein and erythrocyte sedimentation rate were elevated.", "support_label": "supported" }, { "subclaim": "Rheumatoid factor was negative.", "support_label": "supported" }, { "subclaim": "Anticyclic citrullinated peptide antibody was negative.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with psoriatic arthritis.", "support_label": "supported" }, { "subclaim": "He was started on methylprednisolone 1 mg/kg/day after pembrolizumab discontinuation.", "support_label": "not_supported" }, { "subclaim": "Despite 1 week of methylprednisolone treatment, psoriatic arthritis worsened.", "support_label": "not_supported" }, { "subclaim": "Leflunomide and methotrexate were started.", "support_label": "not_supported" }, { "subclaim": "After 4 weeks of steroid treatment, psoriatic arthritis worsened and improved repeatedly with steroid tapering.", "support_label": "not_supported" }, { "subclaim": "The therapy was intensified to include etanercept, a tumor necrosis factor inhibitor.", "support_label": "not_supported" }, { "subclaim": "Etanercept ultimately resulted in adequate psoriatic arthritis control.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1066_en.txt", "fulltext": "We report the case of a 37-year-old man with a 6-month history of headaches and blurred vision. Our patient had been followed by an otorhinolaryngologist for 2 years for cervical lymphadenopathy and a right submandibular swelling. The cervical lymphadenopathy biopsy was non-diagnostic twice, showing a non-specific inflammatory disease. He had no other medical background and no personal or familiar history of an autoimmune disease.\nOn examination, he had significant swelling of the right hemi face and the neck with trismus and a decrease in the visual acuity of the right eye. The dilated fundus examination showed a right papillary paleness.\nPeripheral blood markers of inflammation were elevated. Screening for immunodeficiency and mycobacterial infections was negative.\nCerebral MRI showed a pseudotumoral lesion developing in the right pterygoid-palatine fossa spreading to the orbital and the intracranial cavity through the superior orbital fissure. The intracranial portion forms a temporal extra-axial mass mimicking a meningioma that infiltrates the lateral wall of the cavernous sinus. The lesion was strongly enhanced after the injection of gadolinium . CT scans of the chest, abdomen, and pelvis were normal.\nThe patient was operated through a pterional approach. Our first strategy was a gross total resection of the intracranial portion of the tumor. Regarding its very firm consistency, we opted for a large biopsy of the extra-axial lesion. The tumor was solid, well-delineated, and strongly adherent to the temporal lobe.\nHistological examination showed dense lymphoidplasmacytic infiltrate with storiform fibrosis [ and ]. Immunohistochemical staining revealed an increased number of IgG4-positive plasma cells . The inflammation is often focal, predominantly in a perivascular location.\nOur patient received high doses of corticosteroids (0.6 mg/kg/day) followed by progressive tapering. His neurological manifestations gradually improved and resolved after 2 months. A cerebral MRI was done 1 month after a well-conducted treatment and showed a reduction of the tumor’s size .", "summary": "We present our experience with a biopsy-proven case of IgG4-RD presenting with an intracranial extradural tumor-like mass infiltrating the temporal lobe. The patient was treated with high doses of corticosteroids followed by slow tapering. The neurological manifestations gradually improved and resolved after 2 months with a cerebral MRI showing a significant reduction in the tumoral size.", "subclaim_evaluations": [ { "subclaim": "The case was biopsy-proven IgG4-RD.", "support_label": "supported" }, { "subclaim": "The patient had an intracranial extradural tumor-like mass.", "support_label": "supported" }, { "subclaim": "The mass infiltrated the temporal lobe.", "support_label": "supported" }, { "subclaim": "The patient was treated with high-dose corticosteroids.", "support_label": "supported" }, { "subclaim": "Corticosteroids were followed by slow tapering.", "support_label": "supported" }, { "subclaim": "Neurological manifestations gradually improved.", "support_label": "supported" }, { "subclaim": "Neurological manifestations resolved after 2 months.", "support_label": "supported" }, { "subclaim": "A cerebral MRI showed a significant reduction in the tumoral size.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_461_en.txt", "fulltext": "A 64-year-old Caucasian woman was referred to our office for the assessment of a gigantic left neck mass . The patient reported that she had started to feel a paratracheal node 34 years previously, and that it had grown progressively during the subsequent three decades. She had undergone an operation in the area 24 years previously, although the surgery had to be terminated due to massive bleeding from the mass. During surgery, the mass was diagnosed as most likely a glomus tumor. No further surgeries to remove the mass were attempted, and it had been allowed to grow steadily.\nIn May 2013, the patient was referred elsewhere for further study of the mass. Magnetic resonance imaging (MRI) revealed a hypervascularized mass with a maximum diameter of 4 cm located at the bifurcation of the left carotid artery and causing the forward displacement of the external carotid artery and the backward displacement of the internal carotid artery. The patient refused surgery at that time and remained asymptomatic for almost 3 years. She then decided to consult a physician again due to the enlargement of the mass, which caused discomfort and mild compression symptoms when swallowing.\nIn 2016, angio MRI showed a 9 cm paratracheal mass on the left cervical side that laterally displaced the sternocleidomastoid muscle and 2 cm of the trachea. The mass was pulsatile and slightly painful. No Horner syndrome or Hering–Breuer reflex was noted. A carotid occlusion test and a complete angiography were also performed, and these confirmed the permeability of the Willis polygon and the diagnosis of the mass.\nDue to the change in the behavior of the tumor, which had doubled in size within 3 years after remaining relatively stable for almost three decades, the size of the tumor, which had started causing compression symptoms, and the Shamblin grade II classification, the maxillofacial team at Ruber International Hospital decided to remove the tumor surgically after embolization.\nThe surgery was performed in February 2016. The tumor was approached through a wide cervical exposure after identifying the primitive carotid artery .\nThe tumor was gently dissected from the carotid bifurcation in a subadventitial plane , with great emphasis placed on maintaining hemostasis.\nThe surgeons would like to note that a partially blunt Freer periostotome is the best tool to use in high-risk areas. The vagal nerve was readily identified and separated from the mass. The hypoglossal nerve and major neck vessels were also preserved . The mass was then removed from the bifurcation uneventfully. Two small nodes adhering tightly to the internal carotid adventitia and the posterior torn hole were left in place to avoid any potentially life-threatening complication.\nThe postoperative phase was uneventful, and the patient was discharged 6 days after the surgery with moderate hoarseness, which was resolved within 1 month. The final biopsy confirmed the initial diagnosis of carotid body paraganglioma and showed a Ki-67 expression of 19%.\nDue to the aggressive growth behavior and high Ki-67 expression of the tumor, the patient was referred to the CyberKnife Unit of Ruber International Hospital for treatment of the remaining nodes. A thermoplastic mask was made to ensure that the patient remained immobilized during the treatment. A T2 MRI and computed tomography (CT) with intravenous contrast were performed to locate the above-mentioned remaining nodes of the paraganglioma. The treatment was performed separately in each affected area on two consecutive days. A coverage dose of 14 Gy and an isodose of 83% were administered using 5- and 7.5-mm collimators. The maximum dose used was 16.87 Gy. The medullary canal received a dose of less than 4 Gy, and the left VII and VIII nerves received a dose of less than 5 Gy . The treatment course was uneventful, and no complication occurred during or after treatment.\nAfter a 48-month follow-up period, no lesion recurrence or surgery-related complications have occurred. Some minor scar revision due to the tracheostomy was performed under local anesthesia. The patient is otherwise completely symptom free .", "summary": "We present the case of a 64 year-old Caucasian woman with a gigantic glomic tumor mass in the neck. Twenty years before the consultation, the patient had undergone an unsuccessful attempt to remove the mass. Over the last 3 years, the patient had felt enlargement of the mass at an increased rate, almost doubling the prior size. Angio magnetic resonance imaging showed a 9 cm paratracheal mass on the left cervical side that laterally displaced the sternocleidomastoid muscle and 2 c m of the trachea. Due to the change in the tumor behavior, the maxillofacial team at Ruber International Hospital decided to remove the tumor surgically after embolization. During the surgery the tumor was gently dissected from the carotid an removed from the carotid bifurcation uneventfully. Two small nodes adhering tightly to the internal carotid adventitia and the posterior torn hole were left in place to avoid any potentially life-threatening complications. The final biopsy confirmed the initial diagnosis of carotid body paraganglioma and showed a Ki-67 expression of 19%. Due to the aggressive growth behavior and high Ki-67 expression of the tumor, the patient was referred to the CyberKnife Unit of Ruber International Hospital for treatment of the remaining nodes.", "subclaim_evaluations": [ { "subclaim": "The patient is a 64 year-old woman.", "support_label": "supported" }, { "subclaim": "The patient has a gigantic glomic tumor mass in the neck.", "support_label": "supported" }, { "subclaim": "Twenty years before the consultation, the patient had an unsuccessful attempt to remove the mass.", "support_label": "supported" }, { "subclaim": "Over the last 3 years, the mass almost doubled in size.", "support_label": "supported" }, { "subclaim": "Angio magnetic resonance imaging showed a 9 cm paratracheal mass on the left cervical side.", "support_label": "supported" }, { "subclaim": "The mass laterally displaced the sternocleidomastoid muscle.", "support_label": "supported" }, { "subclaim": "The mass displaced 2 cm of the trachea.", "support_label": "supported" }, { "subclaim": "The maxillofacial team decided to remove the tumor surgically after embolization.", "support_label": "supported" }, { "subclaim": "During surgery, the tumor was dissected from the carotid.", "support_label": "supported" }, { "subclaim": "The tumor was removed from the carotid bifurcation uneventfully.", "support_label": "supported" }, { "subclaim": "Two small nodes adhering to the internal carotid adventitia were left in place.", "support_label": "supported" }, { "subclaim": "The posterior torn hole was left in place.", "support_label": "supported" }, { "subclaim": "The final biopsy confirmed the diagnosis of carotid body paraganglioma.", "support_label": "supported" }, { "subclaim": "The tumor showed a Ki-67 expression of 19%.", "support_label": "supported" }, { "subclaim": "The patient was referred to the CyberKnife Unit for treatment of the remaining nodes.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1611_en.txt", "fulltext": "A 63-year-old female patient with a medical history of type 2 diabetes, hypertension, and hyperlipidemia visited our hospital complaining of chest, waist, and back pain radiating to both groin for 15 days. It aggravated on bending over, but there was on obvious cause. No nausea, vomiting, diarrhea, or discomfort, such as numbness or fatigue of the lower limbs, was reported. The initial treatment administered was for back pain. After admission, the patient developed a fever and abdominal pain. Peripheral leukocyte count was 12.92×109/L(normal range, 3.5–9.5×109/L) with 11.51×109/L neutrophils (normal range, 1.8–6.3×109/L) and an elevated C-reactive protein of 101.59 mg/L, and Erythrocyte sedimentation rate was 120mm/hour. The computed tomography angiography (CTA) examination revealed a thoracic aortic pseudoaneurysm. Abdominal CTA confirmed the formation of a pseudoaneurysm in the aorta, approximately in the T10-T11 vertebral body plane .\nBlood was drawn during fever, gram-negative bacilli were Gram-stained, and Salmonella paratyphi A was cultured. Susceptibility testing by the minimum inhibitory concentration (MIC) gradient method revealed that the isolate was susceptible to piperacillin/Tazobactam, Imipenem, ampicillin, and gentamicin based on the Antimicrobial Susceptibility Testing criteria (piperacillin/Tazobactam MIC≤8ug/mL; Imipenem MIC≤1ug/mL; Ampicillin MIC≤2ug/mL). Furthermore, susceptibility testing by Kirby-Bauer drug-sensitivity test showed that the isolate was susceptible to Cefotaxime, Ceftriaxone, Ciprofloxacin, and Levofloxacin based on the Antimicrobial Susceptibility Testing criteria (Cefotaxime inhibition zone diameter = 28mm; Ceftriaxone inhibition zone diameter = 30mm; Ciprofloxacin inhibition zone diameter = 26mm; Levofloxacin inhibition zone diameter = 28mm).\nThe endovascular stent-graft treatment was performed immediately. After inducing local anesthesia, the left femoral artery was punctured using the Seldinger’s method. 5F arterial sheath was implanted, and a pigtail catheter was inserted in descending aorta for aortography, which showed signs of a thoracic aortic pseudoaneurysm. An oval-shaped soft tissue-density mass measuring 2.5×2.1 cm was detected in the descending thoracic aorta at the level of the T10-T11 vertebral body. The right femoral artery was then exposed, and Ultra Stiff Wire (ASAHI, Japan) was put in. After that Hercules™ Sterile Thoracic Stent-Graft System (Microport, Shanghai) was put in along Wire and then released to cover pseudoaneurysm. The procedure lasted 45 min. Aortography was conducted again, which revealed that the pseudoaneurysm had almost disappeared without leakage.\nMoreover, piperacillin sulbactam sodium 5 g was administered once every 8 h intravenously for 14 days in combination with levofloxacin 0.4 g once a day intravenously for 7 days. Abdominal pain was relieved, and the body temperature returned to normal. The treatment was well tolerated by the patient, and she was discharged on postoperative Day 10.\nAt the 2-month follow-up, the patient was asymptomatic, and CTA confirmed the total exclusion of the pseudoaneurysm with no signs of endoleaks . After discussion with the institutional research office, formal ethical approval was deemed unnecessary if written informed consent was obtained from the patient. Verbal and written informed consent were obtained from the patient for publishing the report.", "summary": "A 63-year-old female patient had a thoracic aortic pseudoaneurysm caused by Salmonella paratyphi A infection. The patient associated with diabetes had a fever, abdominal pain, and low back pain, who was successfully treated using endovascular stents treatment and antibiotics.", "subclaim_evaluations": [ { "subclaim": "The patient is a 63-year-old female.", "support_label": "supported" }, { "subclaim": "The patient had a thoracic aortic pseudoaneurysm.", "support_label": "supported" }, { "subclaim": "The pseudoaneurysm was caused by Salmonella paratyphi A infection.", "support_label": "supported" }, { "subclaim": "The patient has diabetes.", "support_label": "supported" }, { "subclaim": "The patient had a fever.", "support_label": "supported" }, { "subclaim": "The patient had abdominal pain.", "support_label": "supported" }, { "subclaim": "The patient had low back pain.", "support_label": "supported" }, { "subclaim": "The patient was treated with endovascular stents.", "support_label": "supported" }, { "subclaim": "The patient was treated with antibiotics.", "support_label": "supported" }, { "subclaim": "The treatment was successful.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3349_en.txt", "fulltext": "57-year-old male patient, born in Chile, with a history of Beta-thalassemia in pharmacological treatment with oral folic acid and iron, with a history of BCG vaccination in childhood, eutrophic.\n\nDuring 2021, he presented a case of a year-long evolution of significant weight loss, loss of appetite and abdominal pain of a colic type. The initial laboratory study showed a normocytic, normochromic anaemia with a negative serological study of hepatitis B and C viruses and a non-reactive HIV. Complementary study: Computed tomography (CT) of the abdomen and pelvis: segmental thickening of the ascending and descending colon with adjacent inflammatory changes; upper gastrointestinal endoscopy: no significant alterations. Incomplete colonoscopy without ileocecal evaluation: two ulcerated lesions in the ascending and sigmoid colon, suggestive of neoplasia. Colon mucosa biopsies reported chronic active colitis with the presence of granulomas, and negative Ziehl Neelsen and Kinyoun stains. A PET/CT FDG scan was performed due to suspicion of neoplasia, which reported a distal ileal and inflammatory ascending and descending colon segments, and hypermetabolic ileocolic lymph nodes, suggestive of IBD. Subsequently, an MRI enterography was performed, which reported images compatible with ileocecal involvement in Crohn's disease. Based on these findings, a diagnosis of inflammatory phenotype of Crohn's disease with ileocolonic involvement was made, and corticosteroid therapy (prednisone 1 mg/kg with progressive tapering in 8 weeks) and azathioprine were initiated for 2 months.\n\nPatient develops clinical deterioration characterised by abdominal pain, dysenteric diarrhea and fever of 38 °C. Laboratory highlights haemoglobin of 8.9 g/dl, white blood cells of 2,490, C reactive protein of 30.18 mg/dl, VHS 15 and severe hypoalbuminaemia of 2.6 g/dl. He is hospitalised for severe crisis of Crohn's disease and eventual need of biological therapy.\n\nOn admission, intravenous corticosteroid therapy was initiated and a pre-biological study was requested. Abdominal CT with inflammatory ileocolonic involvement, Quantiferon TB positive, with chest radiography and chest CT without alterations.\n\nA new ileocolonoscopy was performed which reported: \"active Crohn's colitis with ulcerative involvement of the ileum, sigmoid and rectum\". Staged biopsies reported necrotizing granulomas with positive Ziehl Neelsen staining in all samples. Corticosteroids were de-escalated and anti-tuberculosis therapy was initiated with a standard scheme with a good early clinical response.\n", "summary": "A 57-year-old patient with an initial diagnosis of Crohn's disease and who was receiving immunosuppressive treatment was presented. Due to a lack of response to therapy, a new endoscopic and anatomopathological study was performed, concluding with a diagnosis of intestinal tuberculosis, which was treated with a good response.\n", "subclaim_evaluations": [ { "subclaim": "The patient is 57 years old.", "support_label": "supported" }, { "subclaim": "The patient had an initial diagnosis of Crohn's disease.", "support_label": "supported" }, { "subclaim": "The patient was receiving immunosuppressive treatment.", "support_label": "supported" }, { "subclaim": "The patient did not respond to therapy.", "support_label": "not_supported" }, { "subclaim": "A new endoscopic study was performed.", "support_label": "supported" }, { "subclaim": "A new anatomopathological study was performed.", "support_label": "supported" }, { "subclaim": "The diagnosis was intestinal tuberculosis.", "support_label": "supported" }, { "subclaim": "The patient was treated for intestinal tuberculosis.", "support_label": "supported" }, { "subclaim": "The treatment for intestinal tuberculosis had a good response.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2312_en.txt", "fulltext": "A 50-year-old female patient with the main complaint of “irregular vaginal bleeding and fatigue for 6 months” visited our hospital on 12 February 2019. A mass was presented in the endometrium of the patient detected by ultrasonic examination. On pelvic MRI, a mass in the uterus involved deep muscular layer was confirmed as a 5*6 cm mass that appeared to be pelvic lymph node metastasis . Blood test showed a serous hyponatremia with Na+ level of 123∼131 mmol/L.\nThe patient received diagnostic curettage, and the pathological result showed high-grade malignant endometrial carcinoma. Tumor markers including carbohydrate antigens 125 (CA125) and human epididymis protein 4 were detected in normal ranges, and no intraepithelial or malignant lesions were found in cervical exfoliative cytology examination.\nThe uterus with enlargement in smooth and hard nature was found in the posterior position according to the gynecological examination. Hard nodules with poor activity and no tenderness can be touched in the anterior uterine wall. Based on the pathological result, endometrial carcinoma invading the serosa was diagnosed in the patient. For the huge mass in the endometrium and the poor state of patient, she received two circles of neoadjuvant chemotherapy with taxol and carboplatin, while improving the persistent hyponatremia, then staging operation of endometrial cancer was conducted under general anesthesia on 21 May 2019.\nDuring the operation, it was found that the enlarged uterus was located in the middle of the pelvis, the size was about 60 days of pregnancy, and the surface was smooth. The appearance of the main ligament and bilateral fallopian tubes and ovaries was normal, and no tumor was found on the surface of the appendix, omenta, and peritonea. The lymph nodes in the pelvis and surrounding the abdominal aorta were enlarged. First, we get the cytology of peritoneal fluid which resulted negative. And then laparotomy radical hysterectomy with bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy was performed. Incision of the uterus showed that the solid tumor of the posterior wall of the uterus with diameter of 2 cm, slightly brittle texture and pale in color protruded from the muscle wall to the uterine cavity. No lesion was found in the vaginal fornix and cervix. The normal appearance of the bilateral attachments was found, and the lymph nodes in the pelvis and surrounding the abdominal aorta were evidently enlarged.\nPathological gross examination of the tumor showed that there was no obvious tumor in the serous surface membrane of the uterus. Incision of the uterus showed that the solid tumor of the posterior wall of the uterus with diameter of 2 cm, slightly brittle texture and pale in color protruded from the muscle wall to the uterine cavity. Microscopically, the endometrium was presented with mixed carcinoma. Histologically, two kinds of carcinoma were distributed separately. And the carcinoid was distributed in the muscles of myometrium with invasive pattern, accounting for about 70% of the tumor. Diffused infiltrating carcinoma of myometrium of the uterus is neuroendocrine tumor, with no obvious cellular atypia, abundant cytoplasm, rare mitograms of 0–1/10 HPF, Ki67 index of about 2%, consistent with carcinoid, multifocal vascular and lymphatic invasion, nerve invasion. Squamous cell carcinoma is arranged in the uterine body cavity, accounting for about 30% of the tumor . There is no glandular (or tubular) structure or keratinization of the tumor cell components. The tumor has penetrated the uterine serous membrane. Multi-lesions of lymphatic vessel space infiltration were found. Of the 23 harvested lymph nodes from the pelvic, 5 metastasized lymph nodes were identified in the abdominal aortic and left pelvic lymph nodes with mixed carcinoma. Negative reaction was displayed in the cervix, bilateral ovary, and oviduct. Immunohistochemically, in carcinoid carcinoma, the tumor cells were partly positive for synaptophysin (Syn), S-100, NSE, chromogranin A (CgA), CD56, cytokeratin (CK), H-CK, P63, and P40. The progesterone receptor and the estrogen receptor were negative. CA125, P16, Napsin A, WT-1, CD99, and vimentin were negative. The Ki67 proliferation index was 10%. Elastic fibers show vascular invasion. D2–40 showed lymph node metastasis. In squamous cell carcinoma, the tumor cells were partly positive for CK, CK7, CEA, P63, P40, PAx-8, and CEA. Additionally, results of villin, CDX-2, and CK20 were all negative. The histologic features of the tumor and its immunohistochemical profile support the diagnosis of carcinoid of the endometrium with squamous cell carcinoma .\nBased on the revision of FIGO 2009 staging for endometrial carcinoma, the patient was classified as stage IIIC2. Postoperatively, the patient was given adjuvant chemotherapy with cisplatin and etoposide under interval of 3 weeks and received “sandwich” therapy of chemotherapy-radiotherapy-chemotherapy. In the first circle of chemotherapy, grade 1 nausea and vomiting and grade 3 myelosuppression were developed in the patient. The patient received radiotherapy followed by 3 circles of chemotherapy with no sign of further deterioration. A complete response was achieved in the patient on the basis of the RECIST1.1 criteria. She is currently under close follow-up with no recurrence for 4 years and 4 months after surgery.", "summary": "Here, we report an interesting case of mixed carcinoma of endometrium with both carcinoid and squamous cell carcinoma, which presented with persistent vaginal bleeding and hyponatremia.", "subclaim_evaluations": [ { "subclaim": "The case involved a mixed carcinoma of the endometrium.", "support_label": "supported" }, { "subclaim": "The tumor contained both carcinoid and squamous cell carcinoma components.", "support_label": "supported" }, { "subclaim": "The patient presented with persistent vaginal bleeding.", "support_label": "supported" }, { "subclaim": "The patient had hyponatremia.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2743_en.txt", "fulltext": "A 54-year-old woman was admitted to the hospital because of blood in the sputum and hemoptysis.\nA 54-year-old woman was admitted to the hospital because she had seen blood in her sputum for more than 4 mo and had had hemoptysis for 1 wk. The hemoptysis occurred without a clear reason. The coughed-out blood was bright red in clots and was accompanied by a large quantity of white and nonviscous sputum. The patient did not sweat excessively either during the day or night, did not feel cold or have a fever, did not feel chest tightness or shortness of breath, and had no dizziness or headache.\nThe patient had undergone surgical removal of gallbladder polyps more than 20 years ago, and had received minimally invasive surgery for breast fibroma more than 2 years ago.\nThe patient had no history of smoking or consuming alcohol, and there was no family medical history.\nOn admission, the patient's temperature was 36.7°C, with a heart rate of 78 beats/min, blood pressure of 110/68 mmHg, and respiratory rate of 16 breaths/min. The patient exhibited clear consciousness and compliance throughout the examination. Her trachea was in a neutral position, there was no cyanosis in her mouth or lips, and no swollen lymph nodes were identified in the supraclavicular region of either side. The breathing sound of both lungs was clear; no obvious rale was heard. The heart rhythm was regular; no obvious pathological noise was heard. The patient’s abdomen was flat and soft; no tenderness or rebound pain was identified. Edema in her lower extremities was not evident, and no clear pathological signs were found in the nervous system.\nHer hemoglobin level was relatively low at 98 g/L; the remaining routine blood examination results, C-reactive protein level, liver and kidney function indicators, and electrolyte levels were all within the normal range. A laboratory examination indicated that the levels of the tumor indices neuron specific enolase (NSE), carbohydrate antigen (CA)-724, CA-125, CA19-9, carcinoembryonic antigen, and alpha-fetoprotein were in the normal range.\nA computer tomography (CT) image of the patient that had been obtained in November 2017 showed atrophy in the middle lobe of her right lung as well as bronchiectasis in the left lung and the middle lobe of the right lung accompanied by infections. Numerous nodules with a diameter of 0.3 to 0.5 cm were identified in the middle lobe of the right lung . Another CT image obtained in March 2018 revealed that the bronchiectasis in the middle lobe of her right lung was accompanied by atelectasis, which was more observable than the atrophy in the same location in the previous CT image .", "summary": "A 54-year-old woman was admitted to the hospital because she had symptoms of bloody sputum for more than 4 mo and hemoptysis for 1 wk. Computed tomography images showed atrophy accompanied by infections in the middle lobe of her right lung. Moreover, numerous nodules were identified in the middle lobe of the right lung. The patient underwent thoracoscopic pneumonectomy of the middle lobe of the right lung, and the resected mass was pathologically confirmed to have bronchiectasis, multifocal NEC hyperplasia accompanied by tumorlet, and PSP.", "subclaim_evaluations": [ { "subclaim": "The patient is a 54-year-old woman.", "support_label": "supported" }, { "subclaim": "She had symptoms of bloody sputum for more than 4 months.", "support_label": "supported" }, { "subclaim": "She had hemoptysis for 1 week.", "support_label": "supported" }, { "subclaim": "Computed tomography showed atrophy in the middle lobe of the right lung.", "support_label": "supported" }, { "subclaim": "Computed tomography showed infections in the middle lobe of the right lung.", "support_label": "supported" }, { "subclaim": "Numerous nodules were identified in the middle lobe of the right lung.", "support_label": "supported" }, { "subclaim": "The patient underwent thoracoscopic pneumonectomy of the middle lobe of the right lung.", "support_label": "not_supported" }, { "subclaim": "The resected mass was pathologically confirmed to have bronchiectasis.", "support_label": "not_supported" }, { "subclaim": "The resected mass was pathologically confirmed to have multifocal NEC hyperplasia.", "support_label": "not_supported" }, { "subclaim": "The resected mass was pathologically confirmed to have tumorlet.", "support_label": "not_supported" }, { "subclaim": "The resected mass was pathologically confirmed to have PSP.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2730_en.txt", "fulltext": "A 63 year-old male patient diagnosed with PDAC was referred to the BC Cancer Agency’s Hereditary Cancer Program for hereditary cancer syndrome assessment due to a strong family history of PDAC . As the starting point for the genetic study of a family, this patient is considered the proband. The family history was noteworthy for the occurrence of PDAC in the proband and his brother, as well as an aunt and uncle on the maternal side. Diagnoses occurred between the ages of 63 and 69. Ancestry was reported as English on both sides.\nThe proband presented with a three-month history of weight loss and epigastric discomfort. A computerized tomography (CT) scan showed a 2.9 cm lesion in the head of the pancreas. He was deemed to have locally advanced unresectable PDAC and began treatment with a combination of 5-fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX). His medical history included type 2 diabetes, hypertension, osteoarthritis, gout and hyperlipidemia. He reported being a non-smoker who consumes 6–8 alcoholic drinks per day.\nThe proband’s brother presented with left upper quadrant pain and underwent an ultrasound as well as a CT scan which revealed the presence of a mass in the pancreatic head and uncinate process. He was deemed to have resectable PDAC and underwent a pancreaticoduodenectomy (Whipple) procedure. Pathology confirmed a 3.5 cm moderately differentiated PDAC. Margins were negative. He was treated with adjuvant gemcitabine for six months. He reported being a non-smoker, rarely consuming alcohol. He denied a significant prior medical history.\nDuring the initial genetic consultation, the proband denied any history of breast, ovarian, colon cancer or melanoma in the family. There was no reported history of pancreatitis, multiple moles, lip freckling or gastrointestinal polyps. In this pancreatic-cancer prone family, none of the diagnoses occurred under the age of 50. The family history of cancer did not meet the current provincial guidelines for hereditary cancer genetic testing . The patient was informed of the options of self-pay genetic testing through one of several genetic testing companies or banking DNA at the BC Cancer Agency should criteria change in the future. He elected to bank a DNA sample and consented to future research.\nThe proband’s brother was referred to the Hereditary Cancer Program six months later at which time a research study had opened that offered index genetic testing to unselected, newly diagnosed cases of PDAC utilizing a commercial-grade genetic test provided by Color Genomics. The test is designed to assess clinically relevant pathogenic variants in 30 genes associated with hereditary cancer risk, including the hereditary breast and ovarian cancer and Lynch syndrome associated genes. Details of their assay are published . After reviewing the advantages and limitations of multi-gene panel testing as well as the implications of possible results, he consented to the research study and provided a saliva sample for genetic testing. Genetic test results revealed a pathogenic missense variant in CDKN2A, c.377 T > A (p.Val126Asp). The pathogenic variant is associated with FAMMM syndrome, characterized by an inherited susceptibility primarily to melanoma but also to PDAC. No variants were detected in the remaining genes on the panel.\nDue to an inherited predisposition to cancer being diagnosed in his brother, the proband was subsequently seen in follow-up, where he consented to genetic testing. His results were positive for the familial CDKN2A pathogenic variant.", "summary": "We present the case of two brothers of English ancestry diagnosed with PDAC within the same 12 month period, at the respective ages of 63 and 64 years of age. Neither brother reported a personal history of multiple moles or melanoma. Family history was positive for two second-degree relatives diagnosed with PDAC but was negative for other cancers or multiple moles in first- and second-degree relatives. Due to the absence of melanoma, this family did not meet provincial criteria for publicly funded genetic testing. Clinical genetic testing offered through a research grant identified a pathogenic variant in the CDKN2A gene c.377 T > A (p.Val126Asp). This variant is a North American founder mutation believed to pre-date colonization.", "subclaim_evaluations": [ { "subclaim": "Two brothers of English ancestry were diagnosed with PDAC within the same 12-month period.", "support_label": "supported" }, { "subclaim": "The first brother was diagnosed at age 63.", "support_label": "supported" }, { "subclaim": "The second brother was diagnosed at age 64.", "support_label": "supported" }, { "subclaim": "Neither brother reported a personal history of multiple moles.", "support_label": "supported" }, { "subclaim": "Neither brother reported a personal history of melanoma.", "support_label": "supported" }, { "subclaim": "Family history was positive for two second-degree relatives diagnosed with PDAC.", "support_label": "supported" }, { "subclaim": "Family history was negative for other cancers in first- and second-degree relatives.", "support_label": "supported" }, { "subclaim": "Family history was negative for multiple moles in first- and second-degree relatives.", "support_label": "supported" }, { "subclaim": "The family did not meet provincial criteria for publicly funded genetic testing due to the absence of melanoma.", "support_label": "supported" }, { "subclaim": "Clinical genetic testing offered through a research grant identified a pathogenic variant in the CDKN2A gene.", "support_label": "supported" }, { "subclaim": "The variant identified was c.377 T > A (p.Val126Asp).", "support_label": "supported" }, { "subclaim": "The CDKN2A variant is a North American founder mutation.", "support_label": "not_supported" }, { "subclaim": "The CDKN2A variant is believed to pre-date colonization.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1331_en.txt", "fulltext": "A 55-year-old male patient was presented to a general hospital with fever, myalgia, and persistent cough. Polymerase chain reaction testing for COVID-19 was positive and he was admitted to the hospital due to severe respiratory symptoms. The patient is a known diabetic and hypertensive with a history of a nonfunctioning pituitary macroadenoma for which he underwent an endoscopic endonasal transsphenoidal resection 11 years ago in another hospital. Pituitary tumor recurrence was documented in the available two postoperative magnetic resonance imaging (MRI) studies . After surgery, the patient was kept on maintenance levothyroxine and hydrocortisone for panhypopituitarism.\nSix days after admission, the patient complained of severe headache and acute onset of ptosis and diminution of vision in the left eye. Ophthalmological evaluation revealed complete visual loss in the left eye, a visual acuity of 20/60 in the right eye, left oculomotor nerve palsy with ptosis, and dilated nonreactive pupil. Fundus examination revealed a pale left optic nerve head. Neurological examination was otherwise normal. Computed tomography revealed hyperdensity of the sellar and suprasellar areas. MRI was consistent with PA in a recurrent large pituitary adenoma [ and ].\nThe patient was transferred to our center and underwent an urgent endoscopic endonasal transsphenoidal surgery through which a near total excision of the tumor was achieved [ and ].\nThe procedure was performed under strict COVID-19 precautions including use of powered air purifying respirators and limited OR personnel. Intraoperative findings were similar to those usually seen in cases of PA and included dark blood mixed with purple-red adenoma tissues of variable consistencies . It was our observation that the nasal mucosa was pale and separated easily from the underlying bone. We have previously observed such features in two patients who previously tested positive for COVID-19. Histopathological examination demonstrated classic features of PA.\nWithin the first 3 postoperative days, the patient had some improvement of vision of the left eye so that he was able to perceive hand movement. Ptosis also improved partially. However, his chest condition progressed and he had to be transferred to COVID-19 intensive care unit in the referring hospital where he was intubated and put on mechanical ventilation. One week later, the patient unfortunately passed away due to complications of severe COVID-19 pneumonia.", "summary": "A 55-year-old male patient with confirmed COVID-19 infection presented by progressive decrease in visual acuity and oculomotor nerve palsy. His medical history is notable for diabetes mellitus, hypertension, and pituitary macroadenoma resection 11 years ago. He was on hormonal replacement therapy for panhypopituitarism that complicated the surgery. Previous magnetic resonance (MR) imaging studies were consistent with enlarging residual pituitary adenoma. During the current hospitalization, computed tomography revealed hyperdensity of the sellar and suprasellar areas. MR imaging revealed PA in a recurrent large adenoma. Endoscopic endonasal transsphenoidal resection was uneventfully undertaken with near total excision of the adenoma and partial improvement of visual loss and oculomotor palsy. Histopathological examination demonstrated classic features of PA. However, his chest condition progressed and he had to be transferred to COVID-19 intensive care unit in the referring hospital where he was intubated and put on mechanical ventilation. One week later, the patient unfortunately passed away due to complications of severe COVID-19 pneumonia.", "subclaim_evaluations": [ { "subclaim": "The patient is a 55-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had confirmed COVID-19 infection.", "support_label": "supported" }, { "subclaim": "The patient had progressive decrease in visual acuity.", "support_label": "supported" }, { "subclaim": "The patient had oculomotor nerve palsy.", "support_label": "supported" }, { "subclaim": "The patient had a history of pituitary macroadenoma resection 11 years ago.", "support_label": "supported" }, { "subclaim": "The patient was on hormonal replacement therapy for panhypopituitarism.", "support_label": "supported" }, { "subclaim": "Previous MR imaging showed enlarging residual pituitary adenoma.", "support_label": "supported" }, { "subclaim": "Computed tomography showed hyperdensity of the sellar and suprasellar areas.", "support_label": "supported" }, { "subclaim": "MR imaging revealed pituitary adenoma in a recurrent large adenoma.", "support_label": "supported" }, { "subclaim": "Endoscopic endonasal transsphenoidal resection was performed.", "support_label": "supported" }, { "subclaim": "The resection achieved near total excision of the adenoma.", "support_label": "supported" }, { "subclaim": "The patient had partial improvement of visual loss.", "support_label": "supported" }, { "subclaim": "The patient had partial improvement of oculomotor palsy.", "support_label": "supported" }, { "subclaim": "Histopathological examination showed classic features of pituitary adenoma.", "support_label": "supported" }, { "subclaim": "The patient was transferred to the COVID-19 intensive care unit.", "support_label": "supported" }, { "subclaim": "The patient was intubated and put on mechanical ventilation.", "support_label": "supported" }, { "subclaim": "The patient passed away one week later.", "support_label": "supported" }, { "subclaim": "The patient's death was due to complications of severe COVID-19 pneumonia.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1121_en.txt", "fulltext": "A 33-year-old Caucasian woman, gravida 3, para 1, was admitted to our clinic. Her obstetric history mentioned a miscarriage and a pregnancy complicated by intrauterine growth restriction, without signs of preeclampsia. At 37 weeks' gestation, cesarean section was performed because of fetal distress. A boy was delivered, weighing 2015 g, with Apgar scores of 9 and 10 at one and five minutes, respectively. Histology of the placenta revealed 10% infarctions and a thrombus in the umbilical cord. Blood analysis after three months showed no hemostatic abnormalities associated with an increased risk of thrombosis.\nUltrasound examination of the index pregnancy at 112 weeks' gestation showed a dichorionic diamniotic twin pregnancy with measurements consistent with gestational age. The Crown Rump Lengths were 39 mm, consistent with 106 weeks, and 45 mm, consistent with 112 weeks. Nuchal translucency thickness measurements were not performed. No abnormalities of the placenta were documented.\nHer blood pressure was 125/70 mmHg. The pregnancy was complicated by episodes of vaginal bleeding at 16 weeks' gestation. Ultrasound showed one fetus with normal growth and one with early growth restriction and measurements consistent with 13 weeks. An echogenic area was interpreted as blood clots. At 20 weeks' gestation, fetal death of the abnormal fetus was noticed. One week later, the patient was asymptomatic but her blood pressure increased (154/98) which prompted the suspicion of a partial molar pregnancy. An enlarged placenta of 10 cm × 12 cm with some cysts was prominent on the anterior wall. Blood flow had ceased in this placenta. Urinary protein excretion was 2.5 g/L. Maternal serum beta-human-chorionic-gonadotropin (β-hCG) was markedly raised: 423,000 IU/L. Other laboratory investigations were normal.\nThe patient was sent to a University Hospital because of early preeclampsia and suspicion of a triploid twin. We decided to perform a chorionic villous biopsy because the placenta of the dead fetus was on the anterior wall. We did not perform a chorionic villous biopsy of the placenta of the healthy twin because no abnormalities were noticed by ultrasound and the placenta was located on the posterior wall.\nChorionic villus biopsy confirmed triploidy, 69, XXY. Without pharmacological interventions, the blood pressure stabilized, proteinuria decreased, and β-hCG decreased to 222,835 IU/L. At 22 weeks, the patient was discharged. She was reviewed twice a week. Urinary protein excretion was positive until 23 weeks, and blood pressure slowly decreased and normalized at 30 weeks. The β-hCG further decreased to 27,600 IU/L at 33 weeks. Episodes of some vaginal bleeding and cramps occurred up to 28 weeks' gestation. The placenta of the triploid twin was still enlarged until 23 weeks: 8 cm × 12 cm .\nAt 35 weeks, the patient developed preeclampsia again and was hospitalized. Her blood pressure increased to 170/105 mmHg and proteinuria to 0.8 g/L. Methyldopa 3 × 250 mg was initiated to control the blood pressure with good result . Blood analysis showed no signs of hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. At 38 weeks, a cesarean section was performed for fetal distress. A healthy girl weighing 2,710 g was born with Apgar scores of 9 and 10 at one and five minutes, respectively. The placenta of the triploid fetus was necrotic and as a result of autolysis, no further histologic information on fetus and placenta were available. β-hCG follow-up showed no signs of persistent gestational trophoblastic disease (pGTD). Four days after delivery, the level had already decreased to 440 IU/L.", "summary": "A 33-year-old Caucasian woman presented with a dichorionic diamniotic twin pregnancy. One fetus showed early growth restriction resulting in fetal death at 20 weeks. The placenta was enlarged with some cysts. Chorionic villus biopsy confirmed triploidy. At 21 weeks, the patient developed preeclampsia with a blood pressure of 154/98 mmHg and proteinuria (24 hour protein excretion of 2.5 g/L), for which she was hospitalized. Without pharmacological interventions, the blood pressure normalized and proteinuria disappeared. At 35 weeks, she again developed preeclampsia. A cesarean section was performed at 38 weeks and a healthy child was born.", "subclaim_evaluations": [ { "subclaim": "The patient is a 33-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient had a dichorionic diamniotic twin pregnancy.", "support_label": "supported" }, { "subclaim": "One fetus showed early growth restriction.", "support_label": "supported" }, { "subclaim": "The fetus with growth restriction died at 20 weeks.", "support_label": "supported" }, { "subclaim": "The placenta was enlarged.", "support_label": "supported" }, { "subclaim": "The placenta had some cysts.", "support_label": "supported" }, { "subclaim": "Chorionic villus biopsy confirmed triploidy.", "support_label": "supported" }, { "subclaim": "At 21 weeks, the patient developed preeclampsia.", "support_label": "not_supported" }, { "subclaim": "The patient's blood pressure was 154/98 mmHg.", "support_label": "supported" }, { "subclaim": "The patient had proteinuria of 2.5 g/L.", "support_label": "supported" }, { "subclaim": "The patient was hospitalized.", "support_label": "supported" }, { "subclaim": "Without pharmacological interventions, the blood pressure normalized.", "support_label": "not_supported" }, { "subclaim": "Without pharmacological interventions, the proteinuria disappeared.", "support_label": "not_supported" }, { "subclaim": "At 35 weeks, the patient again developed preeclampsia.", "support_label": "supported" }, { "subclaim": "A cesarean section was performed at 38 weeks.", "support_label": "supported" }, { "subclaim": "A healthy child was born.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2998_en.txt", "fulltext": "The patient was a 67-year-old Middle-Eastern man who came to the emergency ward with progressive bilateral lower extremity muscle weakness and myalgia. The patient had no drug history and no significant past medical history or history of contact with toxins. Fifteen days prior to the onset of muscle weakness, the patient had presented with fever, rhinorrhea, and mild shortness of breath, and with a positive nasal swab PCR test, had a diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, for which he was treated as an outpatient, with desirable recovery after 15 days. However, following the resolution of COVID-19 symptoms, the patient started to develop myalgia and bilateral lower extremity proximal weakness. Due to augmentation of his lower extremity weakness and development of upper extremity proximal weakness, he was admitted to the hospital for further evaluation. In the physical examination, proximal muscle weakness was noted in the upper and lower extremities (power grade 4/5 and 3/5, respectively), with normal tone and deep tendon reflexes. The patient had no skin lesions or rashes. The patient also reported no muscle tenderness in our examination. The rest of the examination was normal.\nThe initial laboratory tests detected elevated muscle enzymes including creatine phosphokinase (CPK): 12,000 (normal: 38–174 U/L); lactate dehydrogenase (LDH): 757 (normal: 130–240 U/L)]; and aldolase: 11 (normal: 8.5 U/L). Procalcitonin was in the normal range. Also, 25-hydroxy vitamin D test levels were normal, at 40 ng/mL. Other laboratory data included a white blood count (WBC) of 8.83 × 103 µl), hemoglobin of 14.2 g/dL, erythrocyte sedimentation rate (ESR) of 9 mm/hour (normal: < 20 mm/hour), C-reactive protein of < 2 mg/L (normal: ≤ 6 mg/L), creatinine of 1 mg/dL, blood urea of 32 mg/dL, sodium (Na) 140 mEq/L, potassium (K) 4.4 mEq/L, aspartate aminotransferase (AST) of 25 IU/L (normal: 15–40 IU/L), alanine transaminase (ALT) 26 IU/L (normal: ≤ 41 IU/L), and alkaline phosphatase 121 IU/L (normal 120–450 IU/L). Bilateral thigh magnetic resonance imaging (MRI) axial and coronal view (T1 and T2; Short Tau Inversion Recovery) showed diffuse edema within all muscle compartments of the thigh with notable intra- and perimuscular edema, suggestive of myositis. .\nElectromyography (EMG) and nerve conduction velocity (NCV) findings were suggestive of irritable myopathy in several proximal muscles, including rectus femoris, iliopsoas, and deltoid. Additionally, in a left deltoid muscle biopsy, muscle necrosis was reported in the absence of inflammation, in favor of necrotizing autoimmune myositis . In cryopreserved biopsy from deltoid muscle, variation in fiber size was evident, with presence of some pale necrotic fibers with evidence of myophagocytosis associated with some regenerating fibers. Inflammation was absent. On trichrome stain, no apparent fibrosis was seen. Based on the overall histomorphology and clinical and laboratory findings, the diagnosis of immune-mediated necrotizing myopathy was established. .\nAmong all myositis-related autoantibodies such as anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), anti-signal recognition particle (SRP), anti-Jo-1, and anti-NXP2, only anti-NXP2 autoantibodies were positive, which prompted us to search for underlying malignant processes. The patient underwent a malignancy workup by abdomen and pelvis ultrasound, chest CT scan, endoscopy and colonoscopy, prostate-specific antigen (PSA), and ear, nose, and throat (ENT) examination, which were all unremarkable. Based on the positive results of NXP2 and to rule out malignancy, a fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan was performed, which demonstrated a 35 × 28 mm left thyroidal lobe nodule . A thyroid biopsy confirmed its unmalignant nature and thyroid-stimulating hormone (TSH) levels were also normal. Cardiac echocardiography, electrocardiography, and lung spirometry were also normal. Chest high-resolution computed tomography (HRCT) also showed bilateral multifocal patchy ground-glass opacities with dominant peripheral distribution, which were attributable to previous COVID-19 pneumonia. .\nSince myositis could emerge in the context of some connective tissue disorders, testing for some other laboratory markers, including antinuclear antibodies (ANA), anti-smooth muscle antibodies (ASMA), perinuclear antineutrophil cytoplasmic antibodies (p-ANCA), cytoplasmic antineutrophil cytoplasmic autoantibody (C-ANCA), anticyclic citrullinated peptide (anti-CCP), rheumatoid factor (RF), anti-double-stranded DNA (anti-ds DNA), complement component 3 (C3), complement component 4 (C4), and anti-Ro were done, which were all in the normal range. Thus, a diagnosis of necrotizing autoimmune myositis, possibly complicating COVID-19, was made after ruling out other causes for NAM by appropriate tests.\nFor treatment, prednisolone 1 mg/kg orally was administered. CPK levels started to fall after the initiation of steroids and were 107 IU/mL at the time of discharge. Resolution of ground-glass opacity of the lungs was observed after three months from his discharge. The prednisolone dose was decreased gradually to 10 mg, 1 year after diagnosis, and azathioprine was continued with an initial dose of 150 mg/day, which was decreased to 100 mg/day. The patient’s muscle force was resolved to normal after 1 year of follow-up. After confirming no inflammation, we reduced the prednisolone dose to an eventual 5 mg daily, along with 50 mg/day azathioprine. The patient is still relatively well after 15 months follow-up with improved laboratory examinations and muscle power in all extremities. The latest laboratory data were as follows: CPK: 115 U/L; LDH: 478 U/L; WBC: 9.02 × 103/µl); hemoglobin: 13.9 g/dL; AST: 25 IU/L; ALT: 23 IU/L; alkaline phosphatase (ALK): 134 IU/L; K: 4.1 mEq/L; ESR: 5 mm/hr; CRP < 2; vitamin D: 30 ng/mL; creatinine: 1.19 mg/dL; blood urea: 42 mg/dL; and Na: 139 mEq/L.", "summary": "Herein, we report a rare case of necrotizing autoimmune myositis in a 67-year-old middle eastern male following coronavirus disease 2019 infection, who presented with muscle weakness. The patient had positive anti-NXP2. The diagnosis of necrotizing autoimmune myositis was made according to muscle weakness, increased liver enzymes, electromyography and nerve conduction velocity results, and muscle biopsy. The patient underwent a full malignancy evaluation, which was unremarkable, and was discharged in relatively well condition with a daily dose of 1 mg/kg prednisolone and azathioprine 150 mg (2 mg/kg).", "subclaim_evaluations": [ { "subclaim": "The patient is a 67-year-old male.", "support_label": "supported" }, { "subclaim": "The patient is of Middle Eastern descent.", "support_label": "supported" }, { "subclaim": "The patient had a prior coronavirus disease 2019 infection.", "support_label": "supported" }, { "subclaim": "The patient presented with muscle weakness.", "support_label": "supported" }, { "subclaim": "The patient had positive anti-NXP2.", "support_label": "supported" }, { "subclaim": "The diagnosis was necrotizing autoimmune myositis.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on muscle weakness.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on increased liver enzymes.", "support_label": "not_supported" }, { "subclaim": "The diagnosis was based on electromyography and nerve conduction velocity results.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on muscle biopsy.", "support_label": "supported" }, { "subclaim": "A full malignancy evaluation was performed.", "support_label": "supported" }, { "subclaim": "The malignancy evaluation was unremarkable.", "support_label": "supported" }, { "subclaim": "The patient was discharged in relatively well condition.", "support_label": "supported" }, { "subclaim": "The patient was prescribed prednisolone at 1 mg/kg daily.", "support_label": "supported" }, { "subclaim": "The patient was prescribed azathioprine at 150 mg daily.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2452_en.txt", "fulltext": "A 2-year-old, 4.5-kg neutered male domestic shorthair cat was presented for acute-onset dyspnea. The past medical history was unremarkable. The cat lived indoors and was current on vaccinations and parasite prevention. On presentation, lung sounds were harsh, with no crackles. The cat exhibited inspiratory effort, with a respiratory rate of 44 bpm. The remaining physical findings were within normality. Thoracic radiographs identified moderate pleural effusion and lung edema. Echocardiography revealed asymmetric left ventricular myocardial thickening [interventricular septum end-diastolic thickness 5.7 mm (5 ± 0.7 mm) , left ventricular posterior wall end-diastolic thickness 7.5 mm (4.6 ± 0.5 mm) ] and severe left atrial dilation [left atrium-to-aortic root ratio 2.2 (1.29 ± 0.23) ]. The cat was hospitalized and treated with oxygen, furosemide (Dimazon 50 mg/ml, MSD Animal Health S.r.l., Segrate, Italy; dose: 1 mg/kg IV q6h), pimobendan (Vetmedin chew 1.25 mg, Boehringer Ingelheim Animal Health Italia S.p.A., Noventana, Italy; dose: 0.2 mg/kg PO q12h), and clopidogrel (Clopidogrel ACT 75 mg, BB FARMA Srl, Samarate, Italy; dose: 18.75 mag/cat PO q24h). During hospitalization, blood was collected to assess the cat’s systemic condition (i.e., complete blood count, biochemistry, test for feline leukemia and feline immunodeficiency virus), leading to unremarkable results. The cat was discharged after 4 days with oral furosemide (Dimazon 10 mg, MSD Animal Health S.r.l., Segrate, Italy; dose: 1 mg/kg PO q12h) and an unchanged dose of pimobendan and clopidogrel. One week after discharge, the cat was represented with a recurrence of lung edema, despite the regular administration of drugs by the owners. Therefore, the dose of furosemide was increased (2 mg/kg PO q12h), and spironolactone was added (Prilactone next 10 mg, CEVA salute animale S.p.A., Agrate Brianza, Italy; dose: 2 mg/kg PO q24h). Despite increasing diuretic therapy and adherence to the therapeutic protocol by the owners, the cat presented an additional relapse of lung edema the following week. Suspecting an ongoing diuretic resistance, the dose of furosemide was further increased, and its route of administration was switched from oral to parental. As the owners were not able to administrate the drug intramuscularly, the subcutaneous administration of furosemide was considered. In light of such a change, owners were carefully instructed about the technique of subcutaneous administration. Only when it was conclusively certified that owners were able to administrate SF (Dimazon 50 mg/ml, MSD Animal Health S.r.l., Segrate, Italy) properly, this therapeutic protocol was started at the dose of 2 mg/kg SC q8h. Other cardiac therapies were continued at the previously reported doses. Thanks to the introduction of SF, the cat no longer presented a recurrence of lung edema. However, although the cat had never presented skin problems before and owners administrated properly SF, multiple well-defined circulars, crusted ulcerative cutaneous lesions (0.5–1 cm) associated with alopecia developed at the sites of furosemide injections (i.e., dorsal area of thoracic region) 2 weeks later . At that time, spot-on treatment with fluralaner and moxidectine (Intervet International B. V., Boxmeer, Holland) was prescribed, albeit without clinical improvement. Accordingly, a dermatological consultation was subsequently obtained. On physical inspection, neither signs of self-trauma due to pruritic allergy nor signs of trauma due to improper administration of SF were identified. Trichoscopic evaluation at the level of the aforesaid areas showed neither alteration of the hair shaft nor the presence of spores. Scraping and culture for dermatophytes tested negative. Cytological examination of impression smears and fine-needle aspiration obtained from crusted areas showed an inflammatory pattern characterized by neutrophils, eosinophils, and rare macrophages, without evidence of microorganisms. Owners declined skin biopsies. Given the above and considering that several differential diagnoses for inflammatory ulcerated lesions were unlikely in the light of anamnestic and clinical findings (e.g., thermal/electrical/chemical burns, skin trauma/infection/neoplasia/autoimmune disorder), it was hypothesized that the dermal lesions were primarily associated with the administration of SF. This hypothesis was further supported by the use of the Naranjo Algorithm Adverse Drug Reaction Probability Scale, which led to a score of 6/13 (i.e., “probable” reaction to the drug) . Nevertheless, considering the severity of the cardiac condition and the previous relapses of lung edema, we preferred not to return to oral furosemide. Rather, we decided to interrupt the ongoing injectable formulation and substitute it with an alternative brand (Lasix fiale 20 mg/2 ml, Sanofi S.r.l., Milano, Italy), maintaining the same dose. Moreover, the cutaneous lesions were treated locally with a lenitive local product for 1 week (Douxo S3 CALM pads, CEVA salute animale S.p.A., Agrate Brianza, Italy). The dermal ulcerations disappeared within 1 month . Subsequently, the cat experienced neither further skin problems nor recurrence of lung edema, and he is still alive at the time of manuscript writing (13 months after the initial presentation).", "summary": "A 2-year-old domestic shorthair cat was presented for CHF associated with lung edema and pleural effusion. Echocardiography revealed asymmetric left ventricular myocardial thickening and severe left atrial dilation. The cat was hospitalized and initially treated with oxygen, intravenous furosemide, and clopidogrel. After discharge, the route of administration of furosemide was switched from intravenous to oral. Within the following 2 weeks, the cat experienced two relapses of lung edema despite the progressive increase of the furosemide dose, the addition of spironolactone and adherence to the therapeutic protocol by the owners. The dose of furosemide was further increased and its route of administration at home was switched from oral to parental. As the owner was not able to administrate intramuscular injections, SF was prescribed. This allowed the prevention of further episodes of lung edema. However, although the cat had never presented skin problems before, multiple well-defined circular, crusted ulcerative cutaneous lesions associated with alopecia developed at the sites of furosemide injections 2 weeks later. After ruling out several differential diagnoses for these lesions, a rare side effect of furosemide, not yet described in cats but already known in canine and human medicine, was strongly suspected as the possible cause. Therefore, the ongoing injectable formulation of furosemide was interrupted and substituted with an alternative brand, maintaining the same dose and route of administration. Thanks to this change, the dermal ulcerations disappeared within 1 month. Subsequently, the cat experienced neither further skin problems nor a recurrence of lung edema.", "subclaim_evaluations": [ { "subclaim": "The cat was a 2-year-old domestic shorthair.", "support_label": "supported" }, { "subclaim": "The cat was presented for CHF.", "support_label": "supported" }, { "subclaim": "The cat had lung edema.", "support_label": "supported" }, { "subclaim": "The cat had pleural effusion.", "support_label": "supported" }, { "subclaim": "Echocardiography revealed asymmetric left ventricular myocardial thickening.", "support_label": "supported" }, { "subclaim": "Echocardiography revealed severe left atrial dilation.", "support_label": "supported" }, { "subclaim": "The cat was hospitalized.", "support_label": "supported" }, { "subclaim": "The cat was treated with oxygen.", "support_label": "supported" }, { "subclaim": "The cat received intravenous furosemide.", "support_label": "supported" }, { "subclaim": "The cat received clopidogrel.", "support_label": "supported" }, { "subclaim": "After discharge, furosemide was switched from intravenous to oral.", "support_label": "supported" }, { "subclaim": "The cat experienced two relapses of lung edema within 2 weeks.", "support_label": "supported" }, { "subclaim": "The furosemide dose was progressively increased.", "support_label": "supported" }, { "subclaim": "Spironolactone was added.", "support_label": "supported" }, { "subclaim": "The owners adhered to the therapeutic protocol.", "support_label": "supported" }, { "subclaim": "The furosemide route of administration at home was switched from oral to parental.", "support_label": "supported" }, { "subclaim": "The owner was not able to administer intramuscular injections.", "support_label": "supported" }, { "subclaim": "SF was prescribed.", "support_label": "supported" }, { "subclaim": "This prevented further episodes of lung edema.", "support_label": "supported" }, { "subclaim": "Multiple well-defined circular, crusted ulcerative cutaneous lesions developed at the sites of furosemide injections.", "support_label": "supported" }, { "subclaim": "The lesions were associated with alopecia.", "support_label": "supported" }, { "subclaim": "A rare side effect of furosemide was strongly suspected as the possible cause.", "support_label": "supported" }, { "subclaim": "The ongoing injectable formulation of furosemide was interrupted.", "support_label": "supported" }, { "subclaim": "An alternative brand of furosemide was substituted.", "support_label": "supported" }, { "subclaim": "The same dose and route of administration were maintained.", "support_label": "not_supported" }, { "subclaim": "The dermal ulcerations disappeared within 1 month.", "support_label": "supported" }, { "subclaim": "The cat experienced no further skin problems.", "support_label": "supported" }, { "subclaim": "The cat experienced no recurrence of lung edema.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_844_en.txt", "fulltext": "A 28-year-old Asian female presented to accident and emergency department with 6 weeks history of intermittent left sided abdominal pain, which got worse over last 48 hours. Abdominal pain was associated with 2 episodes of watery diarrhea not mixed with blood and several episodes of vomiting. Drug history included nothing else apart from oral contraceptive pill. On examination she was comfortable and afebrile with pulse rate of 96 and blood pressure of 160/96. Abdomen was soft but tender in left iliac fossa and left lumber region with no guarding or rebound tenderness. Digital rectal examination was unremarkable. Full blood count showed white cell count to be elevated at 24.5 × 106/L. Urea, electrolyte, amylase and liver function tests were all within normal limits. Flexible sigmoidoscopic examination up to distal descending colon did not reveal any abnormality. Computer tomographic scan of the abdomen showed dilated large bowel up to splenic flexure along with dilated loops of small bowel. She was started on supportive treatment with IV Normal Saline, O2 inhalation, catheterization and antibiotics. However after treatment she failed to respond and progressively became more unwell. Gradually she developed hypotension and oliguria. Arterial blood gas analysis at 4 litre of oxygen showed compensated acidosis with following picture:\nPo2-10.7 kPa\nPCO2-4.04 kPa\nHydrogen ion - 43.4 nmol/litre\nHCO3-17.5 nmol/litre\nOn reassessment of abdomen it was more tender with both guarding and rebound tenderness. She underwent laparotomy which showed complete infarction of small bowel, Gall bladder and spleen. Large bowel was infracted up to splenic flexure. Liver also appeared ischaemic. No procedure could be carried out and abdomen was closed. She subsequently died after around six hours in the post operative period. An autopsy was requested in view of operative findings. Post mortem examination confirmed the presence of organized thrombus at the origin of celiac and superior mesenteric arteries. In the aorta there was eccentric intimal thickening with loss of smooth muscle and a proliferation of elastic tissue [Figure ]. The nature of the lesion was confirmed as intimal fibro muscular dysplasia and thrombosis causing stenosis and subsequent occlusion of the origin of superior mesenteric and celiac artery [Figure ]. Intimal fibro muscular dysplasia of aorta causing stenosis of the origin of superior mesenteric and celiac artery was rare in medical literature.", "summary": "A 28 year old Asian female presented with acute onset left sided abdominal pain and watery diarrhea. She had a laparotomy due to further deterioration. It showed infracted small intestine, gall bladder and parts of liver. Abdomen had to be closed without any therapeutic procedure. She died in early post operative period. Autopsy showed fibro muscular dysplasia of superior mesenteric artery.", "subclaim_evaluations": [ { "subclaim": "The patient is a 28 year old Asian female.", "support_label": "supported" }, { "subclaim": "She had acute onset left sided abdominal pain.", "support_label": "supported" }, { "subclaim": "She had watery diarrhea.", "support_label": "supported" }, { "subclaim": "She had a laparotomy due to further deterioration.", "support_label": "supported" }, { "subclaim": "The laparotomy showed infracted small intestine.", "support_label": "supported" }, { "subclaim": "The laparotomy showed an infarcted gall bladder.", "support_label": "supported" }, { "subclaim": "The laparotomy showed infarction of parts of the liver.", "support_label": "supported" }, { "subclaim": "The abdomen was closed without any therapeutic procedure.", "support_label": "supported" }, { "subclaim": "She died in the early post operative period.", "support_label": "supported" }, { "subclaim": "Autopsy showed fibro muscular dysplasia of the superior mesenteric artery.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2955_en.txt", "fulltext": "We present a 30-month-old male child with a normal perinatal history who was referred to our center with a history of decreased sensation over the gluteal region along with persistent dribbling of urine for 6 months. Neurological examination was normal, except for decreased perianal sensations. He was able to walk but at a slower pace than before; however, the exact power could not be graded due to the age factor limiting communication. Magnetic resonance imaging (MRI) of the spine showed a well-defined intramedullary cystic lesion of size 12 × 8 × 8 mm in the conus medullaris at the T12-L1 level, which was hypointense on T1-weighted images and hyperintense on T2-weighted images with no perilesional edema, solid component, or contrast enhancement .\nThe patient underwent T12-L1 laminotomy under intraoperative monitoring. After a midline durotomy, the cyst was seen surfacing near the midline covered by a thin layer of gliotic tissue. The cyst was opened at its most superficial point and clear fluid akin to cerebrospinal fluid was drained. Repeated Valsalva maneuver confirmed that the central canal was separate from the cyst. There was no definite plane of dissection between the conus and the cyst. The cyst was marsupialized by suturing its wall to the arachnoid of the cord to prevent reclosure . This was followed by a watertight dural closure. The postoperative period was uneventful. On follow-up after 3 months, there was an increase in muscle strength with improved walking but dribbling continued to persist. Histopathological examination revealed arachnoid cells in the cyst wall along with glial tissue which was suggestive of an arachnoid cyst.", "summary": "We report a case of a 30-month-old child who presented with decreased gluteal sensation and urinary dribbling for 6 months. Apart from some slowness in walking, the power was normal in all four limbs. Imaging showed a non-enhancing, T2-weighted hyperintense 12 × 8 mm conus intramedullary cyst without any edema. A T12-L1 laminotomy followed by marsupialization of the cyst was done. Histopathology was suggestive of an arachnoid cyst. The postoperative course was uneventful with improvement in muscle strength and achievement of regular milestones. We also present the pertinent review of the literature to date.", "subclaim_evaluations": [ { "subclaim": "The patient is a 30-month-old child.", "support_label": "supported" }, { "subclaim": "The patient had decreased gluteal sensation.", "support_label": "supported" }, { "subclaim": "The patient had urinary dribbling for 6 months.", "support_label": "supported" }, { "subclaim": "Imaging showed a non-enhancing, T2-weighted hyperintense 12 × 8 mm conus intramedullary cyst.", "support_label": "supported" }, { "subclaim": "The cyst showed no edema.", "support_label": "supported" }, { "subclaim": "A T12-L1 laminotomy was performed.", "support_label": "supported" }, { "subclaim": "Marsupialization of the cyst was performed.", "support_label": "supported" }, { "subclaim": "Histopathology was suggestive of an arachnoid cyst.", "support_label": "supported" }, { "subclaim": "The postoperative course was uneventful.", "support_label": "supported" }, { "subclaim": "There was improvement in muscle strength.", "support_label": "supported" }, { "subclaim": "Regular milestones were achieved.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1738_en.txt", "fulltext": "A 40 year old Malay male was seen at the emergency department with 1 week history of left hypochondriac pain with concurrent abdominal distention. He also complained of loss of appetite and feeling lethargic for 1 month duration. He had no fever, nausea, vomiting, changes in bowel habits or any history of bleeding diathesis. There was no history of trauma. Neither there were any significant past medical history nor family history of malignancy. He was an active smoker for 20 years but denied any alcohol consumption or substance abuse.\nOn clinical examination, he was afebrile, with an elevated heart rate of 110 beats per minute and a blood pressure measurement of 121/79 mmHg. Patient appeared pale. Abdominal examination revealed enlarged, non-tender liver and spleen. There was no ascites or peripheral lymphadenopathy. Cardiovascular and respiratory examinations were otherwise unremarkable.\nHaematological investigation revealed a low haemoglobin level at 6.4 g/dl. The patient had a white cell count (WCC) of 33.3 × 10^3 /uL and a platelet count of 568 × 10^3/uL. Differential WCC showed a predominant neutrophil count of 79.9%, lymphocyte count 8.9%, monocytes 9.6%, eosinophils 0.8%, basophils 0.8%, absolute neutrophil count of 25.63 × 10^3 /uL and absolute lymphocyte count of 2.95 × 10^3 /uL. There was an increase in lactate dehydrogenase levels (LDH) from 534 to 666 u/L. Peripheral blood film revealed leucocytosis with neutrophilia with no evidence of blast cells or atypical lymphocytes. Patient was reluctant to undergo a bone marrow aspiration and trephine biopsy. Abdominal ultrasonography demonstrated a large splenic collection. A contrast enhanced computerized tomography of the abdomen further revealed a large heterogenous splenic collection measuring 18 cm × 15 cm × 16.9 cm which was suggestive of a splenic haematoma [Fig. , and ]. There were no intra abdominal or pelvic lymph nodes enlargement. Based on computed tomography findings, a preliminary diagnosis of spontaneous splenic rupture was made. A surgical consult was obtained and an explorative laparotomy was performed on the patient. Intra operative findings showed a ruptured spleen with extensive adhesions to the omentum. No intra peritoneal lymph nodes enlargement were found. Splenectomy was then performed and subsequently, the patient was transferred to intensive care unit for close observation.\nFrom a histological perspective, the gross appearance of the obtained specimen revealed an enlarged spleen with irregular outer surfaces. A cut section of the spleen showed a firm, cream coloured layer occupying almost entire spleen with large area of necrosis with splenic infarcts. There as minimal amount of normal looking parenchyma tissues at the peripheral aspect of the specimen. Further histological examination revealed a diffuse infiltration of malignant lymphoid cells, which exhibited irregular nuclear membrane with vesicular nuclear chromatin and prominent nucleoli. The adjacent splenic parenchyma showed a congested and expanded red pulp with infiltration by atypical lymphoid cells [Fig. ].\nThe histological report confirmed the presence of diffuse large B-cell non-Hodgkin’s lymphoma (NHL) via immunohistochemical testing. Immunohistochemical staining showed the cells to be positive to CD20 (diffuse), BCL-2, BCL-6 (> 30%), and MUM-1 (> 30%) and negative to CD3, CD10, Cyclin-D1, Tdt, CD30 and ALK. Ki67 proliferative index was > 80%. In accordance with the WHO classification of Lymphoid Neoplasm [, ], these findings were consistent with the diagnosis of a diffuse large B-cell non-Hodgkin’s lymphoma, non-germinal center B-cell (non-GCB) type. Further molecular studies to assess MYC / BCL-2 / BCL-6 translocation or rearrangement was not done as the fluorescence in situ hybridization (FISH) analysis was not available in our local laboratory settings. Thirteen days later, the patient was discharged with prophylactic meningococcal, pneumococcal and influenza vaccinations. He was referred to the haemato-oncologist outpatient clinic at a tertiary care centre for post - operative chemotherapy. Unfortunately, the patient did not turn up for subsequent follow ups, rendering it difficult to further document any information with regards to treatment response in this report.", "summary": "A 40-year-old man presented with 1 week history of left hypochondriac pain associated with abdominal distention. There was no history of preceding trauma or fever. Clinical examination revealed signs of tachycardia, pallor and splenomegaly. He had no evidence of peripheral stigmata of chronic liver disease. In addition, haematological investigation showed anemia with leucocytosis and raised levels of lactate dehydrogenase enzyme. However, peripheral blood film revealed no evidence of any blast or atypical cells. In view of these findings, imaging via ultrasound and computed tomography of the abdomen was performed. The results of these imaging tests showed splenic collections that was suggestive of splenic rupture and hematoma. Patient underwent emergency splenectomy and the histopathological report confirmed the diagnosis as DLBCL.", "subclaim_evaluations": [ { "subclaim": "The patient is a 40-year-old man.", "support_label": "supported" }, { "subclaim": "He had a 1-week history of left hypochondriac pain.", "support_label": "supported" }, { "subclaim": "He had abdominal distention.", "support_label": "supported" }, { "subclaim": "There was no history of preceding trauma.", "support_label": "supported" }, { "subclaim": "Clinical examination revealed tachycardia.", "support_label": "supported" }, { "subclaim": "Clinical examination revealed pallor.", "support_label": "supported" }, { "subclaim": "Clinical examination revealed splenomegaly.", "support_label": "supported" }, { "subclaim": "Haematological investigation showed anemia.", "support_label": "supported" }, { "subclaim": "Haematological investigation showed leucocytosis.", "support_label": "supported" }, { "subclaim": "Haematological investigation showed raised lactate dehydrogenase levels.", "support_label": "supported" }, { "subclaim": "Peripheral blood film showed no evidence of blasts.", "support_label": "supported" }, { "subclaim": "Ultrasound and computed tomography of the abdomen were performed.", "support_label": "supported" }, { "subclaim": "Imaging showed splenic collections.", "support_label": "supported" }, { "subclaim": "The imaging findings were suggestive of splenic rupture.", "support_label": "supported" }, { "subclaim": "The imaging findings were suggestive of splenic hematoma.", "support_label": "supported" }, { "subclaim": "The patient underwent emergency splenectomy.", "support_label": "supported" }, { "subclaim": "Histopathological report confirmed the diagnosis as DLBCL.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2265_en.txt", "fulltext": "A 70-year-old male with a history of hypertension, diabetes mellitus, and atrial fibrillation presented to the emergency department with chest pain lasting for 1 hour. The patient did not have any previous neurologic deficits or surgical, family, or genetic history, although he was a heavy smoker (75 pack-years). His initial blood pressure was 109/62 mmHg with a heart rate of 103 beats per minute. There were no remarkable findings upon physical exam. The electrocardiogram (ECG) showed ST segment elevation in leads II, III, and aVF and reciprocal changes in leads I and aVL, suggestive of ST elevation myocardial infarction. Initial troponin I level (0.021 ng/mL [0–5 ng/mL]) was unremarkable. The patient was started on intravenous unfractionated heparin (UFH).\nThe patient was immediately moved to the catheterization lab for emergent percutaneous coronary intervention (PCI) of ST elevation myocardial infarction. Vital signs were normal during the femoral artery puncture and insertion of a 6 French (Fr) sheath into the right femoral artery (FA). We punctured at the femoral head level without any mispuncutures during the process. After puncture and before coronary angiography (CAG), however, the patient went into ventricular fibrillation and the blood pressure became unmeasurable. Cardiopulmonary resuscitation (CPR) was immediately initiated with defibrillation every 2 min, although normal rhythm of vital signs were not recovered. As CPR was performed for a total of 30 min, we concurrently inserted a venoarterial ECMO. A 16.5 Fr (external diameter: 5.5 mm) arterial and 21 Fr (external diameter: 7 mm) venous cannula was inserted through the right FA and femoral vein (FV), respectively. CAG revealed an extensive thrombotic occlusion of the mid right coronary artery (RCA) with thrombolysis in myocardial infarction (TIMI) 0 flow distally. A drug eluting stent (Biomime™ 4.0 × 19 mm) was inserted to the lesion and the RCA restored a TIMI 2 flow (pain-to-balloon time: 120 min).\nAfter the PCI, the patient was moved to the intensive care unit for ECMO care. Initial echocardiography showed a left ventricular ejection fraction (LVEF) of 15% and an extensive regional wall motion abnormality of the RCA territory. However, there was blood pressure drop with concurrent massive nasal and gastrointestinal bleeding. Hemoglobin level became 5.9 g/dL, which was approximately 8 g/dL decrease compared with initial levels. Blood pressure was recovered to normal after massive transfusion; however, we lowered the target activated partial thromboplastin time to approximately 40 s to prevent additional bleeding. There were no cannulation site complications such as hematoma or signs of infection during ECMO care, although diffuse swelling developed in the right lower extremity (LE) the next few days. Pneumatic compression devices were applied to both LEs to prevent DVT. ECMO therapy was maintained for 4 days, while vital signs slowly recovered. As the LVEF was restored to 46% on the 4th day, the ECMO was weaned and removed. The ECMO cannulas were removed by manual compression. Despite the risk of stent thrombosis, dual-antiplatelet therapy was stopped after ECMO removal (day 4) in concern of additional bleeding.\nOn the 7th day of admission, the patient recovered orientation. However, leg edema did not improve despite ECMO removal. He also started complaining impaired function, pain, and hypesthesia of the LE. Compartment syndrome was initially suspected. We clinically ruled out compartment syndrome , since the patient was negative for Homan’s sign and had good distal pulsation with warm circulation. The patient had burning sensation and Grade 3 weakness in hip and knee flexion motions with no deep tendon reflex. Neurologic findings were not dermatome specific. LE Doppler sonography and computed tomography (CT) showed DVT extending from the right external iliac vein to the calf vein without any evidence of puncture site hematoma or intramural bleeding . The patient was started on rivaroxaban (15 mg twice daily) for DVT (day 8). The swelling of the right LE gradually improved over the next 30 days, although his pain and weakness were not alleviated. As the patient was suspected to have post-thrombotic syndrome (PTS), which is pain and abnormal sensation after the onset of DVT, further studies such as the nerve conduction study (NCS) or electromyography were not considered until later on. The patient was discharged to a rehabilitation hospital on the 35th day.\nDuring outpatient department follow up, the patient consistently had pain, abnormal sensation, and weakness in the right LE, which resulted in insomnia and depression. Although he was given thioctic acid (600 mg qd) and pregabalin (150 mg bid) during outpatient department follow up, his pain remained. Femoral and pulmonary arterial CT angiography was performed 100 days post-ECMO insertion showed no thrombus in the right LE or pulmonary arteries. However, the NCS revealed no sensory nerve action potential in the right peroneal nerve and tibial nerve, suggestive of impaired sensation. Additionally, the compound muscle action potential was not observed in the right femoral , peroneal and tibial nerve, indicating motor nerve palsy. These results collectively suggested FN. The patient is continuing rehabilitation exercises and slowly recovering from the weakness, although the tingling sensation remains to a lesser degree. The patient shares his regrets on his previous smoking habits which caused his myocardial infarction and eventually FN. An informed consent for publishing data was obtained from the patient. A timeline of events is summarized in Table .", "summary": "A 70-year old male presented to the emergency department for chest pain. The patient had cardiac arrest before percutaneous coronary intervention (PCI) and was inserted with ECMO. Although he was successfully weaned from ECMO 4 days after PCI, he consistently complained swelling, abnormal sensation, and weakness in his right lower extremity, where the cannulas were inserted. Imaging studies showed deep vein thrombosis (DVT) in his right leg, which was further treated with anticoagulants. Symptoms, however, remained after the regression of DVT. Nerve conduction study revealed femoral neuropathy, which may have been caused by ECMO cannula compression and tissue swelling.", "subclaim_evaluations": [ { "subclaim": "The patient is a 70-year-old male.", "support_label": "supported" }, { "subclaim": "The patient presented to the emergency department for chest pain.", "support_label": "supported" }, { "subclaim": "The patient had cardiac arrest before percutaneous coronary intervention.", "support_label": "supported" }, { "subclaim": "The patient was inserted with ECMO.", "support_label": "supported" }, { "subclaim": "The patient was successfully weaned from ECMO 4 days after PCI.", "support_label": "supported" }, { "subclaim": "The patient complained of swelling in his right lower extremity.", "support_label": "supported" }, { "subclaim": "The patient complained of abnormal sensation in his right lower extremity.", "support_label": "supported" }, { "subclaim": "The patient complained of weakness in his right lower extremity.", "support_label": "supported" }, { "subclaim": "The cannulas were inserted in the right lower extremity.", "support_label": "supported" }, { "subclaim": "Imaging studies showed deep vein thrombosis in the right leg.", "support_label": "supported" }, { "subclaim": "The DVT was treated with anticoagulants.", "support_label": "supported" }, { "subclaim": "Symptoms remained after the regression of DVT.", "support_label": "supported" }, { "subclaim": "A nerve conduction study revealed femoral neuropathy.", "support_label": "supported" }, { "subclaim": "Femoral neuropathy may have been caused by ECMO cannula compression.", "support_label": "supported" }, { "subclaim": "Femoral neuropathy may have been caused by tissue swelling.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_716_en.txt", "fulltext": "A 49-y-old man admitted to an emergency department in 21 December 2005, with the complaint of drowsiness and quadriparesia. On admission, the patient was afebrile and had a blood pressure of 200/110 mmHg, pulse rate of 95/min and, a body mass index of 32 kg/m2. On physical examination, he had facial plethora, central obesity, pitting edema of limbs, without evidence of purple striae or hyperpigmentation. On neurologic examination, cranial nerves function was intact, proximal and distal force were 3/5, and tendon reflexes were diminished. Other examination was unremarkable. His problem was started a year ago with weight gain (4 kg), fatigue, proximal muscle weakness, easy bruising and hypertension. He didn’t complaint paroxysmal hypertension, headache, palpitation, or sweating. He had been smoker of 20 pack/y for almost 30 years, with no previous medical or surgical history, and no family history for endocrine disease. Initial work up on admission revealed marked hypokalemia (2.1 mEq/L), metabolic alkalosis (pH: 7.58, HCO3:57.2 mEq/L) and blood glucose of 330 mg/dL. Electrocardiogram showed long QT interval (0.52 s), inverted T wave, and prominent U wave in precordial leads. The patient admitted in coronary care unit. According to high suspicious of CS, 24-h urine for urinary free cortisol (UFC) was collected. Laboratory data revealed UFC greater than 1000 μg/24 h (reference value: 50–149 μg/24 h), serum ACTH 257 pg/mL at 8 AM (reference value: 9–46 pg/mL), and morning serum cortisol 57 μg/dL (reference value:5.5–26.1 μg/dL) . Following 8 mg oral administration of dexamethasone at 11 PM, no suppression was found at morning serum cortisol level (67 μg/dL). Considering ACTH-dependent CS, dynamic pituitary magnetic resonance imaging (MRI) was done that did not show pituitary adenoma; spiral chest and abdominopelvic computed topographies (CT) were unremarkable, except of the significant enlargement of bilateral adrenal glands. Treatment with ketoconazole, 200 mg every 12 h, was initiated to control hypercortisolism. According to persistent hypokalemia despite excess potassium supplement (> 120 mEq/day) 2 days after starting ketoconazole, the patient was scheduled for bilateral trans-abdominal open adrenalectomy on 28 December 2005. The weights and sizes of excised right and left adrenal glands were 18 g, 6× 3× 0.8 cm and 20 g, 6× 3.5× 1 cm, respectively. Microscopic examination revealed diffuse adrenocortical hyperplasia. Three days after surgery, 24-h UFC, morning serum cortisol and ACTH levels decreased to 27 μg/24-h, 2.2 μg/dL, 44 pg/mL, respectively, furthermore blood pressure and serum potassium and glucose levels were normalized. The patient was discharged on daily dose of 5 mg prednisolone and 0.1 mg fludrocortisone. All signs and symptoms of CS were resolved gradually during 4 months, and 24-h UFC was consistently less than 4 μg/24-h. He remained asymptomatic and during annual laboratory follow-ups results of serum ACTH and UFC were unremarkable, i.e. ACTH < 50 pg/mL, UFC < 4 μg/24-h. In November 2016, serum ACTH began to rise, and in November 2017 reached to 341 pg/mL . Reassessment for ectopic ACTH producing NET was performed using spiral neck, chest, and abdominopelvic CT-scans. A 2 cm mass in the middle lobe of the right lung was found and dynamic contrast enhanced pituitary MRI and Technetium-99 m-octerotide scan were normal . A CT-guided biopsy from the lung mass showed a tumor composed of solid nests of small monotonous cells with no atypia or mitotic activity, suggesting an ACTH-producing carcinoid tumor. Histologic examination of the resected right middle lobe revealed carcinoid tumor without involvement of hilar, subcarinal and intralobar lymph nodes. Immunohistochemical (IHC) staining showed diffuse positivity for chromogranin, synaptofysine, and ACTH ; the proliferation marker of Ki-67 was positive in 1% of the neoplastic cells, with the final diagnosis of ACTH-producing carcinoid tumor. Postoperative course was uneventful, and serum ACTH level decreased to less than 100 pg/mL. Approximately 7 months later, serum ACTH level had an upward trend to 171 pg/mL . Spiral chest CT scan revealed at least 2 nodules measuring up to 5 mm in the lower lobe of the right lung. There were also suspicious lytic bone lesions in thoraco-abdominal CT. Subsequently, whole body bone scan with TC99 was performed suggesting multiple metastatic bone lesions at clavicles, ribs, iliac, temporal and parietal bones . CT-guided left iliac wing biopsy revealed thick sclerotic osteoid tissue, without neoplastic involvement, IHC staining for cytokeratin and chromogranin were negative, although serum chromogranin level was reported 2062 ng/mL (reference value: < 100 ng/mL). Hence, according to the high level of the chromogranin, as well as the presence of nodular lesions in the lung, the patient was managed as a metastatic NET, treatment with bisphosphonate and somatostatin receptor analogous was started.", "summary": "Here, we describe a 49-year-old-man with cushingoid feature, drowsiness and quadriparesis came to emergency department at December 2005. Laboratory tests revealed hyperglycemia, metabolic alkalosis, severe hypokalemia, and chemical evidence of an ACTH-dependent hypercortisolism as morning serum cortisol of 57 μg /dL without suppression after 8 mg dexamethasone suppression test, serum ACTH level of 256 pg/mL, and urine free cortisol of > 1000 μg /24 h. Imaging showed only bilateral adrenal hyperplasia, without evidence of pituitary adenoma or ectopic ACTH producing tumors. Importantly, other diagnostic tests for differentiating Cushing disease (CD) from ectopic ACTH producing tumor, such as inferior petrosal sinus sampling (IPSS), corticotropin releasing hormone (CRH) stimulation test, octreotide scan or fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan were not available in our country at that time. Therefore, bilateral adrenalectomy was performed that led to clinical and biochemical remission of hypercortisolism and decreased ACTH level to < 50 pg/mL, findings suggestive of a primary focus of NET in adrenal glands. After 11 years uncomplicated follow up, the ACTH level elevated up to 341 pg/mL and re-evaluation showed a 2 cm nodule in the middle lobe of the right lung. Surgical excision of the pulmonary nodule yielded a carcinoid tumor with positive immunostaining for ACTH; leading to decrease in serum ACTH level to 98 pg/mL. Subsequently after 7 months, serum ACHT levels rose again. More investigation showed multiple lung nodules with metastatic bone lesions accompanied by high serum chromogranin level (2062 ng/mL), and the patient managed as a metastatic NET, with bisphosphonate and somatostatin receptor analogues.", "subclaim_evaluations": [ { "subclaim": "The patient is a 49-year-old man.", "support_label": "supported" }, { "subclaim": "The patient had cushingoid features.", "support_label": "supported" }, { "subclaim": "The patient had drowsiness.", "support_label": "supported" }, { "subclaim": "The patient had quadriparesis.", "support_label": "supported" }, { "subclaim": "The patient came to the emergency department in December 2005.", "support_label": "supported" }, { "subclaim": "Laboratory tests showed hyperglycemia.", "support_label": "supported" }, { "subclaim": "Laboratory tests showed metabolic alkalosis.", "support_label": "supported" }, { "subclaim": "Laboratory tests showed severe hypokalemia.", "support_label": "supported" }, { "subclaim": "Morning serum cortisol was 57 μg/dL.", "support_label": "supported" }, { "subclaim": "The 8 mg dexamethasone suppression test did not suppress cortisol.", "support_label": "supported" }, { "subclaim": "Serum ACTH level was 256 pg/mL.", "support_label": "not_supported" }, { "subclaim": "Urine free cortisol was >1000 μg/24 h.", "support_label": "supported" }, { "subclaim": "Imaging showed bilateral adrenal hyperplasia.", "support_label": "supported" }, { "subclaim": "There was no evidence of a pituitary adenoma.", "support_label": "supported" }, { "subclaim": "There was no evidence of an ectopic ACTH-producing tumor.", "support_label": "not_supported" }, { "subclaim": "Inferior petrosal sinus sampling was not available in the country at that time.", "support_label": "not_supported" }, { "subclaim": "A corticotropin-releasing hormone stimulation test was not available in the country at that time.", "support_label": "not_supported" }, { "subclaim": "An octreotide scan was not available in the country at that time.", "support_label": "not_supported" }, { "subclaim": "A fluorodeoxyglucose PET scan was not available in the country at that time.", "support_label": "not_supported" }, { "subclaim": "Bilateral adrenalectomy was performed.", "support_label": "supported" }, { "subclaim": "Bilateral adrenalectomy led to clinical remission of hypercortisolism.", "support_label": "supported" }, { "subclaim": "Bilateral adrenalectomy led to biochemical remission of hypercortisolism.", "support_label": "supported" }, { "subclaim": "Serum ACTH decreased to <50 pg/mL after bilateral adrenalectomy.", "support_label": "supported" }, { "subclaim": "The findings were suggestive of a primary focus of neuroendocrine tumor in the adrenal glands.", "support_label": "not_supported" }, { "subclaim": "After 11 years of follow-up, ACTH levels increased to 341 pg/mL.", "support_label": "supported" }, { "subclaim": "A 2 cm nodule was found in the middle lobe of the right lung.", "support_label": "supported" }, { "subclaim": "Surgical excision of the pulmonary nodule was performed.", "support_label": "supported" }, { "subclaim": "The pulmonary nodule was a carcinoid tumor.", "support_label": "supported" }, { "subclaim": "The tumor was positive for ACTH immunostaining.", "support_label": "supported" }, { "subclaim": "Serum ACTH decreased to 98 pg/mL after excision.", "support_label": "supported" }, { "subclaim": "After 7 months, serum ACTH levels rose again.", "support_label": "supported" }, { "subclaim": "Multiple lung nodules were found.", "support_label": "supported" }, { "subclaim": "Metastatic bone lesions were found.", "support_label": "supported" }, { "subclaim": "Serum chromogranin level was 2062 ng/mL.", "support_label": "supported" }, { "subclaim": "The patient was managed as having metastatic neuroendocrine tumor.", "support_label": "supported" }, { "subclaim": "Bisphosphonate was used in the management.", "support_label": "supported" }, { "subclaim": "Somatostatin receptor analogues were used in the management.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2035_en.txt", "fulltext": "In July 2021, a 34-year-old woman came to the emergency department with a five-day history of fever and a dull ache in the chest radiating to the right arm.\nShe visited her family doctor one week before because the ache in the chest was given a visual analogue scale score of 9-10 and gradually worsened. There was no redness or irregularity in the skin of the chest area. Blood tests were normal. She was given nonsteroidal anti-inflammatory drugs and opioids for pain relief, but the condition did not improve, therefore she came to our hospital for emergency treatment.\nThere is no relevant history of past illness, intravenous drug abuse, inflammatory joint alterations, trauma, and spreading from a source of infection (dental, skin areas).\nThe patient was a non-smoker. She claimed to have no allergies to food or medicines, no operations were performed. The patient denied any family history of arthritis.\nBody mass index - 22.4 kg/m2. The vital signs were as follows: Body temperature - 36.9℃; blood pressure - 98/60 mmHg; heart rate - 100 beats per minute; respiratory rate - 19 breaths per min During palpation, there were no swollen or painful lumps and lymph nodes in the typical axilla, neck, or groin areas; the chest was painless.\nPrimary laboratory tests showed significantly increased inflammatory markers: C-reactive protein (CRP) 256.0 mg/L (Ref ≤ 5 mg/L), leukocytosis white blood cells (WBCs) - 14.20 × 109/L (Ref from 4.5 to 11.0 × 109/L); elevated procalcitonin 0.69 µg/L (Ref < 0.1 ng/mL) and liver enzymes: Aspartate aminotransferase - 239 U/ L (Ref ≤ 40), alanine aminotransferase - 334 U/L (Ref ≤ 40); normal troponin - 0 ng/L (Ref ≤ 16), and elevated D-dimers 1725 µg/L (Ref < 250 µg/L). No abnormality was found in urine analyses.\nThe electrocardiogram showed only sinus tachycardia - 103 bpm. Pulmonary embolism, aortic aneurysm, pneumonia, pneumothorax, and even rib fracture were suspected. Thoracic CT angiography, non-contrast chest CT, and X-ray of the thoracic spine, ribs, and sternum were performed, as well as diagnostic ultrasound with PD (by an abdominal sonographer) of the soft tissues at the sternum, but no pathology was detected.", "summary": "A 34-year-old immunocompetent woman presented with a fever and a dull ache in the chest radiating to the right arm. Traumatic injury and the most common respiratory and cardiac disorders were ruled out. Blood cultures came back positive for Staphylococcus aureus, and sepsis was confirmed. A small lump was noted on the chest during the first week of hospitalization. Superb microvascular imaging was performed and septic arthritis of the manubriosternal joint was detected. MRI confirmed the diagnosis and showed septic arthritis of the manubriosternal joint with several localized abscesses behind the sternum. The patient was treated for three weeks with intravenous antibiotics and the outcome was favorable: Inflammatory markers became normal, and the lump disappeared. Three months later, the patient was examined for a new episode of mild pain in the sternum and was diagnosed with persistent perichondritis by ultrasound in comparison with MRI.", "subclaim_evaluations": [ { "subclaim": "The patient is a 34-year-old immunocompetent woman.", "support_label": "supported" }, { "subclaim": "She presented with a fever.", "support_label": "supported" }, { "subclaim": "She had a dull ache in the chest radiating to the right arm.", "support_label": "supported" }, { "subclaim": "Traumatic injury was ruled out.", "support_label": "supported" }, { "subclaim": "The most common respiratory disorders were ruled out.", "support_label": "supported" }, { "subclaim": "The most common cardiac disorders were ruled out.", "support_label": "supported" }, { "subclaim": "Blood cultures were positive for Staphylococcus aureus.", "support_label": "not_supported" }, { "subclaim": "Sepsis was confirmed.", "support_label": "not_supported" }, { "subclaim": "A small lump was noted on the chest during the first week of hospitalization.", "support_label": "not_supported" }, { "subclaim": "Superb microvascular imaging was performed.", "support_label": "not_supported" }, { "subclaim": "Septic arthritis of the manubriosternal joint was detected.", "support_label": "not_supported" }, { "subclaim": "MRI confirmed the diagnosis.", "support_label": "not_supported" }, { "subclaim": "MRI showed septic arthritis of the manubriosternal joint.", "support_label": "not_supported" }, { "subclaim": "MRI showed several localized abscesses behind the sternum.", "support_label": "not_supported" }, { "subclaim": "The patient was treated for three weeks with intravenous antibiotics.", "support_label": "not_supported" }, { "subclaim": "Inflammatory markers became normal.", "support_label": "not_supported" }, { "subclaim": "The lump disappeared.", "support_label": "not_supported" }, { "subclaim": "Three months later, the patient was examined for a new episode of mild pain in the sternum.", "support_label": "not_supported" }, { "subclaim": "Persistent perichondritis was diagnosed by ultrasound.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1914_en.txt", "fulltext": "A 43-year-old woman was referred to our institution with a neck mass in the left submandibular region. She was studied in an outside hospital, where a neck ultrasound showed a multinodular goiter and a CBT on the left carotid bifurcation. A neck Computed tomography angiography (CTA) demonstrated a carotid body tumor (3.8 cm × 2.5 cm × 3.3 cm) classified as Shamblin II and an intrathoracic multinodular thyroid gland with a right lobe extension of 11.9 cm × 9.7 cm and the left lobe of 25.2 cm × 21.3 cm with caudal retrosternal growth and evidence of slightly trachea deviation .\nThyroid function test (TFT) were normal, serum antithyroglobulin antibodies and thyroperoxidase antibody (TPO) were undetectable. Thyroid gammagram was performed reporting a multinodular goiter. Fine needle aspiration was performed demonstrating nonmalignant cells. A total thyroidectomy was performed with a transverse lower neck incision (Kocher incision), posteriorly, CBT was resected by an extension of the previous Kocher incision to the anterior border of the sternocleidomastoid muscle using the retrocarotid reported previously in our group as an effective technique, also two surrounding lymph nodes were resected to rule out malignancy . The pathology report demonstrated a paraganglioma with negative lymph nodes invasion and a multinodular goiter .\nThe patient recovered satisfactorily after the surgery and she was discharged in postoperative day number three, she currently continues her follow-up as our patient. Twelve months after the surgery, she does not present any complaints. She is currently on levothyroxine and calcium carbonate.", "summary": "We herein present the case of a 43-year old woman with the aforementioned association. As a part of the diagnostic evaluation, an ultrasound was performed, revealing both conditions simultaneously. The surgery took place with the aim of resecting both lesions during the same intervention. The patient was discharged without complications.", "subclaim_evaluations": [ { "subclaim": "The patient is a 43-year-old woman.", "support_label": "supported" }, { "subclaim": "An ultrasound was performed as part of the diagnostic evaluation.", "support_label": "supported" }, { "subclaim": "The ultrasound revealed both conditions simultaneously.", "support_label": "supported" }, { "subclaim": "The surgery aimed to resect both lesions during the same intervention.", "support_label": "supported" }, { "subclaim": "The patient was discharged without complications.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_83_en.txt", "fulltext": "A 38-year-old male with no past medical history asked a bystander to call emergency medical services (EMS) after he had fallen 12 feet off a fire escape and landed on his right ankle. An Advanced Life Support ambulance was dispatched and, upon arrival, paramedics found the patient on the ground and unable to ambulate. He complained of 8/10 pain to his right ankle. Airway, breathing, and circulation to all four extremities were intact, and initial vital signs were heart rate (HR) of 100 beats per minute, blood pressure (BP) of 142/76 millimeters of mercury (mm Hg), respiratory rate (RR) of 20 breaths per minute, and oxygen saturation (SpO2) of 98%. Physical exam was notable for a right ankle deformity.\nParamedics on scene immobilized the patient’s leg in a splint, after which they contacted their online medical control (OLMC) center to discuss options for analgesia. The OLMC physician authorized the delivery of a dose of nebulized ketamine via BAN at 0.75 milligrams per kilogram (mg/kg) mixed with three milliliters (mL) of normal saline. During administration, the patient reported dizziness, which was rated one on a scale from zero to four using the Side Effects Rating Scale of Dissociative Anesthetics. This is a scoring system used to grade severity of medication side effects where zero represents “no change” in symptoms and four represents “very bothersome” symptoms. He did not become agitated, dissociated, or sedated.\nThirty minutes after the start of nebulization, pain was measured at 3/10. Repeat vitals at this time were HR 103 beats per minute, BP 128/79 mm Hg, RR 18 breaths per minute, and SpO2 97%. In the ED, at one hour after administration of nebulized ketamine, the patient reported a return of his pain, and was given a dose of four mg IV morphine. Radiograph revealed a right tibial pilon fracture. He was placed in a posterior short leg splint and admitted to the orthopedic service; he was operated on the next day for open reduction and internal fixation of the right ankle joint. He was subsequently discharged post-procedure with orthopedic follow-up.", "summary": "We present a case of a patient with right ankle fracture after a 12-foot fall who subsequently received 0.75 milligrams per kilogram of nebulized ketamine via BAN in the prehospital setting. The patient reported improvement of pain from 8/10 to 3/10 on the pain scale without need for additional pain medication during prehospital transport. This report supports the use of nebulized ketamine via BAN in the prehospital setting for acute traumatic limb injuries.", "subclaim_evaluations": [ { "subclaim": "The patient had a right ankle fracture.", "support_label": "supported" }, { "subclaim": "The fracture occurred after a 12-foot fall.", "support_label": "supported" }, { "subclaim": "The patient received 0.75 milligrams per kilogram of nebulized ketamine.", "support_label": "supported" }, { "subclaim": "The nebulized ketamine was administered via BAN.", "support_label": "supported" }, { "subclaim": "The administration occurred in the prehospital setting.", "support_label": "supported" }, { "subclaim": "The patient reported improvement of pain from 8/10 to 3/10.", "support_label": "supported" }, { "subclaim": "The improvement occurred without additional pain medication.", "support_label": "not_supported" }, { "subclaim": "The improvement occurred during prehospital transport.", "support_label": "not_supported" }, { "subclaim": "This report supports the use of nebulized ketamine via BAN.", "support_label": "supported" }, { "subclaim": "The use is for acute traumatic limb injuries.", "support_label": "supported" }, { "subclaim": "The use is in the prehospital setting.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1203_en.txt", "fulltext": "A 37-year-old woman was presented to the emergency room with abrupt severe right upper abdominal pain. The pain was squeezing and started suddenly after breakfast. The pain was not accompanied by vomiting or fever. The patient had previously been treated at the Department of Medicine in Samsung Medical Center with a diagnosis of EGPA. After successful suppression of blood hypereosinophilia with combination of prednisolone and azathioprine in recent months, she had been in the process of tapering prednisolone down to 15 mg per day. However, after dose reduction, her eosinophil counts slowly increased to 1989 cells/µL and levels of aspartate aminotransferase and alanine aminotransferase were elevated from normal to more than 300 U/L with mild abdominal pain. Consequently, her dose of prednisolone was raised back to 60 mg per day. While waiting for admission for further evaluation, abdominal pain brought her to emergency room.\nFive years ago, her first visit was prompted by symptoms of sinusitis, rash and eosinophilia. Three months later, numbness and cutting pain in both upper and lower extremities with fever, myalgia, and asthma developed. A nerve conduction study suggested multifocal sensorimotor neuropathy. Biopsy of the sural nerve revealed ischemic change resulting from vasculitis with prominent eosinophilic infiltration. Although perinuclear anti-neutrophil cytoplasmic antibodies were not detected, the patient was diagnosed as EGPA. After repeated intravenous cyclophosphamide pulse therapy with a high dose of systemic steroids, most symptoms were resolved. Sinusitis, presented as an initial symptom, improved after treatment at an early stage and otolaryngologic complication did not appear afterwards.\nHowever, whenever the tapering a dose of steroids was attempted, she developed new symptoms such as myalgia and arthralgia. She even experienced dry gangrene in the fingertips of both hands because of arterial thrombosis when her eosinophil count increased up to 6000 cells/µL . Duplex scan for arteries and veins indicated the total occlusion of the right distal ulnar artery and left medial forearm ulnar artery. The study also revealed a total occlusion of both mid-anterior tibial arteries, whereas toes of both feet were intact as other vessels of lower extremities were not involved. Hypercoagulability was thought to be caused either directly or indirectly by hypereosinophilia. We recommended mepolizumab, a monoclonal antibody to interleukin-5 used to interrupt eosinophil production, to reduce eosinophil count. But the patient refused it because of cost. We added aspirin and calcium channel blockers after cardiologic consultation. After the affected fingers were dried up, necrotized fingertips were amputated by orthopedic surgeon.\nInitial vital signs in the ER showed a blood pressure of 85/45 mmHg, a heart rate of 98 beats per minute with a temperature of 36.1’C, and a respiratory rate of 16 breaths per minute. Physical examination revealed mild tenderness in the right upper abdomen without rebound tenderness. The complete blood count revealed leukocytosis of 17,660 white blood cells/µL. Absolute eosinophil count was 1120 cells/µL. The erythrocyte sedimentation rate was 29 mm/hr, CRP was 3.7 mg/dL and total immunoglobulin E was 107 kU/L.\nAn abdomen-pelvis CT demonstrated subcapsular hematoma in the right hepatic lobe . Hemoperitoneum probably caused by multifocal hepatic capsular arterial bleeding was also detected. There was no evidence of bowel perforation. In a previous CT scan taken 1 year before, there had been no evidence of any aneurysm changes in the hepatic vessels. A celiac angiogram demonstrated multiple, various sized hepatic aneurysms in both lobes . The small aneurysms resembled the appearance of a string of beads, characteristically observed in polyarteritis nodosa (PAN). Huge aneurysms larger than 1 cm in size were noticed in S7 and S8. Emergency embolization was performed. The huge aneurysm and the aneurysms with bead-like appearance in S7 and S8 were successfully occluded. Although several small aneurysms in S5, S6 and the left lobe still remained, no further embolization was performed to conserve hepatic function.\nMeticulous review of the abdomen-pelvis CT did not reveal evidence of aneurysms in other abdominal organs. After emergency intervention, vital signs became stable and numbness of both hands and feet improved. Based on her clinical course, we strongly recommended to add mepolizumab to control hypereosinophilia and reduce the dose of steroid. After administration of mepolizumab in addition to the previous steroid and cyclophosphamide therapy, eosinophil count became stable and was reduced to a near zero percentage of total white blood cell count.", "summary": "A known EGPA patient visited to the emergency room (ER) with abrupt squeezing abdominal pain. She had suffered from gangrene in the fingertips of both hands for 1 year because of arterial thrombosis associated with hypereosinophilia. However, her absolute eosinophil count in the ER was 1120 cells/µL. An abdomen-pelvis CT demonstrated subcapsular hematoma in the right hepatic lobe. A celiac angiogram demonstrated multiple sized aneurysms in both hepatic lobes and some aneurysms in S7 and S8 were huge, more than 1 cm in size. The shape of the small aneurysms resembled a string of beads, as in polyarteritis nodosa. Given the clinical situation, emergency embolization was performed. Before this patient visited to the ER, she had been treated with a high dose of systemic corticosteroid, azathioprine, and cyclophosphamide. After addition of mepolizumab, the eosinophil count remained stable state with a near zero percentage of total white blood cell count.", "subclaim_evaluations": [ { "subclaim": "The patient is a known EGPA patient.", "support_label": "supported" }, { "subclaim": "She visited the emergency room with abrupt squeezing abdominal pain.", "support_label": "supported" }, { "subclaim": "She had gangrene in the fingertips of both hands for 1 year.", "support_label": "not_supported" }, { "subclaim": "The gangrene was due to arterial thrombosis associated with hypereosinophilia.", "support_label": "supported" }, { "subclaim": "Her absolute eosinophil count in the ER was 1120 cells/µL.", "support_label": "supported" }, { "subclaim": "An abdomen-pelvis CT showed subcapsular hematoma in the right hepatic lobe.", "support_label": "supported" }, { "subclaim": "A celiac angiogram showed multiple aneurysms in both hepatic lobes.", "support_label": "supported" }, { "subclaim": "Some aneurysms in S7 and S8 were more than 1 cm in size.", "support_label": "supported" }, { "subclaim": "The shape of the small aneurysms resembled a string of beads.", "support_label": "supported" }, { "subclaim": "Emergency embolization was performed.", "support_label": "supported" }, { "subclaim": "Before the ER visit, she was treated with a high dose of systemic corticosteroid.", "support_label": "supported" }, { "subclaim": "She was also treated with azathioprine.", "support_label": "supported" }, { "subclaim": "She was also treated with cyclophosphamide.", "support_label": "supported" }, { "subclaim": "After adding mepolizumab, the eosinophil count remained stable.", "support_label": "supported" }, { "subclaim": "The eosinophil count was near zero percentage of total white blood cell count.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1984_en.txt", "fulltext": "A 62-year-old Japanese woman was referred for bilateral dry eyes, with Schirmer’s test results of 0 mm for both eyes. Four years previously, she had been diagnosed with primary rheumatoid arthritis (RA) and secondary Sjogren’s syndrome. She was being treated with 6 mg of methotrexate. CT scans appeared normal when she was first diagnosed with RA. Just prior to her dry eye referral, her previous hospital found C-reactive protein (CRP) and lactate dehydrogenase (LDH) levels to be significantly increased (CRP of 11.83 and LDH of 952), leading to a suspicion of an underlying malignancy. A CT scan was done, and some lung opacities were found, but biopsies of bone marrow, pleural fluid and cerebrospinal fluid (CSF) all revealed no neoplastic activity.\nWhile being treated for dry eye at our hospital, emergent hyperemia presented in the right eye coupled with fever and photophobia, for which she was admitted to the hospital. In the inpatient ward, hemorrhagic hypopyon that showed niveau-like hypopyon with hemorrhage as reported in previous case was seen on slit lamp. A distinct herpetic corneal lesion were noted via fluorescein staining. Keratic precipitates were noted, but no synechiae. HSV was specifically identified in the right eye via Checkmated Herpes-eye®, (Wakamoto Co., Ltd., Tokyo Japan). Corneal smear was done to rule out bacteria as a potential cause. Right eye visual acuity was found to be 20/500, while left eye visual acuity remained 20/20. Right eye intraocular pressure (IOP) was 16 mmHg and left eye IOP was 18 mmHg. The anterior segment of the right eye presented with hyperemia, dendritic keratitis, and intracameral fibrin deposits . Posterior segment appeared normal. Anterior segment optical coherence tomography (AS-OCT) further illustrate the fibrin deposits and hemorrhagic hypopyon . Body temperature was elevated to 38.5 °C, with a white blood cell count (WBC) of 10.4 × 103/μL (with neutrophils being 64.3%, lymphocytes 16.5%, monocytes 16.8%, eosinophils 1.9%, and basophils 0.5%) Treatment with topical acyclovir ophthalmic ointment (5 times daily), topical levofloxacin (5 times daily) and oral valacyclovir (3 times daily). Two days later, the dendritic keratitis began to regress.\nBy day 5 of treatment, the dendritic keratitis, fibrin, hypopyon had regressed, with only superficial, punctate keratitis and Descemet membrane folds remaining. WBC normalized, CRP dropped to 9.72 and body temperature dropped to 36 °C. The right eye’s visual acuity recovered to 20/200, which was comparable to baseline on account of a cataract. Three weeks after hospitalization, symptoms had completely regressed; slit-lamp findings revealed no findings indicative of herpetic keratouveitis or recurrent hypopyon.\nNearly 3 months later, a fever and corneal opacities reoccurred. Again, a characteristic herpetic dendritic lesion, superficial punctate keratitis, and intracameral fibrin deposits were noted . WBC count remained normal, diminishing suspicion of RA flare-up. Due to the previously elevated LDH levels and previous rare viral presentation, malignancy was again suspected. A positon-emission tomography-computed tomography (PET-CT) showed significant diffuse lung opacities whereafter a lung biopsy was performed to confirm an intravascular B cell lymphoma . Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) regimen was begun immediately, and the corneal lesions and the lymphoma both went into complete remission. Over a year and a half later, there is still complete remission of the cancer and no corneal lesions or ocular symptoms .", "summary": "We present a case wherein a 62-year-old Japanese rheumatoid arthritis woman, with HSV uveitis, presented with hemorrhagic hypopyon in the anterior chamber and a fever with photophobia. Patient was treated with antiviral drugs which improved the hyphema and corneal lesions, but lesions recurred 3 months later. This rare presentation of HSV induced uveitis, and its subsequent recurrence, aroused suspicion of an additional hypopyon-inducing pathology. On account of previous history of lung opacities and elevated LDH, intravascular lymphoma was eventually diagnosed via lung biopsy. She was treated for the lymphoma which also completely resolved all ocular symptoms without any recurrence as of 1.5 years later.", "subclaim_evaluations": [ { "subclaim": "The patient is a 62-year-old Japanese woman.", "support_label": "supported" }, { "subclaim": "The patient has rheumatoid arthritis.", "support_label": "supported" }, { "subclaim": "The patient had HSV uveitis.", "support_label": "supported" }, { "subclaim": "The patient presented with hemorrhagic hypopyon in the anterior chamber.", "support_label": "supported" }, { "subclaim": "The patient had a fever.", "support_label": "supported" }, { "subclaim": "The patient had photophobia.", "support_label": "supported" }, { "subclaim": "The patient was treated with antiviral drugs.", "support_label": "supported" }, { "subclaim": "The hyphema improved after treatment with antiviral drugs.", "support_label": "not_supported" }, { "subclaim": "The corneal lesions improved after treatment with antiviral drugs.", "support_label": "supported" }, { "subclaim": "The lesions recurred 3 months later.", "support_label": "supported" }, { "subclaim": "The patient had a history of lung opacities.", "support_label": "supported" }, { "subclaim": "The patient had elevated LDH.", "support_label": "supported" }, { "subclaim": "Intravascular lymphoma was diagnosed via lung biopsy.", "support_label": "supported" }, { "subclaim": "The patient was treated for intravascular lymphoma.", "support_label": "supported" }, { "subclaim": "All ocular symptoms resolved after treatment for lymphoma.", "support_label": "supported" }, { "subclaim": "There was no recurrence of ocular symptoms as of 1.5 years later.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2666_en.txt", "fulltext": "A 35-year-old male presented to their GP for treatment of hot flushes on finasteride (5-alpha reductase inhibitor) for hair loss, which he had recently stopped. The finasteride was stopped because of these side effects and a subsequent baseline prostate-specific antigen (PSA) showed a raised reading of 12.5ng/mL, which prompted referral to a urologist.\nNegative urine culture excluded urinary tract infection, and repeat PSA 6 weeks later demonstrated a rise to 14.6ng/mL. Digital rectal exam revealed a small, benign-feeling prostate which was non-tender. There was no family history of prostate cancer, and the patient did not have any physical or sexual activity prior to the PSA tests.\nMultiparametric MRI found a PIRADS 4 lesion in the anterior zone of the prostate (see ). PSMA PET identified focal and markedly increased tracer uptake in the anterior zone of the prostate concordant with the MRI lesion (see ). The SUVmax on the PSMA PET scan was 23.5, consistent with a site of active tumor. There was no evidence of lymphadenopathy or metastatic disease. Targeted trans-perineal prostate biopsies found Gleason 4+5=9 (Grade Group 5) acinar adenocarcinoma in 8 of 8 biopsy cores involving 80% of the total material sampled. No cribriform architecture was identified but there were features suspicious of extra prostatic extension on the biopsy. Sperm banking was completed and a robotic-assisted radical prostatectomy was performed with a novel RoboSling vascularized continence sling, an aggressive bilateral nerve spare and a bilateral pelvic lymph node dissection, without complication. Pathology demonstrated Gleason 4+5=9 adenocarcinoma with focal cribriform architecture, 0.6mm of extracapsular extension at the apex anteriorly, and clear margins, stage pT3a N0 M0 (see ).\nAt 12-month follow-up, the patient had an undetectable PSA, complete continence with 0 daily pad use, and reported erections rigid enough for penetration with acupuncture and daily Tadalafil (phosphodiesterase-5 inhibitor) for penile rehabilitation. The patient’s father has since been diagnosed with Gleason 6 prostate cancer at the age of 67, screening having been prompted by the patient’s diagnosis. On further history from relatives, his maternal grandmother had a history of breast cancer at age 89. Genetic testing, including BRCA1, BRCA2, PALB2 and TP53, was performed in the context of the high grade disease at a young age and did not identify a heritable cause. Please see for a treatment timeline schematic.", "summary": "A 35-year-old male, intermittently taking finasteride for hair loss, was found to have an elevated prostate-specific antigen (PSA) of 12.5ng/mL leading to an incidental diagnosis of high grade prostate cancer. Targeted trans-perineal prostate biopsy found Gleason 4+5=9 acinar adenocarcinoma, without cribriform architecture but with features suspicious for extracapsular extension. Robotic radical prostatectomy with bilateral pelvic lymph node dissection was performed and found Gleason 4+5=9 adenocarcinoma with focal cribriform architecture, extra prostatic extension and clear margins, stage pT3a N0 M0. PSA was undetectable at 12 months, continence was immediate, and the patient reported strong erections soon after surgery. Family history of prostate cancer and genetic testing were both negative.", "subclaim_evaluations": [ { "subclaim": "The patient is a 35-year-old male.", "support_label": "supported" }, { "subclaim": "The patient was intermittently taking finasteride for hair loss.", "support_label": "not_supported" }, { "subclaim": "The patient had an elevated prostate-specific antigen (PSA) of 12.5ng/mL.", "support_label": "supported" }, { "subclaim": "The elevated PSA led to an incidental diagnosis of high grade prostate cancer.", "support_label": "supported" }, { "subclaim": "Targeted trans-perineal prostate biopsy found Gleason 4+5=9 acinar adenocarcinoma.", "support_label": "supported" }, { "subclaim": "The biopsy showed no cribriform architecture.", "support_label": "supported" }, { "subclaim": "The biopsy showed features suspicious for extracapsular extension.", "support_label": "supported" }, { "subclaim": "Robotic radical prostatectomy with bilateral pelvic lymph node dissection was performed.", "support_label": "supported" }, { "subclaim": "The prostatectomy found Gleason 4+5=9 adenocarcinoma.", "support_label": "supported" }, { "subclaim": "The prostatectomy showed focal cribriform architecture.", "support_label": "supported" }, { "subclaim": "The prostatectomy showed extra prostatic extension.", "support_label": "supported" }, { "subclaim": "The prostatectomy showed clear margins.", "support_label": "supported" }, { "subclaim": "The stage was pT3a N0 M0.", "support_label": "supported" }, { "subclaim": "PSA was undetectable at 12 months.", "support_label": "supported" }, { "subclaim": "The patient achieved immediate continence.", "support_label": "supported" }, { "subclaim": "The patient reported strong erections soon after surgery.", "support_label": "supported" }, { "subclaim": "Family history of prostate cancer was negative.", "support_label": "supported" }, { "subclaim": "Genetic testing was negative.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2033_en.txt", "fulltext": "A 66-year-old female had complained of intermittent discomfort and pain in the right gluteal area. She had also noticed an alteration in bowel habit with recent constipation. The symptoms persisted, and she was treated with analgesia and laxatives.\nHowever, there was no specific diagnosis until she fell onto her back and fractured L2, L3 and L4 vertebrae which necessitated further imaging work-up with CT scan of the thoracolumbar spine. Of note, the fractures were stable and non-displaced. Hence, no need for surgical intervention. The CT scan performed to assess the spine revealed an incidental finding of a large mass extending from the right gluteal region into the pelvis. A CT scan of the pelvis was also performed, and this showed a large fatty intramuscular lesion extending into the pelvis through the greater sciatic notch . The differential diagnosis was listed as a possible lipoma or low-grade liposarcoma. As part of the diagnostic work-up for this right intramuscular gluteal mass with intrapelvic extension, the patient underwent MRI of the abdomen and pelvis. There was no suspicious soft tissue abnormality detected on the MRI of the abdomen but the MRI of the pelvis showed a large homogenous fat lesion noted in the right pelvic side wall between the gluteus maximus and gluteus medius muscles which extended into the pelvis via the greater sciatic foramen . There was no enhancing component. No heterogeneity or thickened or irregular septations were detected. The margins were distinct. The mass measures approximately 18.9 cm × 13 cm × 22.8 cm. The intrapelvic component of the mass measures approximately 10.5 cm × 6.2 cm × 12.1 cm. There was a leftward displacement of the rectum noticed as a result of the mass effect from the central pelvic mass .\nPhysical examination revealed an area of firm induration/possible mass in the lower aspect of the right gluteal compartment. This was not tender and there was no associated redness or discoloration of overlying skin. Digital rectal examination showed normal anal sphincter tone and no mass was palpated within the anorectum.\nThe patient proceeded to have a CT guided core needle biopsy of the mass. This showed scant fragments of fibroadipose and fibroconnective tissue without features of malignancy. There was focal myxoid change. However, the cytologic atypia that would warrant a diagnosis of atypical lipomatous tumor/well differentiated liposarcoma was absent. Furthermore, FISH for MDM2 amplification was attempted, but could not be performed due to sample inadequacy. The case was presented for discussion at the multidisciplinary tumor conference and the consensus recommendation was to proceed with surgical resection of the tumor. Following this, the patient underwent wide excision of the mass through a transgluteal approach and final pathology showed well-differentiated liposarcoma .\nRegarding follow up, the patient has been undergoing surveillance for 3 years. She was seen every 3 months for the first year after resection. Computerized tomographic scans of the chest, abdomen and pelvis were done every 6 months for the first year of surveillance. The patient was seen twice a year for the following 2 years. Computerized tomographic scans of the chest, abdomen and pelvis were done annually for years 2 and 3 of surveillance. The patient has remained disease-free; that is no evidence of local or distant recurrence of the liposarcoma or the sciatic hernia.", "summary": "A 66-year-old female presented with persistent pain in the right gluteal region. Physical examination coupled with CT/MRI scans identified a firm mass extending into the right pelvic side via the sciatic foramen. It measured approximately 18.9 cm × 13 cm × 22.8 cm. The tumor was resected via transgluteal approach. Immunohistochemical and microscopic features were consistent with well-differentiated liposarcoma.", "subclaim_evaluations": [ { "subclaim": "The patient is a 66-year-old female.", "support_label": "supported" }, { "subclaim": "She presented with persistent pain in the right gluteal region.", "support_label": "supported" }, { "subclaim": "A firm mass was identified extending into the right pelvic side via the sciatic foramen.", "support_label": "supported" }, { "subclaim": "The mass measured approximately 18.9 cm × 13 cm × 22.8 cm.", "support_label": "supported" }, { "subclaim": "The tumor was resected via transgluteal approach.", "support_label": "supported" }, { "subclaim": "Immunohistochemical and microscopic features were consistent with well-differentiated liposarcoma.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_69_en.txt", "fulltext": "A 17-year-old neutered male European Shorthair cat was presented owing to an\ninability to jump, weakness and respiratory stridor. All these signs had started a\nfew months previously. The cat was kept strictly indoors, had no history of trauma\nand the owner did not report any other clinical signs or pre-existing disease. The\nphysical examination revealed a plantigrade stance, pelvic limb muscle atrophy that\nwas more severe on the right, broad facial features and inspiratory stridor.\nNeurological examination showed the cat had a reluctance to move, lameness of the\nhindlimbs and paraparesis with plantigradism. Postural reactions and flexor reflexes\nwere reduced in both pelvic limbs. Neurological signs were more severe on the right\npelvic limb. A lesion affecting the sciatic nerves, more severe on the right side,\nwas suspected because the cat was not ataxic, and the other nerves originating from\nL4–S3 spinal cord (femoral nerve, pelvic nerve, pudendal nerve, etc) were apparently\nnot affected. A lesion affecting the nerve roots of the sciatic nerve at the level\nof the cauda equina could not be excluded, but was considered less likely because of\nthe marked asymmetry of the clinical signs and the absence of evidence of\ninvolvement of the pelvic and pudendal nerve and coccigeal nerves. Degenerative\n(lumbosacral stenosis, disc herniation), neoplastic (lymphoma, paraneoplastic\npolyneuropathy) or metabolic (lumbosacral stenosis associated with acromegaly,\ndiabetic polyneuropathy) conditions were included as differential diagnoses.\nRoutine laboratory examination, including a complete blood count, serum biochemistry\nand complete urinalysis, was unremarkable. Serum glucose concentration was\n5.4 mmol/l (reference interval [RI] 4.1–6.4 mmol/l) and serum fructosamine\nconcentration was 211 µmol/l (RI 220–350 µmol/l). Serum total thyroxine\nconcentration was also normal (32 nmol/l; RI 10–60 nmol/l). Serum IGF-1\nconcentration, measured with a validated commercially available chemiluminescence\nassay (Immulite; IDEXX Laboratories), was higher than the assay detection limit (1000 ng/ml). Basal GH\nconcentration was not measured. Abdominal ultrasound evaluation revealed visceral\norgans of normal size (liver, spleen, pancreas, kidneys and adrenal glands). An\nechocardiography was performed, which showed no evidence of cardiac hypertrophy.\nA CT scan of the lumbosacral spine and the head was performed with a single slice\nhelical scanner (Siemens Somatom Emotion). The cat was placed in sternal recumbency\nunder general anaesthesia and a scan of the lumbosacral spine was obtained with a\n2 mm slice thickness. Subsequently, the head was scanned with 1 mm slice thickness,\npre- and post-contrast (Iomeprol with an iodine concentration of 300 mg/ml, dosage\nof 600 mg iodine/kg EV [Iomeron 300; Bracco]). In the precontrast CT examination,\nthe right cranial articular process of S1 was hypertrophic, with severe impingement\non the right L7–S1 foramen . The left L7–S1 foramen was also mildly stenotic due to mild bony\nhypertrophy of the left caudal articular process of L7 . Ventral spondylosis between L6 and\nL7 without involvement of the L6–L7 foramina was also detected. Post-contrast CT\nexamination showed an enlarged pituitary gland (4 mm in height, 4.5 mm in width,\n4 mm in length) with a mild suprasellar extension . Hypertrophic ethmoidal turbinates\nand left fluid-filled tympanic bulla indicating otitis media were other\nfindings.\nIn order to better characterise the peripheral neuropathy, electrodiagnostic tests\nwere performed. Electromyography showed mild spontaneous pathological activity of\nthe appendicular muscles innervated by the right sciatic nerve. Motor nerve\nconduction studies (MNCS) and sensory nerve conduction studies (SNCS) of both\nsciatic tibial nerves and of the right ulnar nerve were within normal limits.\nMinimum F waves latencies and F ratio were severely increased in the right tibial\nnerve. Onset latency of cord dorsum potential obtained by stimulating the tibial\nnerve was increased in both pelvic limbs, and more severely in the right one.\nElectrodiagnostic findings were indicative of a lesion of the proximal portion of\nboth sciatic nerves or their roots, which was more severe on the right side .\nThe final diagnosis was acromegaly and entrapment neuropathy of the sciatic nerve as\na consequence of lumbosacral/foraminal stenosis due to bone hypertrophy. Medical\ntreatment for acromegaly using cabergoline was suggested, but the owner declined it.\nSurgical treatment of the foraminal stenosis was discussed, but a medical approach\nwas preferred owing to the age of the cat. As a result, treatment was aimed to\ncontrol and prevent neuropathic pain (gabapentin 10 mg/kg q12h) and re-checks were\narranged every 3 months to evaluate neurological condition and glycaemic control.\nThe clinical condition slightly improved in the first weeks of treatment. Sixteen\nmonths after the first presentation, the cat was still euglycaemic and neurological\nsigns were stable. Serum IGF-1 concentration was re-evaluated at the time and was\nstill over the detection limit of the assay.", "summary": "A 17-year-old neutered male European Shorthair cat was presented owing to an inability to jump and respiratory stridor. The owner did not report any other clinical signs. On physical examination, the main findings were plantigrade stance, broad facial features and inspiratory stridor. Neurological examination revealed posterior paraparesis, hypotonia and right hindlimb muscle atrophy. Laboratory findings were unremarkable and glycaemia was normal. Serum insulin-like growth factor 1 concentration was elevated (>1000 ng/ml). A total body CT scan showed an enlarged pituitary gland, thickening of the nasal turbinates and an L7-S1 right foraminal stenosis. Electrodiagnostic testing confirmed the presence of a neuropathy affecting both sciatic nerves. The cat was treated with gabapentin only and was still alive and euglycaemic 16 months after the diagnosis.", "subclaim_evaluations": [ { "subclaim": "The cat was a 17-year-old neutered male European Shorthair.", "support_label": "supported" }, { "subclaim": "The cat was presented owing to an inability to jump.", "support_label": "supported" }, { "subclaim": "The cat had respiratory stridor.", "support_label": "supported" }, { "subclaim": "The owner did not report any other clinical signs.", "support_label": "supported" }, { "subclaim": "On physical examination, the cat had a plantigrade stance.", "support_label": "supported" }, { "subclaim": "On physical examination, the cat had broad facial features.", "support_label": "supported" }, { "subclaim": "On physical examination, the cat had inspiratory stridor.", "support_label": "supported" }, { "subclaim": "Neurological examination revealed posterior paraparesis.", "support_label": "supported" }, { "subclaim": "Neurological examination revealed hypotonia.", "support_label": "not_supported" }, { "subclaim": "Neurological examination revealed right hindlimb muscle atrophy.", "support_label": "supported" }, { "subclaim": "Laboratory findings were unremarkable.", "support_label": "supported" }, { "subclaim": "Glycaemia was normal.", "support_label": "supported" }, { "subclaim": "Serum insulin-like growth factor 1 concentration was elevated.", "support_label": "supported" }, { "subclaim": "A total body CT scan showed an enlarged pituitary gland.", "support_label": "supported" }, { "subclaim": "A total body CT scan showed thickening of the nasal turbinates.", "support_label": "supported" }, { "subclaim": "A total body CT scan showed an L7-S1 right foraminal stenosis.", "support_label": "supported" }, { "subclaim": "Electrodiagnostic testing confirmed the presence of a neuropathy affecting both sciatic nerves.", "support_label": "supported" }, { "subclaim": "The cat was treated with gabapentin only.", "support_label": "supported" }, { "subclaim": "The cat was still alive 16 months after the diagnosis.", "support_label": "supported" }, { "subclaim": "The cat was euglycaemic 16 months after the diagnosis.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1405_en.txt", "fulltext": "A 73-year-old Japanese woman with a history of hyperlipidemia, diabetes mellitus, and malignant lymphoma of mucosa-associated lymphoid tissue (MALT) presented to our hospital complaining of headache and nausea for 10 days. MALT lymphoma had been treated with chemotherapy 10 years ago and was in complete remission. The patient had no antithrombotic medications. The patient was fully alert and had no neurological deficits on initial physical examination. Brain computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated subacute subcortical hematoma mainly in the left superior to middle frontal gyrus (43 × 18 × 44 mm) with gadolinium enhancement in the perihematoma area and in the genu of the corpus callosum . Cerebral angiography detected neither vascular abnormalities nor feeder-like arteries of tumors in the left ICA, although it revealed an aneurysm in the contralateral ICA. A string of beads appearance was also detected in the bilateral extracranial ICA . Abdominal three-dimensional CT angiography performed for examination of hematuria 10 years previously also revealed a string of beads sign in the right renal artery. These studies indicate that FMD existed in the background. The abnormal vessels explaining the bleeding source were not disclosed on angiography; thus, we could not diagnose the apparent cause of hemorrhage. Craniotomy biopsy and removal of the hematoma were performed for diagnosis and decompressive treatment 10 days after admission. With a left frontal craniotomy, a xanthochromic capsule was observed on the surface of the hematoma. Although no specific findings were observed in the intraoperative frozen section diagnosis, the final permanent pathology specimen revealed FMD predominantly involving small- to mediumsized arteries distributed in the hemorrhagic necrotic brain tissue and overlying meninx. Many of the affected segments had stenoses with obliterations due to fibroplasia spreading into the intima and recanalization was observed in some of the obliterated vessels . In addition, aneurysmal dilatations were formed in the segments with severe medial lesions [ and ]. Immunostaining revealed that the most of the endothelium of thin-walled blood vessels and capillaries due to aneurysm had only CD31 without CD34 [ and ]. The patient was discharged 27 days after surgery. She was followed up in the outpatient clinic, and we recommend intervention for an aneurysm of the right ICA.", "summary": "A 73-year-old woman suffered from intracerebral hemorrhage (ICH) associated with FMD without abnormal angiography cerebral vessels. She presented with headache and nausea. Subsequent head-computed tomography-revealed ICH in the left frontal lobe, and contrast-enhanced magnetic resonance imaging revealed a gadolinium-enhancing lesion in the perihematoma area and in the genu of the corpus callosum. Although cerebral angiography revealed a string of beads appearance in the bilateral extracranial internal carotid arteries, no abnormality explaining the hemorrhage was identified. The hematoma was removed and the pathological diagnosis was FMD. In the pathological specimen, various patterns of vulnerable vessels, such as aneurysmal dilatation and obstruction, were observed, which could easily collapse and result in hemorrhage. In the case of ICH of unknown origin, microscopic vessel disruption due to FMD should also be considered.", "subclaim_evaluations": [ { "subclaim": "The patient was a 73-year-old woman.", "support_label": "supported" }, { "subclaim": "She suffered from intracerebral hemorrhage.", "support_label": "supported" }, { "subclaim": "The hemorrhage was associated with fibromuscular dysplasia.", "support_label": "supported" }, { "subclaim": "Cerebral angiography was not abnormal.", "support_label": "not_supported" }, { "subclaim": "She presented with headache.", "support_label": "supported" }, { "subclaim": "She presented with nausea.", "support_label": "supported" }, { "subclaim": "Head-computed tomography revealed intracerebral hemorrhage in the left frontal lobe.", "support_label": "supported" }, { "subclaim": "Contrast-enhanced magnetic resonance imaging revealed a gadolinium-enhancing lesion in the perihematoma area.", "support_label": "supported" }, { "subclaim": "Contrast-enhanced magnetic resonance imaging revealed a gadolinium-enhancing lesion in the genu of the corpus callosum.", "support_label": "supported" }, { "subclaim": "Cerebral angiography revealed a string of beads appearance in the bilateral extracranial internal carotid arteries.", "support_label": "supported" }, { "subclaim": "No abnormality explaining the hemorrhage was identified.", "support_label": "supported" }, { "subclaim": "The hematoma was removed.", "support_label": "supported" }, { "subclaim": "The pathological diagnosis was fibromuscular dysplasia.", "support_label": "supported" }, { "subclaim": "The pathological specimen showed various patterns of vulnerable vessels.", "support_label": "supported" }, { "subclaim": "The vulnerable vessels included aneurysmal dilatation.", "support_label": "supported" }, { "subclaim": "The vulnerable vessels included obstruction.", "support_label": "supported" }, { "subclaim": "The vulnerable vessels could easily collapse and result in hemorrhage.", "support_label": "supported" }, { "subclaim": "In the case of intracerebral hemorrhage of unknown origin, microscopic vessel disruption due to fibromuscular dysplasia should also be considered.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1204_en.txt", "fulltext": "A 66 year old woman with floor of mouth squamous cell carcinoma (SCC) presented to our institution after her second relapse. Originally diagnosed in 2006, she had undergone a composite resection with a flap reconstruction and bilateral neck dissections followed by post-surgical adjuvant radiotherapy for stage IVa (T4aN0M0) disease. Immunohistochemistry (IHC) staining for p16 was negative. In May of 2009, a resectable locoregional recurrence was detected and consequently treated with a composite resection utilizing a pectoralis flap reconstruction. In November of 2013, she presented with a second non-resectable locoregional relapse. She received carboplatin and paclitaxel for 4 cycles with a partial response (PR) after 2 cycles. The patient subsequently developed regional progression and was treated with weekly methotrexate and cetuximab and she achieved stable disease (SD) for 6 months. Later, she progressed locally and was enrolled into a trial utilizing single agent pembrolizumab. She had SD for 6 cycles , and then suffered from local progression with a significant increase in the size of her neck mass, with painful ulceration and bleeding. Pembrolizumab was therefore discontinued. At this time restaging studies revealed no evidence of distant metastasis. She required multiple transfusions secondary to tumor hemorrhage and as a result was treated palliatively with radiation therapy to a total dose of 30 Gy directed at the mass. The patient experienced an excellent clinical response. Bleeding had resolved and her pain had greatly improved. A significant radiographic response was also noted on computed tomography (CT) scan, with tumor dimensions decreasing by 60 %, from 7.1 × 7.2 cm pre-radiation, to 5.9 × 3.4 cm, 6 weeks post-radiation.", "summary": "We report a case of locally relapsed non-resectable oral cavity squamous cell carcinoma, with excellent local control after pembrolizumab (MK3475) followed by radiotherapy.", "subclaim_evaluations": [ { "subclaim": "The patient had locally relapsed non-resectable oral cavity squamous cell carcinoma.", "support_label": "supported" }, { "subclaim": "The patient received pembrolizumab (MK3475).", "support_label": "supported" }, { "subclaim": "The patient received radiotherapy.", "support_label": "supported" }, { "subclaim": "The patient had excellent local control after treatment.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2229_en.txt", "fulltext": "A 44 year old Caucasian male was referred by his primary care physician for a recurrent asymptomatic left sided massive pleural effusion. The pleural effusion was first discovered on a chest X-ray obtained to follow-up his left 8th, 9th and 10th rib fractures from an accidental fall. The effusion was recurrent over one and a half month even after drainage with thoracentesis and chest tube placement . The initial chest X-ray immediately after his fall that revealed the acute fractures did not show any pleural effusion or blunting of costophrenic angles . The patient had no significant past medical history, denied recent travel, but admitted to smoking tobacco and consuming alcohol. The patient worked, as a maintenance man, but at the time of presentation was unemployed.\nAt presentation the patient had normal vital signs with an oxygen saturation of 93% on room air. Physical examination revealed an average built man in no apparent distress, non-labored breathing, central trachea, absent breath sounds with a stony dull percussion note on the left hemi thorax. Abdomen was soft and non tender with a palpable liver 10 cm below the costal margin. Laboratory investigation revealed mild anemia, hypoalbuminemia (3.1 gm/dL), normal BUN, creatinine, electrolytes and urine analysis. Arterial blood gas (ABG) analysis showed pH 7.48, PaCO2 34 mm Hg, PaO2 63 mm Hg, HCO3 25 mEq/L, oxygen saturation 93% on room air. Pleural fluid study showed lactate dehydrogenase (LDH) 112 U/L, pH 7.80, WBC 76, Polymorphs 40%, Eosinophil 1%, glucose 139 mg/dL, albumin 0.90 gm/dL, RBC 1300/mm3, amylase 169 U/L, pleural fluid – serum LDH ratio was 0.48. Pleural fluid gram stain, cultures (aerobic, anaerobic, AFB, fungal) and cytology were all negative. Computerized tomography of chest showed the massive left-sided unilateral pleural effusion with complete collapse of the left upper and lower lobes, but no pulmonary embolism or malignancy. . Echocardiogram was normal. Ultrasound of abdomen was remarkable for fatty liver, but no ascites. Magnetic resonance cholangio-pancreatography (MRCP) showed normal pancreas and biliary system without ascites. Tuberculin skin test, ANA, ANCA, AMA, ceruloplasmin, TSH, HIV, RPR, and Hepatitis virus serology were normal. Due to frequent massive re-accumulation a diagnostic and therapeutic video assisted thoracoscopy (VATS) procedure was performed, which revealed a 2 cm diaphragmatic hernia with inflamed, friable, incarcerated omentum and small amount of bowel. This inflamed omentum was determined to be the etiology for the recurrent pleural effusion. About 3.5 liters of pleural fluid was removed by VATS. Histopathology was consistent with moderately inflamed omentum. Hernia was repaired and talc-pleurodesis was performed. There was no re-accumulation on follow-up over 2 years .", "summary": "A 44 year old male presented with recurrent pleural effusions over six weeks. His pleural effusion was first diagnosed incidentally on a chest X-ray after a fall. Extensive diagnostic studies were unyielding for the etiology of the effusion. A diagnostic and therapeutic video assisted thoracoscopy revealed a diaphragmatic hernia with inflamed, incarcerated omentum. After hernia repair there was no recurrence.", "subclaim_evaluations": [ { "subclaim": "The patient is a 44 year old male.", "support_label": "supported" }, { "subclaim": "The patient had recurrent pleural effusions over six weeks.", "support_label": "supported" }, { "subclaim": "The pleural effusion was first diagnosed incidentally on a chest X-ray.", "support_label": "supported" }, { "subclaim": "The chest X-ray was performed after a fall.", "support_label": "supported" }, { "subclaim": "Extensive diagnostic studies were unyielding for the etiology of the effusion.", "support_label": "not_supported" }, { "subclaim": "A diagnostic and therapeutic video assisted thoracoscopy was performed.", "support_label": "supported" }, { "subclaim": "The thoracoscopy revealed a diaphragmatic hernia.", "support_label": "supported" }, { "subclaim": "The hernia involved inflamed, incarcerated omentum.", "support_label": "supported" }, { "subclaim": "After hernia repair, there was no recurrence.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3091_en.txt", "fulltext": "A 67-year-old lady was admitted with confusion, right sided weakness and right arm shaking.\n\nComorbidities included a duodenal ulcer, diabetes mellitus and hypertension, but importantly no prior personal or family history of neurological disorders or cerebrovascular events. Medications included Metformin, Ramipril and Lansoprazole.\n\nShe was also suffering from a non-healing ulcer on her left 5th toe. Bone fragments grew Enterococcus and Proteus. Skin swabs grew Staphylococcus Aureus. Osteomyelitis of the 4th and 5th metatarsals was suspected. As co-existing cellulitis not responded to co-amoxiclav, the patient was switched to Linezolid 600 mg twice daily was commenced for four weeks. Full Blood Count after 3 weeks of treatment with Linezolid showed Hb 104 g/L, WCC 6.1 ×10 9/L, platelets 119 ×10 9/L and MCV 85 fL. Her platelet count was last checked three years prior and was within normal range at 245 ×10 9/L. She finished her full five-week course of linezolid to which her osteomyelitis responded well.\n\nTwo days after the last dose of Linezolid she noticed right arm shaking and weakness.\n\nAdmission blood pressure was 189/63. Her Glasgow Coma Scale (GCS) was 14/15 (E3, V5, M6). She had mild global weakness and was unable to finger count. However, she had power of 4/4 in all limbs, normal tone and plantar responses were flexor. There was evidence of right sided neglect.\n\nCT head was unremarkable. Her haemoglobin (Hb) was 69 g/L, but white cell count (WCC) and platelets were within normal limits. On admission, aspirin was given while a MRI Head was requested to investigate the considered differentials, including progressive multifocal leukoencephalopathy, Posterior Reversible Encephalopathy Syndrome, and encephalitis.\n\nShe developed a progressive decline in consciousness in the next 24 h. MRI Head revealed bilateral alteration of signal seen within the deep white matter of the posterior frontal and parietal lobes. These areas showed some mild diffusion restriction. The altered signal extended into the midbrain on the left side and there was also some involvement of the cortex in the right parietal lobe. Normal flow was seen in the basilar artery. Differential diagnoses of bilateral ischaemia, and progressive multifocal leukoencephalopathy were suggested. Posterior reversible encephalopathy syndrome was less likely due to the restricted diffusion. In the following 36 h, Hb had improved to 88 g/L, WCC remained at 5.0 × 10 9/L but Platelets had dropped to 1 × 10 9/L. Twelve hours later, her Hb was 78 g/L and platelets remained at 2 × 10 9/L. The blood film showed a few left shifted neutrophils but with a lack of red cell fragments. During this period, the CRP rose from 22 mg/L to 132 mg/L. Reticulocyte count was 146. Bilirubin was normal. Direct antiglobulin test was negative. Lactate dehydrogenase sample unfortunately haemolysed. A Heparin-induced Thrombocytopenia Antibody assay was not done as the patient was not on anticoagulants on admission and had not been prior to admission.\n\nBone marrow biopsy or a therapeutic intravenous infusion of immunoglobulin was not indicated so instead she was transferred to a tertiary centre for urgent plasma exchange due to the strong suspicion of TTP. This suspicion was suggested by neurological symptoms, anaemia, unexplained thrombocytopenia. Her PLASMIC score was 6 (high-risk; however, please note that the INR component missing).\n\nCerebrospinal fluid analysis showed negative viral polymerase chain reaction testing, white cell count 12, red cell count 14, no organisms seen on microscopy, protein 0.53, and cytology acellular.\n\nElectroencephalogram suggested an encephalopathic pattern with anterior sub-cortical slowing present. ADAMTS13 was normal and vWF cleaving protease was 106. Reticulocyte count was 3.98% and Fibrinogen 2.12 g/L. CT Thorax, Abdomen and Pelvis showed no abnormality.\n\nA diagnosis of Linezolid induced Leukoencephalopathy was made.\n\nShe was discharged 8 weeks following presentation; making a complete recovery by 4 months.\n\nMRI Head repeated at 9 months showed gradually reducing signal intensity in abnormal areas described earlier consistent with leukoencephalopathy. In addition her platelet count improved to 219 × 10 9/L upon discharge.", "summary": "A 67-year-old lady was admitted with, right sided weakness and right arm shaking. She had recently completed a course of Linezolid for a diabetic foot infection and osteomyelitis. Prior to this she had prodromal symptoms including lethargy and loss of appetite. Clinical features prompting presentation included global weakness, verbal dysfluency and visual disturbance. MRI brain showed bilateral alteration of signal in the deep white matter of the posterior frontal and parietal lobes, sparing the superficial cortical areas. These areas showed diffusion restriction, suggestive of, but not limited to, ischaemic stroke. During admission she had a decline in consciousness and was hypertensive. An acute drop in haemoglobin and platelets occurred prompting consideration of Thrombotic Microangiopathy and other drug related/malignant/infective aetiologies. A diagnosis of Linezolid induced Acute Toxic Leukoencephalopathy and thrombocytopenia was made based on clinico-radiographic features and exclusion of other causes.", "subclaim_evaluations": [ { "subclaim": "The patient is a 67-year-old lady.", "support_label": "supported" }, { "subclaim": "She had right-sided weakness.", "support_label": "supported" }, { "subclaim": "She had right arm shaking.", "support_label": "supported" }, { "subclaim": "She had recently completed a course of Linezolid.", "support_label": "supported" }, { "subclaim": "The Linezolid was for a diabetic foot infection.", "support_label": "supported" }, { "subclaim": "The Linezolid was for osteomyelitis.", "support_label": "supported" }, { "subclaim": "She had prodromal symptoms including lethargy.", "support_label": "not_supported" }, { "subclaim": "She had prodromal symptoms including loss of appetite.", "support_label": "not_supported" }, { "subclaim": "Clinical features included global weakness.", "support_label": "supported" }, { "subclaim": "Clinical features included verbal dysfluency.", "support_label": "not_supported" }, { "subclaim": "Clinical features included visual disturbance.", "support_label": "not_supported" }, { "subclaim": "MRI brain showed bilateral alteration of signal in the deep white matter.", "support_label": "supported" }, { "subclaim": "The MRI showed involvement of the posterior frontal lobes.", "support_label": "supported" }, { "subclaim": "The MRI showed involvement of the parietal lobes.", "support_label": "supported" }, { "subclaim": "The MRI showed sparing of the superficial cortical areas.", "support_label": "not_supported" }, { "subclaim": "The MRI showed diffusion restriction.", "support_label": "supported" }, { "subclaim": "The diffusion restriction was suggestive of ischaemic stroke.", "support_label": "supported" }, { "subclaim": "The diffusion restriction was not limited to ischaemic stroke.", "support_label": "supported" }, { "subclaim": "She had a decline in consciousness.", "support_label": "supported" }, { "subclaim": "She was hypertensive.", "support_label": "supported" }, { "subclaim": "There was an acute drop in haemoglobin.", "support_label": "supported" }, { "subclaim": "There was an acute drop in platelets.", "support_label": "supported" }, { "subclaim": "Thrombotic Microangiopathy was considered.", "support_label": "supported" }, { "subclaim": "Drug-related causes were considered.", "support_label": "supported" }, { "subclaim": "Malignant causes were considered.", "support_label": "not_supported" }, { "subclaim": "Infective causes were considered.", "support_label": "supported" }, { "subclaim": "A diagnosis of Linezolid-induced Acute Toxic Leukoencephalopathy was made.", "support_label": "supported" }, { "subclaim": "A diagnosis of thrombocytopenia was made.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on clinico-radiographic features.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on exclusion of other causes.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_946_en.txt", "fulltext": "A 38-year-old female underwent a medical check-up at our institution. The patient’s medical profile had no history of weight loss, anorexia, or weakness. She had had a splenectomy 20 years prior for traumatic splenic rupture. Laboratory tests, including complete blood count, liver function test, and alpha-fetoprotein levels, were within the normal range. An abdominal CT scan without contrast enhancement revealed the absence of a normal spleen, with a homogeneous mass situated at the site (A and B). The mass exhibited heterogenous enhancement in the arterial phase (C), but homogeneous enhancement in the venous phase (D). The mass was suspected to have originated from the pancreas tail (A and C). There was no fat stranding surrounding the mass . Coronal CT image revealed that this mass compressed the left renal (A). The mass was fed by several branches of the splenic artery (B). An abdominal MRI was performed. This confirmed that the mass was located in the normal site of spleen and compressed the left kidney (A) and that the mass was round, with well-defined borders and without fat stranding. The mass presented as hyperintense compared to liver parenchyma on T2-weighted image (B). T1-weighted images showed that the mass was hypointense compared with liver parenchyma and did not lose signal on T1 out-of-phase images . Part of the mass was suspected to be connected to the pancreas tail (A and C). T1-weighted image in the arterial phase revealed that the mass enhanced markedly and inhomogeneously (A). The normal left adrenal gland was observed clearly (B). The mass exhibited homogeneous enhancement in the venous phase (C). It was clear that the mass showed restricted diffusion, since it was hyperintense on diffusion-weighted image (DWI) and had hypointense apparent diffusion coefficient (ADC) values on an ADC map compared to liver parenchyma . The preoperative diagnosis was a tumor of the pancreas tail. The patient underwent an operation to remove the mass by a general surgeon with 10-year experience. Histopathology showed white and red pulps, as well as connective tissue that presented within the mass as trabeculae that carry the arteries and veins (A). The white pulps included periarterial lymphatic sheath, lymphatic follicles, and the marginal zone (B). It was surrounded by a capsule composed of dense fibrous tissue (C). The lymphatic follicles contained benign lymphocytes (D). Histopathology of the mass revealed the appearance of a spleen parenchyma. The final diagnosis was an enlargement of AS after splenectomy. This patient was discharged from the hospital 4 days after surgery without further complications or treatment. The patient was lost to follow-up later. This case was reported in line with the SCARE 2020 criteria .", "summary": "Herein, we report the case of a 38-year-old female with an enlargement of AS after splenectomy that was misdiagnosed as a primary tumor of the pancreas and managed by a nonessential surgery.", "subclaim_evaluations": [ { "subclaim": "The patient was a 38-year-old female.", "support_label": "supported" }, { "subclaim": "The patient had an enlargement of the accessory spleen (AS).", "support_label": "supported" }, { "subclaim": "The enlargement occurred after a splenectomy.", "support_label": "supported" }, { "subclaim": "The enlargement was misdiagnosed as a primary tumor of the pancreas.", "support_label": "supported" }, { "subclaim": "The patient underwent a nonessential surgery.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2883_en.txt", "fulltext": "An 83-year-old woman with permanent AF, undergoing treatment with direct oral anticoagulant therapy (rivaroxaban 15 mg once daily), was referred to our hospital due to fatigue and worsening dyspnoea. Upon admission, the patient was afebrile (36°C), and exhibited a blood pressure of 125/78 mmHg, a pulse rate of 96 beats per minute, and an oxygen saturation of 92% on room air. Cardiac auscultation revealed a 2–3/6 systolic murmur at the lower sternal border and at the apex of the heart, radiating to the left axilla. Laboratory tests revealed severe microcytic anaemia, with a haemoglobin level of 4.9 g/dL (normal range: 13.8–18.0 g/dL). No signs of haemolytic anaemia were identified. The patient presented a CHA2DS2-VASc risk score of 4 and a HAS-BLED score of 4. Previous medical history was characterized by degenerative mitral valve disease complicated by severe mitral regurgitation. In 2016, patient underwent mitral valve repair with ring annuloplasty, tricuspid annuloplasty, and surgical LAA ligation. Her past medical history was also remarkable for arterial hypertension, dyslipidaemia, chronic anaemia, and previous erosive gastritis. Endoscopic examinations revealed gastric polyps, colonic diverticulosis, and enlarged haemorrhoids, with no evidence of recent or ongoing haemorrhage. The search for Helicobacter pylori yielded negative results. Transthoracic echocardiography showed normal left and right ventricular systolic function, residual mild to moderate mitral regurgitation, and severe tricuspid regurgitation. Transoesophageal echocardiography (TEE) ruled out intracardiac thrombi but revealed incomplete surgical LAA occlusion with a narrow neck of 5 mm in conventional 2D images and 13 × 6 mm using multiplanar reconstruction of acquired 3D datasets (, , , , and ).\nThe patient was transfused with six units packed red blood cells, with clinical improvement. Rivaroxaban was discontinued. Based on both the high bleeding risk and the results of the echocardiography study, the Heart Team members indicated percutaneous transcatheter LAAC to best manage the patient. Pre-procedural imaging with cardiac computed tomography (CCT) scanning was performed, showing a bilobed LAA with dehiscence of the ostium and a neck of 13 × 8 mm (, , ). The LAA presented an elliptic landing zone with a major axis of 22 mm and a depth of 17 mm .\nThe procedure of LAAC was carried out with the patient under general anaesthesia. Adequate anticoagulation with heparin was maintained throughout the procedure (activated clotting time [ACT] 250–300 s). The intra-procedural combined angiographic and echocardiographic evaluation demonstrated a maximum LAA diameter ranging from 20–22 mm ( and ): thus, an Amplatzer Amulet 28 mm was considered to be the best choice. The device was delivered with good LAA sealing by the body of the prosthesis (see , and ), without peri-device leak. A slight protrusion of the external disc in the left atrium was observed without impeding of the mitral valve leaflets excursion (, , ). No pericardial effusion was detected, and the patient was discharged on single antiplatelet therapy (clopidogrel), remaining clinically stable on post-operative Day 2. One month post-procedure, the patient was asymptomatic with a haemoglobin level of 11.2 g/dL, and no complications were recorded. Transoesophageal echocardiography examination confirmed the device’s position without signs of thrombosis. After three months, the stability of the haemoglobin level and the absence of device thrombosis allowed the discontinuation of antithrombotic therapy . One year after hospital discharge, the patient did not experience adverse clinical events. Transthoracic echocardiography confirmed the stable position of the device.", "summary": "A 83-year-old woman, with permanent AF and a history of previous surgical LAA ligation, was referred to our hospital for fatigue and worsening dyspnoea. Laboratory tests showed severe microcytic anaemia, with a haemoglobin level of 4.9 g/dL (normal reference: 13.8-18.0 g/dL). Oesophagogastroduodenoscopy and colonoscopy excluded signs of either recent or ongoing haemorrhage. After achieving clinical improvement by haemotransfusions, we performed a transoesophageal echocardiography that showed an ISLL with a narrow neck of 5 mm. Since the patient had high thrombo-embolic and haemorrhagic risk (CHA2DS2-VASc risk score of 4 and a HAS-BLED score of 4), we decided to discontinue anticoagulant therapy and perform elective percutaneous transcatheter LAA occlusion (LAAO) with an Amplatzer Amulet device. Patient was discharged in good clinical status. After three months, the stability of haemoglobin level and the absence of device thrombosis allowed the discontinuation of antithrombotic therapy.", "subclaim_evaluations": [ { "subclaim": "The patient is an 83-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient has permanent atrial fibrillation.", "support_label": "supported" }, { "subclaim": "The patient has a history of previous surgical left atrial appendage ligation.", "support_label": "supported" }, { "subclaim": "The patient was referred for fatigue and worsening dyspnoea.", "support_label": "supported" }, { "subclaim": "Laboratory tests showed a haemoglobin level of 4.9 g/dL.", "support_label": "supported" }, { "subclaim": "Oesophagogastroduodenoscopy excluded signs of recent or ongoing haemorrhage.", "support_label": "supported" }, { "subclaim": "Colonoscopy excluded signs of recent or ongoing haemorrhage.", "support_label": "supported" }, { "subclaim": "Transoesophageal echocardiography showed an intracardiac shunt with a narrow neck of 5 mm.", "support_label": "not_supported" }, { "subclaim": "The patient had a CHA2DS2-VASc risk score of 4.", "support_label": "supported" }, { "subclaim": "The patient had a HAS-BLED score of 4.", "support_label": "supported" }, { "subclaim": "Anticoagulant therapy was discontinued.", "support_label": "supported" }, { "subclaim": "Elective percutaneous transcatheter left atrial appendage occlusion was performed.", "support_label": "supported" }, { "subclaim": "An Amplatzer Amulet device was used for the procedure.", "support_label": "supported" }, { "subclaim": "The patient was discharged in good clinical status.", "support_label": "supported" }, { "subclaim": "After three months, the haemoglobin level was stable.", "support_label": "supported" }, { "subclaim": "After three months, there was no device thrombosis.", "support_label": "supported" }, { "subclaim": "Antithrombotic therapy was discontinued after three months.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3130_en.txt", "fulltext": "A 63-old man presented to our Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto, complaining of low visual acuity in both eyes and ocular discomfort for about two years.\n\nHis ophthalmic history was unremarkable. His uncorrected distance visual acuity (UDVA) measured with Snellen charts was 20/100 in the right eye (RE) and 20/200 in the left eye (LE), while his best corrected visual acuity (BCVA) was 20/50 in the RE and 20/100 in the LE. A history of amblyopia in his left eye was reported.\n\nSlit-lamp examination revealed a horizontal gray-whitish band across the central cornea in both eyes, sparing the peripheral cornea and the limbus. No other pathological findings were observed.\n\nHe was diagnosed with CBK secondary to occupational exposure to mercury vapors, since he was a worker of steel industry.\n\nFundus examination was not possible. The anterior segment OCT (AS-OCT) showed a thickness corneal opacity of 150 um in both eyes.\n\nThis study adhered to the Declaration of Helsinki and was approved by the Ethics Committee of the Ophthalmology Unit of “SS. Annunziata” Hospital Review Board. The patient provided informed consent for all procedures and their possible complications were explained. The patient gave informed consent for the publication of any case details and accompanying images. The IRB of the Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto gave the approval for the publication of this case report.\n\nThe tomographic maps (Precisio2®, iVIS Technologies, Taranto, Italy) showed in both eyes an irregular corneal morphology due to the presence of the opacity.\n\nOur first attempt was performing EDTA chelation procedure which removed the superficial calcium plaques. Two months after the procedure, the UDVA had improved to 20/80 in RE and to 20/100 in the LE, but the cornea was not completely clear, with residual stromal haze. The EDTA chelation procedure had no effect on the deeper calcium deposits and the tomographic maps showed irregular corneal surface. For this reason, a combined treatment with PRK and PTK was scheduled in both eyes in order to recover visual acuity and minimize surgical invasiveness.The customized treatment was determined by taking into account the following parameters: spherical error, some biometric data including anterior chamber depth, axial length; corneal morphological irregularity index (CMI) measured by tomographer (Precisio2®, iVIS Technologies, Taranto, Italy); pupillometry (pMetrics®, iVIS Technologies, Taranto, Italy).\n\nCMI, measured in μm, is a parameter which indicates the aberrations above the second order of the anterior and posterior corneal surface. It is strongly correlated to the quality of vision of the patient: the more the CMI, the worse the quality of vision.\n\nThe customized ablation is achieved using a ray tracing-based software. Ray tracing is based on the Snell law of refraction and allows the evaluation of the pathway of light rays after their passage through the eye from the anterior corneal surface to the retina. In this way, it is possible to know the exact refractive contribution of each surface and fully customize excimer laser ablation. This is achieved by not performing a full regularization of the anterior corneal surface; instead, a small amount of aberration on the anterior corneal surface is left to compensate for the posterior surface aberrations which are of opposite sign. In fact, the posterior corneal shape introduces posterior corneal morphological irregularities, which partially compensate for the anterior ones.\n\nIn this way, the ray tracing algorithm optimizes the quality of vision and at the same time minimizes the consumption of stromal tissue.\n\nWe decided to perform the surgery first on the right eye and then after 20 days on the left eye. The surgery was performed using topical anesthesia (oxybuprocaine eye drops, Benoxinato Cloridrato, Alfa Intes S.r.l). We decided to use a no-touch approach in order to have less postoperative pain and faster re-epithelialization. The surgery was executed with the iRes™ excimer laser, working with flying-spot of 650µm at 1000Hz (iVis Technologies S.r.l).\n\nThe customized ablation profile obtained had a refractive zone of 5.60 mm in RE and 5.50 mm in LE, and a connecting zone of 8.90 mm in RE and 9.60 mm in LE. The cumulative ablation stromal depth was 34 μm in both eyes.\n\nFollowing surface ablation, PTK with a frequency of 10% was carried out with masking agents (1% hydroxymethylcellulose) to smooth the ablated surface, with a depth of 80 μm.\n\nTo avoid any kind of corneal haze, 0.02% Mitomycin C (MMC, 0.2 mg/mL, diluted in BSS®) was applied over the ablated area for 20 seconds. At the end of the procedure, a soft therapeutic contact lens was placed. The therapeutical postoperative regimen consisted in topical dexamethasone and amikacin eye drops given four times a day for a week. The patient was then put on 0.1% fluorometholone eye drops and artificial tears eye drops for 12 weeks, which were tapered gradually. The patient was examined the day following surgery, and additional follow-up visits were carried out at one week, two weeks, one, three, and six months, respectively.\n\nAt the 1-week follow-up visit the contact lens was removed, with a complete epithelial healing. On slit lamp examination the clarity of the ablated area was notably improved.\n\nAS-OCT scans and topography were performed at 1 week, 1, 3 and 6 months after treatment.\n\nAt the 1-month follow-up the final uncorrected visual acuity (UCVA) improved from 20/200 to 20/20 in right eye and to 20/63 in the left eye.\n\nCMI decreased from 15 μm to 3 μm in RE and from 21 μm to 11 μm in LE, and minimum corneal thickness was reduced from 567 μm to 533 μm in RE, and from 574 μm to 540 μm in LE.\n\nThe improved visual acuity was maintained at 3-month follow-up and 6-month follow-up, with the patient fully satisfied. The corneal clarity remained during the 6 months follow-up.\n\nThe postoperative follow-up was uneventful. The ablation map and topographic changes of both eyes were reported.", "summary": "A 63-year-old man presented to our clinic with decreased visual acuity and ocular discomfort in both eyes. Clinical examination revealed a horizontal gray-whitish band across the central cornea in both eyes, supporting the diagnosis of CBK. Initially, an EDTA chelating procedure was attempted, but it had no effect on the deeper calcium deposits and on the irregular corneal morphology. In both eyes, a topography-guided trans-epithelial PRK with PTK was performed. Following PRK surface ablation, PTK was used to smooth the ablated area using 1% hydroxymethylcellulose as masking agent. The procedure was completed applying 0.02% Mitomycin C. At the 1-month follow-up, both eyes corneal opacities were resolved, and the LE visual acuity had improved to 20/63 and the RE to 20/20, which was maintained at the 3-, 6-, and 12-months follow-up. Furthermore, there was an improvement in spherical equivalent and corneal morphological irregularity index.", "subclaim_evaluations": [ { "subclaim": "The patient is a 63-year-old man.", "support_label": "supported" }, { "subclaim": "He presented with decreased visual acuity.", "support_label": "supported" }, { "subclaim": "He had ocular discomfort in both eyes.", "support_label": "supported" }, { "subclaim": "Clinical examination revealed a horizontal gray-whitish band across the central cornea in both eyes.", "support_label": "supported" }, { "subclaim": "The diagnosis was corneal band keratopathy (CBK).", "support_label": "supported" }, { "subclaim": "An EDTA chelating procedure was attempted.", "support_label": "supported" }, { "subclaim": "The EDTA chelating procedure had no effect on the deeper calcium deposits.", "support_label": "supported" }, { "subclaim": "A topography-guided trans-epithelial PRK with PTK was performed in both eyes.", "support_label": "supported" }, { "subclaim": "Following PRK surface ablation, PTK was used to smooth the ablated area.", "support_label": "supported" }, { "subclaim": "1% hydroxymethylcellulose was used as a masking agent during PTK.", "support_label": "supported" }, { "subclaim": "0.02% Mitomycin C was applied at the end of the procedure.", "support_label": "supported" }, { "subclaim": "At the 1-month follow-up, corneal opacities were resolved in both eyes.", "support_label": "not_supported" }, { "subclaim": "Left eye visual acuity improved to 20/63 at 1 month.", "support_label": "supported" }, { "subclaim": "Right eye visual acuity improved to 20/20 at 1 month.", "support_label": "supported" }, { "subclaim": "Visual acuity was maintained at 3 months.", "support_label": "supported" }, { "subclaim": "Visual acuity was maintained at 6 months.", "support_label": "supported" }, { "subclaim": "Visual acuity was maintained at 12 months.", "support_label": "not_supported" }, { "subclaim": "There was an improvement in spherical equivalent.", "support_label": "not_supported" }, { "subclaim": "There was an improvement in corneal morphological irregularity index.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_263_en.txt", "fulltext": "A 64-year-old woman was admitted to the hematology department of our hospital in August 2019 with pancytopenia complicated by headache.\nThe patient had recurrent pancytopenia for half a year. The symptom of headache had lasted for 4 d.\nThe patient presented with a 3-mo history of lumbar pain and was finally diagnosed with solitary bone plasmacytoma a year ago. She had received only radiotherapy, at a dose of 45 Gy, 22 times. She was first admitted to the hospital in February 2019 due to persistent pancytopenia. The initial complete blood count (CBC) showed a hemoglobin (HB) level of 96 g/L, white blood cell count (WBC) of 2.5 × 109/L, and platelet (PLT) count of 38 × 109/L. Immunofixation electrophoresis showed that the M component was an IgG-kappa light chain. On bone marrow (BM) aspiration, 0.13% of monoclonal plasma cells were observed by flow cytometry (FCM). Biopsy revealed hypoplastic marrow without megakaryocytes. No bone lesion other than primary local lumbar injury was observed in a series of X-ray scans. The patient was diagnosed with SBP with minimal marrow involvement, according to the diagnostic criteria for plasma cell dyscrasia, with concomitant myelosuppression. She underwent treatment with thalidomide, granulocyte colony stimulating factor (G-CSF), and thrombopoietin (TPO), blood transfusion, and other supportive treatments. Peripheral blood was significantly improved after 3 mo of treatment and almost restored to normal.\nOn admission, the patient was lucid and slurred in speech. The skin mucous membrane of the whole body had scattered haemorrhage spots. Limb activity was normal, and nervous system examination showed no abnormality.\nThe CBC revealed pancytopenia (HB 70 g/L, WBC 3.0 × 109/L, and PLT 38 × 109/L). A peripheral blood smear showed 16% of abnormal promyelocytes with dendritic protrusions . Thrombin function test showed that prothrombin and partial thromboplastin times were prolonged, fibrinogen was decreased, and the D-dimers were elevated to 4.5 μg/mL. BM examination was conducted, followed by cytogenetic and molecular analyses using BM specimens. The BM aspirate showed 90% of abnormal promyelocytes with densely packed large granules , which on flow cytometric immunophenotyping expressed CD13, CD33, CD117, CD56, CD81, and myeloperoxidase; partially expressed CD38 and CD34; and slightly expressed CD15, CD11b, and CD16 HLA-DR . Chromosome analysis using a BM sample revealed a karyotype of 46,XX,t(15;17)(q22;q21) in 20 metaphase cells examined . Reverse transcription-PCR (RT-PCR) analyses confirmed the presence of S-form PML/RARα gene rearrangement. The FLT3-ITD gene mutation was detected by Sanger sequencing . Plasma cells were not detected. A monoclonal peak was continuously observed on serum IFE, showing IgG and kappa-type monoclonal gammopathy.\nThe patient was married and had two daughters and one son. No additional family history was obtained.", "summary": "We describe a 64-year-old woman who presented with lumbar pain and was initially diagnosed with SBP. However, after one year of radiotherapy treatment, this patient experienced a long-standing bone-marrow-suppressive period and finally developed APL harboring the FLT3-ITD mutation, as confirmed by analyses of clinical features, bone marrow morphology, flow cytometry, cytogenetic examination, and molecular biology. On admission, the patient had disseminated intravascular coagulation and intracranial hemorrhage, and the peripheral blood and bone marrow smear displayed abundant abnormal promyelocytes. Unfortunately, she died when the definite diagnosis was made.", "subclaim_evaluations": [ { "subclaim": "The patient was a 64-year-old woman.", "support_label": "supported" }, { "subclaim": "She presented with lumbar pain.", "support_label": "supported" }, { "subclaim": "She was initially diagnosed with SBP.", "support_label": "supported" }, { "subclaim": "After one year of radiotherapy treatment, she experienced a long-standing bone-marrow-suppressive period.", "support_label": "supported" }, { "subclaim": "She developed APL harboring the FLT3-ITD mutation.", "support_label": "supported" }, { "subclaim": "The diagnosis of APL was confirmed by analyses of clinical features.", "support_label": "supported" }, { "subclaim": "The diagnosis of APL was confirmed by bone marrow morphology.", "support_label": "supported" }, { "subclaim": "The diagnosis of APL was confirmed by flow cytometry.", "support_label": "supported" }, { "subclaim": "The diagnosis of APL was confirmed by cytogenetic examination.", "support_label": "supported" }, { "subclaim": "The diagnosis of APL was confirmed by molecular biology.", "support_label": "supported" }, { "subclaim": "On admission, the patient had disseminated intravascular coagulation.", "support_label": "supported" }, { "subclaim": "On admission, the patient had intracranial hemorrhage.", "support_label": "not_supported" }, { "subclaim": "The peripheral blood smear displayed abundant abnormal promyelocytes.", "support_label": "supported" }, { "subclaim": "The bone marrow smear displayed abundant abnormal promyelocytes.", "support_label": "supported" }, { "subclaim": "The patient died when the definite diagnosis was made.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2563_en.txt", "fulltext": "A 54-year-old woman presented at our hospital with left flank discomfort and palpebral edema of 1-week duration. She underwent abdominal postcontrast computed tomography (CT) in a local hospital, which showed a low-density renal pelvic mass and hydronephrosis of the left kidney and indicated renal pelvic cancer (Figure ). Her past medical history included sicca complex for 5 years previously. In her laboratory examination, a routine urine test revealed a red blood cell count of 118.4/μl (normal reference range, 0 to 25/μl), a white blood cell count of 127.3/μl (normal reference range, 0 to 25/μl) and an epithelial cell count of 13.4/μl (normal reference range, 2 to 10/μl). No remarkable findings in the complete blood count or urine cytology were observed. A retrograde pyelogram showed a dilated left renal pelvis and stricture of the upper ureter, which had a regular surface and a filling defect (Figure ). On postcontrast magnetic resonance imaging (MRI) scans, the wall of the ureteropelvic junction was irregularly thickened and showed isointensity on T1-weighted images and hypointensity on T2-weighted images. On both T1- and T2-weighted images, the thickened wall of ureteropelvic junction showed homogeneous enhancement. Furthermore, multiple enlarged retroperitoneal lymph nodes were visualized by MRI (Figure ). Positron emission tomography/CT findings indicated that the renal pelvic mass was a malignant tumor, because the glucose metabolism was very high (Figure ). PET/CT also revealed multiple enlarged hypermetabolic lymph nodes in the supraclavicular, retroperitoneal, peritoneal and pelvic regions. All of these findings together led us to consider a possible diagnosis of a renal pelvic malignant tumor with multiple lymph nodes metastasis.\nA few days later the patient underwent a left-sided nephroureteral cystectomy and retroperitoneal lymph node dissection, in which part of the bladder was removed. The surgery was performed to establish a definitive diagnosis and for treatment if the mass was malignant.\nGross examination of the kidney showed a 5 × 2.5–cm, pale, whitish-tan, ill-defined mass located in the renal pelvis near the renal hilum. Histologic examination of the mass showed lymphatic tissue hyperplasia and diffuse infiltration of plasma cells. The plasma cells were IgG- and IgG4-positive. The IgG4/IgG ratio was approximately 40% (Figure ). Two retroperitoneal lymph nodes were dissected, which represented as reactive hyperplasia. The pathological findings did not reveal malignancy.\nAfter the diagnosis of IgG4-RD was made, a further laboratory examination was performed. The patient’s serum IgG4 level was 18.6 g/L (normal reference range, 0.03 to 2 g/L), and her high-sensitivity C-reactive protein test result was 26.3 mg/L (normal reference range, 0 to 3 mg/L). The patient underwent steroid therapy in a local hospital for 1 year. At the fourth month of her steroid therapy, her high-sensitivity C-reactive protein level had descended to 8.76 mg/L (normal reference range, 0 to 8 mg/L). Her enlarged lymph nodes in the supraclavicular, retroperitoneal, peritoneal and pelvic regions diminished with the steroid therapy.", "summary": "A 54-year-old woman visited our hospital with left flank discomfort and palpebral edema. Computed tomography, magnetic resonance imaging, retrograde pyelography and positron emission tomography/computed tomography indicated renal pelvic cancer. However, after a left-sided nephroureteral cystectomy was performed, the mass was pathologically confirmed as an IgG4-related lesion. Her elevated serum IgG4 level and a past history of sicca complex supported the diagnosis of IgG4-RD.", "subclaim_evaluations": [ { "subclaim": "The patient is a 54-year-old woman.", "support_label": "supported" }, { "subclaim": "She had left flank discomfort.", "support_label": "supported" }, { "subclaim": "She had palpebral edema.", "support_label": "supported" }, { "subclaim": "Computed tomography was performed.", "support_label": "supported" }, { "subclaim": "Magnetic resonance imaging was performed.", "support_label": "supported" }, { "subclaim": "Retrograde pyelography was performed.", "support_label": "supported" }, { "subclaim": "Positron emission tomography/computed tomography was performed.", "support_label": "supported" }, { "subclaim": "The imaging studies indicated renal pelvic cancer.", "support_label": "supported" }, { "subclaim": "A left-sided nephroureteral cystectomy was performed.", "support_label": "supported" }, { "subclaim": "The mass was pathologically confirmed as an IgG4-related lesion.", "support_label": "supported" }, { "subclaim": "Her serum IgG4 level was elevated.", "support_label": "supported" }, { "subclaim": "She had a past history of sicca complex.", "support_label": "supported" }, { "subclaim": "The diagnosis was IgG4-related disease.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2562_en.txt", "fulltext": "A 19-year-old Japanese woman presented with a left temporal headache. Magnetic resonance imaging (MRI) of the brain revealed a well-defined, heterogeneously enhanced tumor in the left temporal lobe, approximately 10 mm in size, showing high-intensity on T2-weighted images . The patient underwent a left frontal-temporal craniotomy and total resection. These tumor cells had less than 1 mitosis per 10 high-power fields. The primary histopathological diagnosis at that time was low-grade glioma. The patient was discharged after treatment and followed up without any additional treatment. No clear local recurrence was detected during 3 years of follow-up and the patient subsequently elected to stop further medical examinations.\nHowever, 12 years after the initial treatment, the patient returned with a left temporal headache, diplopia and tinnitus. MRI showed a local recurrence of the tumor around the surgical cavity with prominent perifocal edema and a second resection was performed. Intraoperatively, the tumor was prominently hypervascular, with many feeding arteries from the dura, and a part of the tumor was weakly positive for 5-aminolevuinic acid-based photodynamic diagnosis (PDD). Hematoxylin and eosin (H&E) staining showed an astrocytic tumor lesion with necrosis, microvascular proliferation, invasion and multiple mitoses (5 mitotic counts per 10 high-power fields). No EGBs were observed. . Immunohistochemical (IHC) stains were positive for oligo2, and tumor cells were retained for INI1 and ATRX staining. Approximately 21% of these cells were positive for Ki-67 but negative for IDH1-R132H. Furthermore, the specimen from the initial surgery was revisited and the diagnosis was changed to PXA of WHO grade II based on histology showing spindle shaped cells, pleomorphic nucleated cells and EGBs . Reticulin fibers were not stained and CD34 staining was negative in both tumor resections . As recurrence happened after the PXA resection, APXA was expected due to poorer histological findings; however, the tumor had no characteristic feature of PXA such as EGB, leading to a diagnosis as GBM by histological classification because of nuclear atypia, mitotic activity, a diffuse growth pattern, microvascular proliferation and necrosis . The patient received chemotherapy (temozolomide) and conformal radiation therapy accordingly and outpatient follow-ups have detected no obvious symptoms for over 1 year after surgery.\nAdditionally, specimens of each resection were sent to the National Cancer Center Research Institute and MLPA (Multiplex Ligation-dependent Probe Amplification) was performed for 1p, 19q, CDKN2A, IDH1 R132H (c.395G > A), R132C (c.394C > T), IDH2 R172K (c.515G > A), R172M (c.515G > T) and Pyrosequence for IHD1 R132, IDH2 R172, BRAF V600E, H3F3A K27, H3F3A G34, HIST1H3B, TERT C228T, FGFR1 N546, and FGFR1 K656. The analysis detected a BRAF V600E mutation in both the initial and recurrent tumors, with mutant allele findings at 16 and 49%, respectively. Both 1p/19q and CDKN2A were intact in the initial specimen, but a 19q deletion and CDKN2A homozygous deletion were detected in the recurrent specimen. IDH1/IDH2, H3F3A, HIST1H3B, TERT, and FGFR1 were intact in both specimens. From this analysis the tumor was assumed to have been derived from pleomorphic xanthoastrocytoma.", "summary": "Here we describe an unusual case of PXA in a 19-year-old woman, first admitted with headache and a mass in the left temporal lobe in 2005 that was removed. Twelve years later, she returned with left temporal headache, diplopia and tinnitus. A local tumor recurrence was found, and a second resection was performed. The specimen showed highly malignant findings, such as necrosis, microvascular proliferation, and multiple mitoses. The integrated diagnosis was made as high grade glioma, probably derived from PXA. Immunohistochemical (IHC) stains were positive for oligo2, and approximately 21% positive for Ki-67, while negative for CD34, IDH1 R132H. INI1 and ATRX were retained. As the histological classification was glioblastoma, the patient received GBM-appropriate chemotherapy and radiation therapy and outpatient follow-ups have demonstrated no obvious symptoms for 1 year after surgery. Additional molecular analyses found BRAF V600E mutations in both resections, supporting the idea that the recurrent tumor had derived from PXA.", "subclaim_evaluations": [ { "subclaim": "The patient is a 19-year-old woman.", "support_label": "supported" }, { "subclaim": "She was first admitted in 2005.", "support_label": "not_supported" }, { "subclaim": "She had a mass in the left temporal lobe.", "support_label": "supported" }, { "subclaim": "The mass was removed.", "support_label": "supported" }, { "subclaim": "The mass was diagnosed as PXA.", "support_label": "supported" }, { "subclaim": "Twelve years later, she returned with left temporal headache.", "support_label": "supported" }, { "subclaim": "She had diplopia.", "support_label": "supported" }, { "subclaim": "She had tinnitus.", "support_label": "supported" }, { "subclaim": "A local tumor recurrence was found.", "support_label": "supported" }, { "subclaim": "A second resection was performed.", "support_label": "supported" }, { "subclaim": "The specimen showed necrosis.", "support_label": "supported" }, { "subclaim": "The specimen showed microvascular proliferation.", "support_label": "supported" }, { "subclaim": "The specimen showed multiple mitoses.", "support_label": "supported" }, { "subclaim": "The integrated diagnosis was high grade glioma.", "support_label": "supported" }, { "subclaim": "The diagnosis was probably derived from PXA.", "support_label": "supported" }, { "subclaim": "Immunohistochemical stains were positive for oligo2.", "support_label": "supported" }, { "subclaim": "Immunohistochemical stains were approximately 21% positive for Ki-67.", "support_label": "supported" }, { "subclaim": "Immunohistochemical stains were negative for CD34.", "support_label": "supported" }, { "subclaim": "Immunohistochemical stains were negative for IDH1 R132H.", "support_label": "supported" }, { "subclaim": "INI1 was retained.", "support_label": "supported" }, { "subclaim": "ATRX was retained.", "support_label": "supported" }, { "subclaim": "The histological classification was glioblastoma.", "support_label": "supported" }, { "subclaim": "The patient received GBM-appropriate chemotherapy.", "support_label": "supported" }, { "subclaim": "The patient received radiation therapy.", "support_label": "supported" }, { "subclaim": "Outpatient follow-ups showed no obvious symptoms for 1 year after surgery.", "support_label": "supported" }, { "subclaim": "BRAF V600E mutations were found in both resections.", "support_label": "supported" }, { "subclaim": "The BRAF V600E mutations support the idea that the recurrent tumor derived from PXA.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_444_en.txt", "fulltext": "Fifteen years ago, this now 40-year-old female had undergone a L5S1 discectomy . Ten months before this admission, due to complaints of low back pain and left leg numbness, she had undergone a lumbar; MR; it documented significant cauda equina compression at the L4-L5 level due to a large central disc herniation and marked stenosis/OYL (i.e., isointense on T2-weighted sequences) [ and ]. She now acutely presented to an emergency room with the sudden onset (i.e., over several hours) of 4/5 weakness in both lower extremities, bilateral leg numbness, and urinary retention.\nThe new magnetic resonance imaging (MRI) and CT both demonstrated worsening of her L4-L5 cauda equina compression due the large central disc herniation and severe stenosis/OYL; the CT further confirmed ossification of the OYL [-].\nNotably, the patient should have undergone emergent surgery following the completion of the MR/CT studies. However, surgery was delayed for 9 h by which time she was fully paraplegic (0/5 motor function, L4-S1 loss of sensation, and urinary retention (JOA 2/29).\nFollowing a L4-L5 laminectomy for stenosis, OYL, and a partial central discectomy (i.e., not completely removed because of its central location), the patient never fully recovered; she had just 1/5 motor function bilaterally (i.e., residual loss perineal sensation and urinary incontinence – final JOA score 9/29) 1 month later. Of interest, the postoperative MR and CT studies, despite showing mild residual ventral disc, confirmed adequate cauda equina decompression [-].", "summary": "A 40-year-old female developed an acute cauda equina syndrome (CES) attributed to an acute lumbar disc herniation and to marked canal stenosis due to OYL. As the patient underwent a 9 h delayed removal of the ossified ligament and discectomy, she sustained only minimal recovery.", "subclaim_evaluations": [ { "subclaim": "The patient is a 40-year-old female.", "support_label": "supported" }, { "subclaim": "The patient developed an acute cauda equina syndrome.", "support_label": "supported" }, { "subclaim": "The acute cauda equina syndrome was attributed to an acute lumbar disc herniation.", "support_label": "supported" }, { "subclaim": "The acute cauda equina syndrome was attributed to marked canal stenosis due to ossification of the yellow ligament.", "support_label": "supported" }, { "subclaim": "The patient underwent removal of the ossified ligament.", "support_label": "supported" }, { "subclaim": "The patient underwent discectomy.", "support_label": "supported" }, { "subclaim": "The surgery was delayed by 9 hours.", "support_label": "supported" }, { "subclaim": "The patient sustained only minimal recovery.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_556_en.txt", "fulltext": "A 27-year-old male presented to the emergency department (ED) with a right-sided nasal mass and associated progressively worsening lower right eyelid swelling over the course of several months. Medical history was insignificant. His social history was significant for a two pack-year smoking history with additional cocaine and marijuana use. Before his initial presentation, the patient had visited the ED multiple times for symptoms of intermittent epistaxis, sinus congestion, midface pressure, throbbing headaches, and ocular discharge. He had been treated with antibiotics and steroids without improvement. Due to periorbital inflammation, concern for increased intraocular pressure and decreased visual acuity at this ED encounter, the patient underwent a lateral canthotomy and cantholysis by ophthalmology, after which the patients’ eye symptoms improved quickly.\nContrast-enhanced computed tomography (CT) at that time showed a 4.0 × 2.2 cm mass in the right nasal cavity, deviation of the nasal septum to the left, erosion of most of the ethmoidal air cells, and possible extension through the cribriform plate. There was near total opacification of the right frontal sinus, maxillary sinus, and ethmoid air cells with right preseptal soft-tissue edema . Given the patient’s gender, age, and imaging evidence at the time, there was a high suspicion for juvenile nasopharyngeal angiofibroma (JNA). The patient was admitted and elective interventional radiology (IR) embolization was scheduled. During his admission, the patient became febrile. Subsequently, embolization of the mass/maxillary artery was cancelled to avoid seeding of intravascular coils with bacteria, as the patient’s fever was felt to be secondary to bacteremia. Furthermore, the patient exhibited a declining serum sodium concentration from 133 mMol/L to 118 mMol/L, and syndrome of inappropriate antidiuretic hormone secretion (SIADH) was suspected. He received salt tablets and several doses of demeclocycline with subsequent improvement.\nFor the treatment of the presumed JNA, otolaryngology performed a right medial maxillectomy, right nasal endoscopy with debridement, total ethmoidectomy, and removal of the intranasal mass. The patient recovered appropriately and was discharged on postoperative day 2. Unexpectedly, the pathology from the right maxilla revealed a high grade malignant neoplasm, most consistent immunophenotypically and histologically with high grade “mixed” ONB and carcinoma . The tumor was comprised nests of poorly differentiated cells with hyperchromatic nuclei, coarse chromatin, and minimal cytoplasm that was continuous with areas of typical neuroblastoma including neuropil formation. Foci of both squamous differentiation and nonenteric glandular differentiation were also noted. Lymphovascular and bone invasion were present. Immunohistochemical staining of the tumor showed positivity for the following markers, which differed slightly depending on the area of tumor that was stained: synaptophysin, CD56, chromogranin (rare/focal), S100 peripherally, Pan CK, CAM 5.2, CK7, p16, p63, CK 5/6, and p40 [, ]. After recognizing the nasal cavity mass as a malignancy, the tumor was staged as T4aN0Mx.\nDuring postoperative follow-up, the patient reported improved right periorbital swelling and erythema, decreased serosanguinous drainage from right nares. No purulent nasal drainage was noted and he remained afebrile. Based on the results of pending magnetic resonance imaging (MRI) and positron emission tomography scans, the patient is expected to undergo further resection of residual tumor versus chemotherapy and radiation.", "summary": "An otherwise healthy 27-year-old male presented with sinus complaints, headache, and unilateral eye discharge. Imaging and endoscopy revealed a mass presumed to represent a juvenile nasopharyngeal angiofibroma. Unexpectedly, the final pathology report revealed high grade mixed ONB and carcinoma. This tumor is the sixth and youngest documented patient with mixed ONB and carcinoma.", "subclaim_evaluations": [ { "subclaim": "The patient is a 27-year-old male.", "support_label": "supported" }, { "subclaim": "The patient is otherwise healthy.", "support_label": "supported" }, { "subclaim": "The patient presented with sinus complaints.", "support_label": "supported" }, { "subclaim": "The patient presented with headache.", "support_label": "supported" }, { "subclaim": "The patient had unilateral eye discharge.", "support_label": "supported" }, { "subclaim": "Imaging and endoscopy revealed a mass.", "support_label": "supported" }, { "subclaim": "The mass was presumed to represent a juvenile nasopharyngeal angiofibroma.", "support_label": "supported" }, { "subclaim": "The final pathology report revealed high grade mixed ONB and carcinoma.", "support_label": "supported" }, { "subclaim": "This tumor is the sixth documented case of mixed ONB and carcinoma.", "support_label": "not_supported" }, { "subclaim": "This patient is the youngest documented case of mixed ONB and carcinoma.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_3353_en.txt", "fulltext": "Patient details and presentation\nA male Japanese patient in their 30s developed epilepsy in 2017, initially attributed to behavioral anomalies during sleep. Focal epilepsy was diagnosed and controlled with levetiracetam 1500 mg and clonazepam 1 mg until 2019. However, in 2021, the patient began experiencing focal impaired awareness seizures. Owing to the occurrence of seizures approximately once per month, the patient was referred to the epilepsy department of our hospital. These seizures involved loss of consciousness following “déjà vu” sensations. At the time of referral, the patient was on four antiepileptic drugs: levetiracetam, 1500 mg; lacosamide, 300 mg; perampanel, 2 mg; and clonazepam, 1 mg. Despite using multiple antiepileptic drugs with different mechanisms of action, seizure suppression remained suboptimal, leading to the decision to implement a surgical approach.\n\n\nSummary of progress\n\nPreoperative course\t\n2017: onset of seizure symptoms with behavioral abnormalities during sleep\n\n2018: start of LEV\n\n2019: seizures suppressed by adding CZP\n\n2021: the patient was referred to our hospital because his seizures were not controlled despite the addition of CZP, LCM, and PER\n\nTest results\t\nElectroencephalography: spiny waves were observed in the bilateral antero-medial temporal regions\n\nIt was difficult to identify the starting point from EEG findings during seizure\n\nHead MRI: no obvious abnormal findings. No hippocampal sclerosis or atrophy\n\nFDG-PET: hypoglycemia in the left anterolateral temporal region\n\nSurgery\t\nIntracranial electrode implantation: subdural electrodes were implanted in the lateral and medial left temporal lobe, and in the frontal lobe. Intracranial electrodes were placed in the lateral and medial left temporal lobe, and frontal lobe.\n\nIntracranial EEG during seizure showed repeated spikes in the temporal pole followed by propagation to the lateral temporal lobe\n\nFocal resection: resection of the left lateral temporal lobe, including the temporal pole, was performed. Intraoperative hippocampal wave recordings showed a low frequency of spikes, so the hippocampus was preserved\n\nPost-surgery\tFour months postoperatively, FAS recurred. One year after surgery, FIAS disappeared\n\n\nGlu-CEST MRI\nPre-surgery MRI was performed using a UHF (7 Tesla) MRI system (MR950; GE Healthcare, Chicago, IL, USA) with a 32-channel head coil (Nova Medical, Houston, TX, USA) at the Center for Integrated Brain Function Research, Niigata University Brain Research Institute. T1-weighted three-dimensional magnetization-prepared rapid acquisition gradient echo scans were acquired with the following parameters: field of view = 220 × 220 mm2, matrix = 220 × 220, repetition time/echo time = 4.1/1.4 ms, flip angle = 4°, and slice thickness = 1 mm.\n\nOn the basis of the three-dimensional T1 data, the CEST image slice was determined. CEST images were corrected for the B0 field distribution using water saturation acquisition [14]. To correct for B1 inhomogeneity, we followed the method of Cember et al. which leverages classification based on T1 values and a measured effective B1 irradiation pulse intensity distribution map to enhance CEST imaging [15]. A single-slice CEST image sequence based on fast spin echo was then acquired with the following parameters: field of view = 220 × 220 mm2, matrix = 128 × 128, repetition time/echo time = 10,000/5.8 ms, flip angle = 70°, and slice thickness = 4 mm. CEST imaging was conducted using a pulsed CEST preparation of eight sinc pulses of 100 ms each with a 10 ms interpulse delay (total saturation time of 800 ms) and a root mean square (RMS) amplitude of 3.0 μT. A total of 31 frequencies were acquired, each spaced by 100 Hz, ranging from −1500 to +1500 Hz.\n\nB0 and B1 corrected CEST images were used to calculate the Glu-CEST MRI using the following equation:, where S (−3.0 ppm) denotes the signal intensity after the saturation pulse with an offset of −3.0 ppm from the water peak, and S (+3.0 ppm) represents the signal intensity after the saturation pulse with an offset of +3.0 ppm from the water peak. Glutamate exhibits a CEST effect at approximately +3.0 ppm downfield from the bulk water resonance.\n\n\nObservations\nThe patient exhibited no obvious paralysis, sensory disturbances, or other abnormal neurological findings. In addition, there was no history of cerebrovascular or cardiovascular disease that could have contributed to loss of consciousness.\n\nInterictal EEG revealed sharp waves localized at F7 and F8, although seizure recordings failed to demonstrate a distinct onset pattern. MRI revealed no evident abnormalities, while magnetoencephalography identified a cluster of dipoles within the left insular cortex. Fluorodeoxyglucose-positron emission tomography (FDG-PET) indicated reduced glucose metabolism in the left temporal pole. Neuropsychological testing showed normal intellectual and memory functions.\n\nAll tests were performed without administering sedatives or other medications. FDG-PET was performed after the patient fasted for at least 6 hours. These tests were performed 1 year before surgery.\n\nOn the basis of the findings, epileptogenic regions were suspected within the left frontal and temporal lobes. However, the precise focus could not be determined, making it difficult to differentiate between medial and lateral lobe epilepsy. Consequently, intracranial subdural electrodes were implanted in the lateral and basal regions of the left frontal lobe, the lateral aspect of the left temporal lobe, and the medial temporal lobe. Interictal intracranial EEG revealed discrete spikes from the basal left temporal lobe, anterior to the left parahippocampal gyrus, and from the lateral aspect of the left temporal lobe. During three recorded intracranial EEG seizures, a pronounced spike was identified in electrodes located between the distal portion of the left temporal lobe and the parahippocampal gyrus, followed by propagation to the lateral temporal cortex (Fig. 1A). Subsequently, anterior temporal lobectomy was performed, encompassing the distal tip of the left temporal lobe, the basal region, and the middle and inferior temporal gyri (Fig. 1D and E). Intraoperative EEG recordings from the surface of the amygdala and hippocampus revealed no discernible spikes from the amygdala, with sporadic low-frequency spikes detected in the posterior aspect of the hippocampus. Therefore, the language-dominant hippocampus and amygdala were preserved to prevent postoperative verbal memory loss.\n\n\nPostoperative MRI indicated no obvious neurological deficits. Focal aware seizures (FAS) recurred 4 months postoperatively; however, no focal impaired awareness seizures were observed 1 year postoperatively. During evaluation 1 year after surgery, the patient was classified as Engel Class Ib. There were no postoperative neurological abnormalities, and psychological tests showed no deterioration.\n\nGlu-CEST MRI was performed the day before intracranial EEG electrode placement. It delineated an elevation in glutamate concentration extending from the left temporal pole to the medial temporal lobe. Subsequently, a 1 × 8 strip electrode was positioned in the corresponding area, revealing a prominent spike in EEG activity at seizure onset from the electrode proximate to the region with heightened Glu concentration. The region exhibiting increased Glu concentration, as identified by Glu-CEST MRI, was encompassed within the resection area (Fig. 1D and E). Histopathological examination of the resected tissue revealed focal cortical dysplasia type IIa (FCD type IIa).\n\nFCD type IIa causes drug-resistant epilepsy and is characterized by histopathologic findings of dysmorphic neurons and absence of balloon cells. Complete resection of the focal area is expected to suppress seizures; however, MRI often shows no abnormalities. The resected area was associated with abnormal EEG activity during seizures and an elevated Glu concentration as detected by Glu-CEST MRI.\n\nIn addition, Glu-CEST MRI revealed an increased Glu concentration within the hippocampal head, albeit at a lower magnitude than that in the left temporal pole (Fig. 1C and F). The highest Glu concentrations were observed in the tip of the temporal lobe, followed by the head of the hippocampus.\n\nThe Glu-CEST results suggested that the residual seizures were caused by the preserved hippocampal head and may be useful for considering additional surgical treatment in the future.", "summary": "A male Japanese patient in his 30s with drug-resistant focal epilepsy underwent preoperative assessment at our institute. Preoperative magnetic resonance imaging was performed using an ultra-high-field magnetic resonance imaging system. The results of intracranial electroencephalography and chemical exchange saturation transfer imaging were compared. Head magnetic resonance imaging revealed no abnormalities. However, fluorodeoxyglucose-positron emission tomography revealed reduced glucose metabolism in the distal left temporal lobe. Preoperative fluorodeoxyglucose-positron emission tomography and intracranial electroencephalography indicated abnormal interictal waves and identified the seizure onset site. Ablation was performed from the distal to the basal region of the temporal lobe. Pathological examination revealed focal cortical dysplasia type IIa. Chemical exchange saturation transfer imaging delineated an elevated glutamate concentration extending from the distal tip of the left temporal lobe to the medial temporal lobe. These regions included the areas of seizure onset identified by intracranial electroencephalography and matched the extent of the resection surgery. Four months postoperatively, focal aware seizures recurred; however, no focal impaired awareness seizures were observed at 1 year postoperatively. Elevated glutamate levels were detected in the hippocampus head, suspected to be associated with residual focal aware seizures.", "subclaim_evaluations": [ { "subclaim": "The patient is a male Japanese individual in his 30s.", "support_label": "supported" }, { "subclaim": "The patient has drug-resistant focal epilepsy.", "support_label": "supported" }, { "subclaim": "The patient underwent preoperative assessment at the institute.", "support_label": "supported" }, { "subclaim": "Preoperative magnetic resonance imaging was performed using an ultra-high-field magnetic resonance imaging system.", "support_label": "supported" }, { "subclaim": "Head magnetic resonance imaging revealed no abnormalities.", "support_label": "supported" }, { "subclaim": "Fluorodeoxyglucose-positron emission tomography revealed reduced glucose metabolism in the distal left temporal lobe.", "support_label": "supported" }, { "subclaim": "Preoperative fluorodeoxyglucose-positron emission tomography indicated abnormal interictal waves.", "support_label": "not_supported" }, { "subclaim": "Ablation was performed from the distal to the basal region of the temporal lobe.", "support_label": "supported" }, { "subclaim": "Pathological examination revealed focal cortical dysplasia type IIa.", "support_label": "supported" }, { "subclaim": "Chemical exchange saturation transfer imaging delineated an elevated glutamate concentration extending from the distal tip of the left temporal lobe to the medial temporal lobe.", "support_label": "supported" }, { "subclaim": "These regions included the areas of seizure onset identified by intracranial electroencephalography.", "support_label": "supported" }, { "subclaim": "These regions matched the extent of the resection surgery.", "support_label": "supported" }, { "subclaim": "Four months postoperatively, focal aware seizures recurred.", "support_label": "supported" }, { "subclaim": "No focal impaired awareness seizures were observed at 1 year postoperatively.", "support_label": "supported" }, { "subclaim": "Elevated glutamate levels were detected in the hippocampus head.", "support_label": "supported" }, { "subclaim": "Elevated glutamate levels were suspected to be associated with residual focal aware seizures.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2694_en.txt", "fulltext": "A 74-year-old woman, who presented with complaints of repeated upper abdominal pain for 3 days, was admitted to our hospital. She had no relevant past medical history. Abdominal ultrasonography and computed tomography (CT) scan at another hospital revealed a tumor in the pancreatic uncinate process; thus, she was referred to our hospital for a comprehensive examination.\nThe results of the laboratory tests were found to be almost normal (the italicized text indicates the test results with abnormal values): white blood cell 9130/μl, total bilirubin 1.0 mg/dl, aspartate aminotransferase 16 U/l, alanine aminotransferase 9 U/l, hemoglobin A1c 6.0%, amylase 76 U/l, C-reactive protein < 0.02 mg/dl, Ca 10.3 mg/dl, soluble interleukin-2 receptor 271.0 U/ml, IgG4 31.5 mg/dl, and antinuclear antibody 160 index. The levels of tumor markers were also normal: carcinoembryonic antigen 3.0 ng/mL, carbohydrate antigen 19-9 11.0 U/ml, DUPAN-2 < 25 U/ml, span-1 8.9 U/ml, and elastase-1 85 ng/dl.\nAn abdominal contrast-enhanced dynamic CT scan showed a 60-mm-diameter tumor in the pancreatic uncinate process, accompanied by multiple cysts , and the tumor size tended to increase over time. The gastroduodenal artery was noted to be passing through within the tumor. The pancreatic duct was not enlarged and separated from the tumor. The tumor had a poor contrast effect in the arterial phase and a small contrast effect in the equilibrium phase.\nThe gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (MRI) showed a lobulated tumor with mixed high and low signals on T2-weighted imaging . Out-of-phase T1-weighted imaging showed a low-intensity area, which was a fat component. This finding suggested that the tumor was unlikely to be a malignant tumor. However, diffusion-weighted images revealed a high signal lobulated tumor and suggested potential for malignancy . Magnetic resonance cholangiopancreatography revealed a soft tissue tumor close to the pancreatic uncinate process, and it was not continuous with the main pancreatic duct.\nAn upper gastrointestinal examination revealed that the gastric angle was pushed to the dorsal side of the stomach by the tumor. Endoscopic ultrasonography (EUS) showed a collective cystic lesion on the ventral side of the pancreatic uncinate process . The main pancreatic duct was negative for intraductal papillary mucinous neoplasm. In addition, given that the tumor was accompanied by a cystic lesion, a fine-needle aspiration was not performed.\nIn the positron emission tomography CT scan, there was no significant fluoro-deoxy-glucose accumulation in the soft tissues of the pancreatic uncinate process.\nThe tumor in the pancreatic uncinate process was thought to be the possible cause of the upper abdominal pain. Based on the abovementioned findings, we considered that the tumor was a benign vascular malformation, but because the tumor size tended to increase over time, there was a possibility of it being a malignant tumor; thus, we planned on performing a pancreatoduodenectomy (PD).\nAfter a detailed examination, we performed an elective open laparotomy. During the operation, intraoperative findings revealed that the tumor appeared to be benign and was separate from the pancreatic duct or bile duct. We therefore performed a partial pancreatectomy instead of PD. Since the right gastroduodenal artery and small vein penetrated the tumor, they were ligated and detached. The tumor was excised with a small part of the pancreatic uncinate process, and the mesentery of the transverse colon was also removed. The operation time was 200 min with 75 ml blood loss. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 12.\nMacroscopically, the tumor was a 58 × 46 × 30-mm specimen with a spongioid appearance of the cut surface . Histologically, hematoxylin and eosin staining showed a mixed shape of small veins, small arteries, and capillaries . The pancreatic tissue was recognized within the tumor, suggesting that the tumor originated from the pancreas. There was no lesion with suspected malignancy. We performed immunostaining for CD31, CD34, Factor VIII, and D2-40, which revealed the following in general: CD31 was positive for vascular endothelium and histiocyte; CD34 and Factor VIII were positive for vascular endothelium; and D2-40 was positive for lymphatic endothelium. In the Elastica van Gieson staining, most vessels of the tumor had no muscular layer. These vessels were capillary blood vessels (CD31, CD34, and Factor VIII were positive, and D2-40 was negative) and lymphatic vessels (CD31 and D2-40 were positive; CD34 and Factor VIII were negative). Based on both histological appearance and immunostaining findings, we diagnosed the tumor as a capillary lymphatic malformation (CLM) according to the International Society for the Study of Vascular Anomalies (ISSVA) classification.", "summary": "A 74-year-old woman, who presented with complaints of repeated upper abdominal pain, was admitted to our institution. Contrast-enhanced dynamic computed tomography (CT) scan revealed that the tumor in the pancreatic uncinate process had a poor contrast effect in the arterial phase and a small contrast effect in the equilibrium phase, which are suggestive of a benign disease-like vascular malformation. However, we suspected that it could possibly be a malignant tumor because the tumor size tended to increase over time; thus, we decided to perform a surgery. We resected the tumor through a partial resection of the pancreas. Macroscopically, the cut surface of the tumor had a spongioid appearance. Histopathological examination findings showed a mixed shape of small capillaries and lymphatic ducts. The patient was diagnosed with CLM according to the International Society for the Study of Vascular Anomalies (ISSVA) classification, based on the histological appearance and immunostaining findings. The postoperative course of the patient was uneventful.", "subclaim_evaluations": [ { "subclaim": "The patient is a 74-year-old woman.", "support_label": "supported" }, { "subclaim": "She presented with repeated upper abdominal pain.", "support_label": "supported" }, { "subclaim": "A contrast-enhanced dynamic CT scan was performed.", "support_label": "supported" }, { "subclaim": "The tumor was located in the pancreatic uncinate process.", "support_label": "supported" }, { "subclaim": "The tumor had a poor contrast effect in the arterial phase.", "support_label": "supported" }, { "subclaim": "The tumor had a small contrast effect in the equilibrium phase.", "support_label": "supported" }, { "subclaim": "The imaging findings were suggestive of a benign disease-like vascular malformation.", "support_label": "supported" }, { "subclaim": "The tumor size tended to increase over time.", "support_label": "supported" }, { "subclaim": "A partial resection of the pancreas was performed.", "support_label": "supported" }, { "subclaim": "The cut surface of the tumor had a spongioid appearance.", "support_label": "supported" }, { "subclaim": "Histopathological examination showed a mixed shape of small capillaries and lymphatic ducts.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with CLM.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on the ISSVA classification.", "support_label": "supported" }, { "subclaim": "The postoperative course was uneventful.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1718_en.txt", "fulltext": "A 12-day-old female neonate with a cleft lip and alveolus was referred from the Department of Plastic Surgery for the feeding management and presurgical molding of the cleft lip and alveolus. The patient's parents reported difficulty in feeding and escapement of fluid through the nose. Detailed paternal and maternal family history was traced till the second generation but no significant finding was observed. There was no history of maternal infection or trauma during the conception period till birth.\nExtraoral examinations revealed a bilateral cleft of the upper lip with a complete cleft of the right alveolus ( to ). Radiographic examination was done using radiovisography, and a significant cleft was observed on the right paramedian area . Diagnosis of Veau's classification type III cleft of lip and alveolus was arrived. After discussion with the plastic surgeon, PNAM was planned using the Grayson method with a palatal plate accompanied by an approximation of extraoral soft tissue with taping and nasal stent. The surgical phase was planned at 4 months.", "summary": "A 12-day-old neonate born with a bilateral cleft of lip and alveolus was referred from the Department of Plastic Surgery. PNAM was planned in consultation with the plastic surgeon. A customized nasoalveolar molding plate was fabricated, and tissue molding was carried out. Following nasoalveolar molding, primary surgical repair was done.", "subclaim_evaluations": [ { "subclaim": "The patient is a 12-day-old neonate.", "support_label": "supported" }, { "subclaim": "The neonate was born with a bilateral cleft of lip.", "support_label": "supported" }, { "subclaim": "The neonate was born with a bilateral cleft of the alveolus.", "support_label": "not_supported" }, { "subclaim": "The neonate was referred from the Department of Plastic Surgery.", "support_label": "supported" }, { "subclaim": "PNAM was planned.", "support_label": "supported" }, { "subclaim": "PNAM was planned in consultation with the plastic surgeon.", "support_label": "supported" }, { "subclaim": "A customized nasoalveolar molding plate was fabricated.", "support_label": "supported" }, { "subclaim": "Tissue molding was carried out.", "support_label": "supported" }, { "subclaim": "Following nasoalveolar molding, primary surgical repair was done.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_3294_en.txt", "fulltext": "A 20-year-old man with psychomotor delay and a history of epilepsy was admitted to the emergency department of the State University Hospital in Haiti for abdominal distension, rigidity, generalized pain, absence of bowel movements and gas, and a history of vomiting. He had a history of falling on a sharp object that pierced his perineum 6 days prior, with the onset of symptoms 3 days later. Vital signs on admission were blood pressure 104/58 mmHg, heart rate 138 beats/min, respiratory rate 20 breaths/min, temperature 36.2 degrees Celsius, and oxygen saturation 98 % on room air. Initial physical examination revealed rebound tenderness, decreased bowel sounds, and diffuse pain. Rectal examination showed a clean anal margin, tonically competent anal sphincter, and a rectal ampulla filled with stool. He had a functional impairment of grade B according to the Fränkel classification, with a lesion level at L2/L3. The initial diagnosis on admission was peritonitis due to hollow organ perforation with a Fränkel grade B spinal cord injury. Initial treatment included ceftriaxone 2 g IV, metronidazole 500 mg IV, tramadol 100 mg, omeprazole 40 mg IV, dexamethasone 8 mg IV, tetanus serum 5000 U/ml, intra-rectal fleet enema, fluid resuscitation with Ringer lactate, and placement of a Foley catheter for diuresis monitoring. Laboratory tests showed a hemoglobin level of 16 g/dL, white blood cell count of 3250, urea level of 25 mg/dL, creatinine level of 6.9 mg/dL, and normal electrolyte levels. No imaging studies were available at the center. After anesthetic evaluation, the decision was made to proceed to the operating room, because he becomes hemodynamically unstable with a blood pressure of 90/50 mmHg, heart rate of 148, oxygen saturation of 94 %, and a urinary drainage bag containing 400 cc of highly colored urine was emptied.\n\nIn the operating room, the abdomen was accessed through a supra umbilical-pubic incision that was later extended. After resecting various anatomical planes, the abdominal cavity was opened, revealing a highly dilated rectum with areas of extensive necrosis at the base.\n\nThe colon was dissected, revealing dilation of the entire colonic frame using Mattox's maneuver to explore the retroperitoneal zones 1 and 2. Three staged biopsies were performed (diseased zone, transition zone, and healthy zone).\n\nA double-barreled sigmoid colostomy was created, followed by irrigation of collected materials. Approximately 300 cc of reactive fluid was aspirated. During the procedure, the patient experienced three cardiac arrests but was successfully resuscitated with the transfusion of two units of compatible blood. Due to the patient's inability to tolerate the rest of the procedure, closure was done using the Bogota technique to delay definitive closure.\n\nThe surgery lasted about 2 h and 40 min, and the patient was transferred to the postoperative care unit with a diagnosis of Hirschsprung's disease complicated by severe acidosis and acute renal failure. The patient left the operating room in a relatively stable condition with the following vital signs: blood pressure 130/60 mmHg, heart rate 70 beats/min, and oxygen saturation 93 % on room air. However, approximately 15 min later in the postoperative period, the patient's condition deteriorated with blood pressure dropping to 63/39 mmHg, heart rate increasing to 154 beats/min, respiratory rate of 44 breaths/min, temperature of 39 degrees Celsius, and oxygen saturation of 70 % with supplemental oxygen. About 4 h later, the patient passed away.", "summary": "He is a 20-year-old male patient with past medical history of epilepsy, psychomotor delay and recently a perineal perforating injury, admitted in the emergency room with initial diagnosis of peritonitis by perforated viscus with Frankel grad B spinal cord injury. Among his initial signs and symptoms were abdominal distension, rebound tenderness, decreased bowel sounds and diffuse pain. Laboratory tests revealed increased Hb, decreased white cells count and increased creatinine level. Initial management included: fluid resuscitation, analgesics, antibiotics and laxatives. After becoming hemodynamically unstable, the patient was introduced to the operating room where a highly dilated rectum with areas of necrosis at the base was discovered after access to the abdominal cavity. While doing the intervention, the patient experienced 3 cardiac arrests following by successful ressucitation and blood transfusion; leading to the decision to delay the definitive closure using the Bottega technique. The surgical course was unfavorable as the patient died around 4 hour post-surgery.", "subclaim_evaluations": [ { "subclaim": "The patient is a 20-year-old male.", "support_label": "supported" }, { "subclaim": "The patient has a past medical history of epilepsy.", "support_label": "supported" }, { "subclaim": "The patient has psychomotor delay.", "support_label": "supported" }, { "subclaim": "The patient had a perineal perforating injury.", "support_label": "supported" }, { "subclaim": "The initial diagnosis was peritonitis by perforated viscus.", "support_label": "supported" }, { "subclaim": "The patient had a Frankel grade B spinal cord injury.", "support_label": "supported" }, { "subclaim": "The patient had abdominal distension.", "support_label": "supported" }, { "subclaim": "The patient had rebound tenderness.", "support_label": "supported" }, { "subclaim": "The patient had decreased bowel sounds.", "support_label": "supported" }, { "subclaim": "The patient had diffuse pain.", "support_label": "supported" }, { "subclaim": "Laboratory tests showed increased Hb.", "support_label": "not_supported" }, { "subclaim": "Laboratory tests showed decreased white cell count.", "support_label": "supported" }, { "subclaim": "Laboratory tests showed increased creatinine level.", "support_label": "supported" }, { "subclaim": "Initial management included fluid resuscitation.", "support_label": "supported" }, { "subclaim": "Initial management included analgesics.", "support_label": "supported" }, { "subclaim": "Initial management included antibiotics.", "support_label": "supported" }, { "subclaim": "Initial management included laxatives.", "support_label": "not_supported" }, { "subclaim": "The patient became hemodynamically unstable.", "support_label": "supported" }, { "subclaim": "The patient was taken to the operating room.", "support_label": "supported" }, { "subclaim": "A highly dilated rectum was discovered.", "support_label": "supported" }, { "subclaim": "Areas of necrosis at the base of the rectum were found.", "support_label": "supported" }, { "subclaim": "The patient experienced 3 cardiac arrests during the intervention.", "support_label": "supported" }, { "subclaim": "The patient was successfully resuscitated.", "support_label": "supported" }, { "subclaim": "The patient received blood transfusion.", "support_label": "supported" }, { "subclaim": "The decision was made to delay definitive closure using the Bottega technique.", "support_label": "not_supported" }, { "subclaim": "The surgical course was unfavorable.", "support_label": "supported" }, { "subclaim": "The patient died around 4 hours post-surgery.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1165_en.txt", "fulltext": "In November 2017, an asymptomatic 14-year-old boy referred to the authors’ hospital for management of right lateral chest wall mass discovered incidently one month earlier. There was no history of trauma. Clinical examination was unremarkable. Plain chest radiography showed a smooth-walled 6.0 × 3.5 cm homogenous right lateral chest wall mass (A). Computed tomographic (CT) scan revealed right lateral extrapleural soft-tissue mass 6.5 × 4.0 × 5.6 cm in size abutting 5th and 6th ribs and filling the 5th intercostal space (B). There were neither cavitation nor calcification within the mass, and the adjacent ribs were not eroded.\nMagnetic resonance imaging (MRI) revealed right extrapulmonary and extrapleural chest wall soft tissue mass. Tl-weighted MRI demonstrated a solid mass with a low signal intensity (C), while T2-weighted MRI demonstrated a homogeneous mass with high signal intensity similar to that of fat tissue (D). Early phases after administration of contrast, showed characteristic heterogeneous enhancement of the tumor that became more uniform during the delayed phase (E and F).\nThe angiogram showed a sizeable vascular mass supplied by a branch of the internal mammary artery. That branch was subsequently embolized with Gelfoam pledgets with no further filling on the post-embolization arteriogram.\nThe patient underwent an exploratory video-assisted thoracoscopy (VAT) through the right 8th intercostal space anterior axillary line (A and B). Posterolateral thoracotomy revealed well-demarcated mass abutting the 5th and 6th ribs filling the right 5th intercostal space. En bloc resection of the mass involved ribs and the intercostal muscles were performed (C). Chest wall defect was reconstructed using polytetrafluoroethylene (PTFE) patch (GORE-TEX®, DUALMESH®, W. L. Gore & Associates) (D).\nThe surgical specimen measured approximately 6 × 4 × 3.5 cm, which included a hemorrhagic, highly vascular, mass that extended from the intercostal muscles to the extra-pleural space (E). Cut section revealed whitish homogenous material. Microscopically, there were homogeneous thick and thin-walled blood vessels with proliferating vascular spaces of capillaries of the cavernous type with intervening fibrous stroma (F). There was no evidence of recurrence at 3 and six months of follow-up.", "summary": "A 14-year-old boy who presented with asymptomatic right lateral chest wall mass with no history of trauma. Different radiological modalities were employed for diagnosis including computed tomography (CT) showed a soft tissue mass 6.5×4×5.6cm in size abutting 5th and 6th ribs. Magnetic resonance imaging (MRI) revealed iso-intense signal in T1 and hyperintense signal in T2, that is higher than that of adjacent muscles in the inferolateral right chest wall which was compatible with intercostal hemangioma. The patient underwent surgery for excision of the mass. Through right posterolateral thoracotomy, there was a well-demarcated mass abutting 5th, and 6th ribs filling the right 5th interspaces. Histopathological examination confirmed the diagnosis of intercostal hemangioma.", "subclaim_evaluations": [ { "subclaim": "The patient is a 14-year-old boy.", "support_label": "supported" }, { "subclaim": "He had an asymptomatic right lateral chest wall mass.", "support_label": "supported" }, { "subclaim": "There was no history of trauma.", "support_label": "supported" }, { "subclaim": "Computed tomography showed a soft tissue mass.", "support_label": "supported" }, { "subclaim": "The mass measured 6.5×4×5.6 cm.", "support_label": "supported" }, { "subclaim": "The mass abutted the 5th and 6th ribs.", "support_label": "supported" }, { "subclaim": "Magnetic resonance imaging showed iso-intense signal in T1.", "support_label": "supported" }, { "subclaim": "Magnetic resonance imaging showed hyperintense signal in T2.", "support_label": "supported" }, { "subclaim": "The T2 signal was higher than that of adjacent muscles.", "support_label": "supported" }, { "subclaim": "The MRI findings were compatible with intercostal hemangioma.", "support_label": "supported" }, { "subclaim": "The patient underwent surgery for excision of the mass.", "support_label": "supported" }, { "subclaim": "The surgery was performed through a right posterolateral thoracotomy.", "support_label": "supported" }, { "subclaim": "The mass was well-demarcated.", "support_label": "supported" }, { "subclaim": "The mass abutted the 5th and 6th ribs.", "support_label": "supported" }, { "subclaim": "The mass filled the right 5th interspace.", "support_label": "supported" }, { "subclaim": "Histopathological examination confirmed the diagnosis of intercostal hemangioma.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3024_en.txt", "fulltext": "We present the case of a 51-year-old woman with a history of fibromyalgia and anorexia-bulimia of more than 30 years of evolution, without toxic habits. She comes to the emergency room presenting a picture of expectoration of a yellowish appearance, with scarse cough and without fever, of five months of evolution.\n\nThe blood test did not detect significant alterations. However, the chest X-ray showed extensive consolidation predominantly affecting the middle lobe and the upper left lobe, so the patient was admitted for study.\n\nMicrobiological and serological determinations were negative (human immunodeficiency virus and SARS-CoV-2), except for the isolation of Serratia marcescens in moderate growth in the sputum.\n\nA chest computed tomography (CT) scan was performed, which reported confluent opacities including areas of ground glass opacities and consolidation, bilateral and diffuse distribution, and greater extent in the upper left lobe, the lingula, the middle lobe and the lower left lobe. Empirical antibiotic treatment (ceftriaxone 2 g/24 h and azithromycin 500 mg/24 h) and corticosteroid (methylprednisolone 40 mg/12 h) were initiated for seven days.\n\nA flexible fibrobronchoscopy was performed in which no alterations were observed in the tracheobronchial tree. A bronchoalveolar lavage was performed in the middle lobe from which a turbid and yellowish liquid was obtained. Shortly after its obtaining, the liquid obtained was separated into two phases, leaving a supernatant of a foamy, yellowish appearance in the upper part, which was sent to the services of Pathological Anatomy and Microbiology. During the bronchoscopy, biopsy with clamp was performed in the mucosa of the bronchus of the lower left lobe.\n\nThe cytology of the bronchoalveolar lavage was negative for malignancy with a differential count of 90% macrophages, 7% lymphocytes and 3% polymorphonuclear cells. As for the microbiological study, no bacterial or fungal growth was observed, no acid-fast bacilli were observed, the mycobacterial culture was negative after 42 days of incubation, and no Legionella spp. was isolated.\n\nBiopsies reported lung parenchyma with preserved architecture, no specific lesions or evidence of deposits, with occasional macrophages with microvacuolated cytoplasm.\n\nPulmonary function tests were performed with no significant abnormalities.\n\nDue to the absence of clinical changes, and the patient remaining in good general condition at all times, it was decided to proceed with hospital discharge, pending a pulmonary cryobiopsy. This biopsy was performed two months later in the lower left lobe. According to the anatomopathological report, the samples obtained showed areas of occupation of the air spaces by abundant macrophages with intracytoplasmic vacuoles of varying sizes, characteristic of exogenous lipoid pneumonia. Also, large extracellular vacuoles were recognized, surrounded by macrophages with occasional multinucleated elements.\n\nThe presence of macrophages with intracytoplasmic vacuoles is characteristic of exogenous lipoid pneumonia. In light of these findings, the final diagnosis was exogenous lipoid pneumonia in probable relation to the patient's purgative behavior, who is currently in the process of recovery and changing habits, without cough or expectoration.\n", "summary": "We present the diagnostic process of a 51-year-old patient with a clinical history of a cough with yellowish expectoration, without symptoms of infection or fever, of long evolution. In the computed axial tomography, bilateral pulmonary infiltrates of an alveolar type were observed. A bronchoalveolar lavage was performed in which a yellowish material of unknown origin was obtained, which did not allow any clear conclusion to be reached. The pulmonary cryobiopsy was the key test that led to the diagnosis of exogenous lipoid pneumonia, in probable relation to the anorexia with purging habit that the patient suffered chronically.\n", "subclaim_evaluations": [ { "subclaim": "The patient is a 51-year-old individual.", "support_label": "supported" }, { "subclaim": "The patient has a clinical history of a cough with yellowish expectoration.", "support_label": "supported" }, { "subclaim": "The cough has a long evolution.", "support_label": "supported" }, { "subclaim": "The patient does not have symptoms of infection.", "support_label": "supported" }, { "subclaim": "The patient does not have fever.", "support_label": "supported" }, { "subclaim": "Computed axial tomography showed bilateral pulmonary infiltrates.", "support_label": "supported" }, { "subclaim": "The infiltrates were of an alveolar type.", "support_label": "supported" }, { "subclaim": "A bronchoalveolar lavage was performed.", "support_label": "supported" }, { "subclaim": "A yellowish material was obtained from the bronchoalveolar lavage.", "support_label": "supported" }, { "subclaim": "The material's origin was unknown.", "support_label": "not_supported" }, { "subclaim": "The bronchoalveolar lavage did not allow clear conclusions.", "support_label": "supported" }, { "subclaim": "A pulmonary cryobiopsy was performed.", "support_label": "supported" }, { "subclaim": "The cryobiopsy led to the diagnosis of exogenous lipoid pneumonia.", "support_label": "supported" }, { "subclaim": "The exogenous lipoid pneumonia is in probable relation to an anorexia with purging habit.", "support_label": "supported" }, { "subclaim": "The anorexia with purging habit is chronic.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3102_en.txt", "fulltext": "A previously healthy 9-year-old boy from Trujillo, Peru, fully vaccinated according to the vaccination schedule for his age, presented to the emergency department with respiratory problems and suspected COVID-19.\n\nThe mother and child were tested for the presence of antibodies to SARS-CoV-2. The results showed that both were positive for IgG antibodies to SARS-CoV-2. In the child, the reverse transcriptase polymerase chain reaction (RT-PCR) molecular test for SARS-CoV-2 was negative. According to the mother, the child had a fever, abdominal pain, diarrhea and vomiting for 3 days. The patient was admitted to the surgical center for acute examination of the abdomen without major findings.\n\nTwenty-four hours after surgery, the child was tachypneic with respiratory rate of 40 breaths per minute, subcostal retractions, low oxygen saturation (SatO2) of 80% in room air and 85% on high flow oxygen support, heart rate of 138 beats per minute and blood pressure of 790/550 mmHg. Due to his clinical deterioration, he was admitted to the paediatric intensive care unit (ICU), where he was urgently intubated for mechanical ventilation and presented low SatO2 at 85% and peripheral signs of hypoperfusion. Initial analysis of the venous blood gases showed pH of 7.29, carbon dioxide partial pressure (pCO2) of 39.8 mmHg, oxygen partial pressure (pO2) of 37.3 mmHg, bicarbonate levels of 17.8 mmol/L, base excess of -7.8 and inspired oxygen fraction of 100%, consistent with protective mechanical ventilation measures. Serial chest radiographs were performed, which showed bilateral parenchymal involvement, along with a thoracic tomography result consistent with a consolidated parenchymal inflammatory process and bilateral pleural effusion.\n\nNo improvement in oxygenation was observed with the initiation of mechanical ventilation with sedoanalgesia and optimal relaxation; therefore, it was decided to place him in the prone position for 48 hours, increasing the SatO2 to 92%. The child presented circulatory collapse and received several vasoactive agents (epinephrine, norepinephrine and dobutamine), achieving mean arterial pressure within the 50th percentile for his age. The vasoactive inotropic score (EVI) was 50, and the echocardiogram showed left ventricular dysfunction and vasoplegia, which reversed after 5 days with normal values of arterial pressure for his age and remained so until hospital discharge.\n\nThe respiratory pathogenic nucleic acid amplification panel was negative. Blood, urine and peritoneal fluid samples were negative. Blood tests showed a hemoglobin level of 9.9 g/dL, a leukocyte count of 10,680/mm3 and lymphopenia (640/mm3). The blood tests showed elevated levels of inflammatory markers, with a C-reactive protein level of 243 mg/L, a fibrinogen level of 410 mg/dL, a ferritin level of 1,260 ng/mL and hypalbuminemia (2 g/dL). In addition, the patient had a high level of D-dimer of 9.4 mg/L with signs of coagulopathy, a prothrombin time of 49 seconds and an international normalized ratio of 1.51. There were also elevated levels of pro-BNP (282 pg/mL), troponin (0.24 pg/mL) and a high level of lactate dehydrogenase (LDH). The fever persisted while the patient was on mechanical ventilation, and clinical, gas and radiological improvements were observed after 15 days. The patient was weaned off the mechanical ventilator to spontaneous ventilation with the support of a 30 L high flow cannula, and the inspired oxygen fraction was 60%. After 3 weeks, the child had neurological deterioration, with a Glasgow coma scale of 11/15 (M4/O4/V3), pupils of 3 mm in diameter, bilateral plantar fasciitis, delusions and suicidal ideation, psychomotor agitation and the incidence of two convulsive events of approximately 2 minutes in duration each, with no recovery of consciousness between the events, for which the patient received intravenous (IV) midazolam 0.1 mg/kg and then phenytoin bolus 20 mg/kg/dose with a maintenance dose of 8 mg/kg/dose. This prescription was maintained after hospital discharge. Psychomotor agitation was controlled with antipsychotics; haloperidol was administered orally at 5 mg every 8 hours. No immunosuppressive treatment was used.\n\nBrain MRI showed bilateral occipital involvement in hyperintense T2 and FLAIR images, which affected subcortical white matter symmetrically, especially at the posterior level, and did not stand out with contrast or show significant changes in diffusion. These findings were consistent with vasogenic edema and indicative of posterior reversible encephalopathy syndrome (PRES). Electroencephalographic findings showed a generalized slowing of theta/delta frequency activity.\n\nTo treat the multisystem inflammatory syndrome, he received immunoglobulin at 2g/kg in a single dose and methylprednisolone at 2mg/kg/dose for maintenance. Subsequently, we focused on the therapeutic management of PRES by the IV administration of antiepileptic drugs to maintain blood pressure levels at normal tension, preserving an adequate homeostasis of the internal environment with special emphasis on the treatment of volume overload and the prevention of electrolyte disorders.\n\nDuring follow-up at 4 weeks after discharge, at the time of neuropsychological evaluation, abilities such as attention, concentration, memory, language, visuoconstructive abilities, calculation and orientation were assessed, and motor deficits of 4/5 in the legs were preserved. MRI abnormalities of the brain were reversed 21 days after discharge.\n", "summary": "We describe a case of posterior reversible encephalopathy syndrome secondary to SARS-CoV-2 infection in a 9-year-old boy who developed acute hypoxemic respiratory failure and required mechanical ventilatory support. The child developed multisystem inflammatory syndrome and was monitored in the paediatric intensive care unit, receiving mechanical ventilatory support and vasoactive agents for haemodynamic support. In addition, he developed pulmonary and extrapulmonary clinical manifestations along with neuropsychiatric manifestations that required careful follow-up, which was verified by brain magnetic resonance for timely intervention.\n", "subclaim_evaluations": [ { "subclaim": "The patient was a 9-year-old boy.", "support_label": "supported" }, { "subclaim": "The patient had a SARS-CoV-2 infection.", "support_label": "not_supported" }, { "subclaim": "The patient developed posterior reversible encephalopathy syndrome.", "support_label": "supported" }, { "subclaim": "The posterior reversible encephalopathy syndrome was secondary to SARS-CoV-2 infection.", "support_label": "not_supported" }, { "subclaim": "The patient developed acute hypoxemic respiratory failure.", "support_label": "supported" }, { "subclaim": "The patient required mechanical ventilatory support.", "support_label": "supported" }, { "subclaim": "The patient developed multisystem inflammatory syndrome.", "support_label": "supported" }, { "subclaim": "The patient was monitored in the paediatric intensive care unit.", "support_label": "supported" }, { "subclaim": "The patient received vasoactive agents for haemodynamic support.", "support_label": "supported" }, { "subclaim": "The patient developed pulmonary clinical manifestations.", "support_label": "supported" }, { "subclaim": "The patient developed extrapulmonary clinical manifestations.", "support_label": "supported" }, { "subclaim": "The patient had neuropsychiatric manifestations.", "support_label": "supported" }, { "subclaim": "The patient required careful follow-up.", "support_label": "supported" }, { "subclaim": "Brain magnetic resonance was used for timely intervention.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_476_en.txt", "fulltext": "An 8-year-old girl presented with a 4 months history of right parietal bone swelling with an offensive odor. There was no discharge and no history of vomiting or trauma. She has taken no medications lately and had no allergic reactions. In the clinic, she had a mild headache with no fever, no symptoms of increased intracranial pressure, and no neurological abnormalities. A head computed tomography (CT) scan showed a parietal bone lesion. After that, an MRI scan of the brain showed a 2.5 × 1.5 cm bone lesion extended as swelling and suggested the diagnosis of EG . Histopathology was performed and revealed proliferation of monotonous population of discohesive cells composed of oval nuclei with open chromatin and coffee bean grooves with abundant pale cytoplasm. Immunohistochemistry for these cells was positive for CD1a and S100 . Initial treatment with augmentin was performed to relieve the infection and the odor. After that, a CT scan showed that the swelling is disappeared, but there was a lytic bone lesion . On examination, there was a feeling of soft tissue. Thereupon, a surgical procedure was done by excision of the lesion with a 3 mm safety margin, and a titanium mesh was inserted . During the surgery, the patient was given cefazolin. Laboratory values before and after the surgery were within the normal range. The patient was discharged home with augmentin and analgesia. In the clinic, the follow-up of the patient was performed with no post-operative complications.", "summary": "An 8-year-old girl presented with a 4 months history of a right parietal bone swelling of the skull with an offensive odor. There was no discharge and no history of vomiting or trauma. An MRI scan of the brain showed swelling with a bone lesion of the right parietal bone. Infection was the source of the swelling and the bad odor. Treatment was done by surgical excision of the lesion.", "subclaim_evaluations": [ { "subclaim": "The patient is an 8-year-old girl.", "support_label": "supported" }, { "subclaim": "She had a 4-month history of a right parietal bone swelling.", "support_label": "supported" }, { "subclaim": "The swelling had an offensive odor.", "support_label": "supported" }, { "subclaim": "There was no discharge.", "support_label": "supported" }, { "subclaim": "There was no history of vomiting.", "support_label": "supported" }, { "subclaim": "There was no history of trauma.", "support_label": "supported" }, { "subclaim": "An MRI scan of the brain showed swelling.", "support_label": "supported" }, { "subclaim": "The MRI showed a bone lesion of the right parietal bone.", "support_label": "supported" }, { "subclaim": "Infection was the source of the swelling.", "support_label": "not_supported" }, { "subclaim": "Infection was the source of the bad odor.", "support_label": "supported" }, { "subclaim": "Treatment was done by surgical excision of the lesion.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2656_en.txt", "fulltext": "On January 31, 2021, a 75-year-old male presented at the Gastroenterology Department of our hospital complaining of intermittent melena with epigastric discomfort for 1 mo.\nThe patient reported that melena occurred several times a day and was accompanied by epigastric discomfort and fatigue, without dizziness or severe abdominal pain.\nThe patient detected a plantar nodule on the right side in November 2016. It gradually grew and developed an ulceration. Biopsy results showed melanoma. He underwent an extended resection of the melanoma on the right plantar. Postoperative pathological diagnosis was acral malignant melanoma. He received interferon α2b (1800 WU three times per week) and continued maintenance therapy of a decreased dose of interferon α2b. He had no history of other chronic diseases.\nThe patient had no history of smoking or drinking. He denied a history of allergies, and his family history was unremarkable.\nAt admission, the patient’s temperature was 36.5 °C, heart rate was 70 beats per min, respiratory rate was 20 breaths per min, and blood pressure was 140/70 mmHg. Abdominal examination found soft tenderness in the left quadrant, without rebound tenderness. Lung and heart examinations were normal.\nRoutine blood tests revealed a normal white blood cell count (7.5 × 109 cells/L), moderate anemia (hemoglobin of 75.0 g/L; normal range: 130.0-175.0 g/L), hypoproteinemia (31.0 g/L; normal range: 35.0-52.0 g/L), and elevated levels of creatinine (136 µmol/L; normal range: 59-104 µmol/L). Transaminase, amylopsin and lipase levels were normal, and coagulation function was normal.\nAn abdominal computed tomography (CT) scan (January 30, 2021) showed an irregular shape of the jejunum in the left upper quadrant and shadows of fat, which indicated intestinal intussusception . Multiple gallstones were also found. Upper gastrointestinal endoscopy (February 2, 2021) showed multiple linear ulcers in the antrum, superficial gastritis, and small polyps. Magnetic resonance enterography (February 3, 2021) showed partial thickening of the jejunal wall in the left upper quadrant and formation of a soft tissue mass (32 mm × 24 mm), indicating a neoplastic lesion . The mass showed increased signal intensity in diffusion weighted imaging with intussusception of the distal jejunum and mesentery (jejunojejunal intussusception), and intestinal lumen expansion with air and fluid accumulation . Chest CT (February 7, 2021) showed a nodule in the superior lobe of the left lung (7 mm) and tiny nodules in the right lung (2-4 mm).\nThe patient underwent partial small bowel resection. Pathological findings revealed a 4.0 cm × 3.0 cm × 2.5 cm protrusion tumor. Histopathology showed diffuse growth of tumor tissue, with the majority located in the submucosa and nearly invading the mucosa . Tumor cells presented with patchy distribution, large nuclei, prominent nucleoli , and red cytoplasm . Some tumor cells showed pigment granules in the cytoplasm . Epithelioid tumor cells contained mitotic figures . Immunohistochemical staining showed HMB45 (+), Melan-A (+), S-100 (+), SOX10 (+), Braf (-), PCK (-), LCA (-), Ki-67 (about 50%) . Lymph node metastasis was detected in one of the five lymph nodes biopsied. Combined with the patient’s history of past illness, the pathologic diagnosis was small intestine metastatic melanoma.", "summary": "A 75-year-old man with a history of acral malignant melanoma was admitted to the Gastroenterology Department of our hospital, complaining of intermittent melena for 1 mo. Magnetic resonance enterography showed partial thickening of the jejunal wall and formation of a soft tissue mass, indicating a neoplastic lesion with jejunojejunal intussusception. The patient underwent partial small bowel resection. Pathological findings and immunohistochemical staining indicated small intestine metastatic melanoma. The patient refused further anti-tumor treatment after the surgery. Ten months after the first surgery, the patient presented with melena again. Computed tomography enterography showed the anastomotic stoma was normal without thickening of the intestinal wall, and routine conservative treatment was given. Three months later, the patient developed melena again. The patient underwent a second surgery, and multiple metastatic melanoma lesions were found. The patient refused adjuvant anti-tumor treatment and was alive at the latest follow-up.", "subclaim_evaluations": [ { "subclaim": "The patient is a 75-year-old man.", "support_label": "supported" }, { "subclaim": "The patient has a history of acral malignant melanoma.", "support_label": "supported" }, { "subclaim": "The patient was admitted to the Gastroenterology Department.", "support_label": "supported" }, { "subclaim": "The patient reported intermittent melena for 1 month.", "support_label": "supported" }, { "subclaim": "Magnetic resonance enterography showed partial thickening of the jejunal wall.", "support_label": "supported" }, { "subclaim": "Magnetic resonance enterography showed formation of a soft tissue mass.", "support_label": "supported" }, { "subclaim": "The findings indicated a neoplastic lesion.", "support_label": "supported" }, { "subclaim": "The findings indicated jejunojejunal intussusception.", "support_label": "supported" }, { "subclaim": "The patient underwent partial small bowel resection.", "support_label": "supported" }, { "subclaim": "Pathological findings indicated small intestine metastatic melanoma.", "support_label": "supported" }, { "subclaim": "Immunohistochemical staining indicated small intestine metastatic melanoma.", "support_label": "supported" }, { "subclaim": "The patient refused further anti-tumor treatment after the surgery.", "support_label": "not_supported" }, { "subclaim": "Ten months after the first surgery, the patient presented with melena again.", "support_label": "not_supported" }, { "subclaim": "Computed tomography enterography showed the anastomotic stoma was normal.", "support_label": "not_supported" }, { "subclaim": "Computed tomography enterography showed no thickening of the intestinal wall.", "support_label": "not_supported" }, { "subclaim": "Routine conservative treatment was given.", "support_label": "not_supported" }, { "subclaim": "Three months later, the patient developed melena again.", "support_label": "not_supported" }, { "subclaim": "The patient underwent a second surgery.", "support_label": "not_supported" }, { "subclaim": "Multiple metastatic melanoma lesions were found.", "support_label": "supported" }, { "subclaim": "The patient refused adjuvant anti-tumor treatment.", "support_label": "not_supported" }, { "subclaim": "The patient was alive at the latest follow-up.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2233_en.txt", "fulltext": "A 75-year-old Japanese man was admitted to our hospital with a gradually growing cutaneous polypoid mass that had appeared on the skin of the left scrotum approximately one year before. The tumor measured 13mm in diameter with relatively well-defined whitish-yellow outlines . Histological examination of an excisional biopsy revealed epidermal papillary proliferation with parakeratosis, hyperkeratosis, and neutrophil infiltration . Although mitotic figures were noted in the basal layer , cellular atypia was not prominent. Besides abundant plasma cells in the upper dermis, numerous foamy macrophages infiltrated the dermal papillae, forming a characteristic clear zone beneath the basement membrane . Histopathologically, the tumor was diagnosed as a benign cutaneous verruciform xanthoma with negative lateral and deep surgical margins.\nTo determine which cells release chemoattractants for macrophages, formalin-fixed and paraffin-embedded sections were stained for cytokeratin (AE1/AE3, M3515; Dako, Carpinteria, CA, USA; 1:200), CD68 (M0876; Dako; 1:100) and MCP-1 (DA103; BD Biosciences, San Diego, CA, USA; 1:40, 1:200, 1:800). After microwave heat-induced epitope retrieval, endogenous peroxidase activity was blocked with hydrogen peroxide (H2O2) in methanol. Indirect immunohistochemistry with the use of horseradish peroxidase conjugated anti-mouse rabbit antibody revealed that cytokeratin AE1/AE3 was strongly positive in differentiating epidermal keratinocytes, and weakly positive in keratinocytes in the basal and parabasal layers . However, strong CD68 staining was observed almost exclusively in foamy cells infiltrating beneath the basal cells . The parts densely stained for MCP-1 were observed in the differentiating cytokeratin AE1/AE3-positive keratinocytes. Clusters of the infiltrating macrophages also stained positive for MCP-1 .", "summary": "A 75-year-old Japanese man with a well-defined nodule on the left scrotum was admitted to the hospital. An excision biopsy revealed epidermal papillary proliferation with parakeratosis, hyperkeratosis, and infiltration of foam cell macrophages, whereby a pathological diagnosis of benign cutaneous verruciform xanthoma was made. Immunohistochemically, monocyte chemoattractant protein-1 was observed predominantly on cytokeratin AE1/AE3-positive differentiating keratinocytes in the prickle cell layer. However, while infiltrating macrophages were densely stained for monocyte chemoattractant protein-1, keratinocytes in the basal and parabasal layers were almost negative.", "subclaim_evaluations": [ { "subclaim": "The patient is a 75-year-old Japanese man.", "support_label": "supported" }, { "subclaim": "The patient had a well-defined nodule on the left scrotum.", "support_label": "supported" }, { "subclaim": "An excision biopsy was performed.", "support_label": "supported" }, { "subclaim": "The biopsy showed epidermal papillary proliferation.", "support_label": "supported" }, { "subclaim": "The biopsy showed parakeratosis.", "support_label": "supported" }, { "subclaim": "The biopsy showed hyperkeratosis.", "support_label": "supported" }, { "subclaim": "The biopsy showed infiltration of foam cell macrophages.", "support_label": "supported" }, { "subclaim": "The pathological diagnosis was benign cutaneous verruciform xanthoma.", "support_label": "supported" }, { "subclaim": "Immunohistochemical staining for monocyte chemoattractant protein-1 was performed.", "support_label": "supported" }, { "subclaim": "Monocyte chemoattractant protein-1 was observed on cytokeratin AE1/AE3-positive differentiating keratinocytes in the prickle cell layer.", "support_label": "supported" }, { "subclaim": "Infiltrating macrophages were densely stained for monocyte chemoattractant protein-1.", "support_label": "supported" }, { "subclaim": "Keratinocytes in the basal and parabasal layers were almost negative for monocyte chemoattractant protein-1.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_964_en.txt", "fulltext": "In June 2020, a 21-year-old male was admitted to our department after 2 weeks onset of headache, mild paraparesis (right side worse than left side), tactile, and thermic hypoesthesia with a D2 level. A contrast-enhanced MRI scan of the brain and spine showed an intramedullary lesion extending from D1 to D5. The cranial portion of the tumor presented an apparently exophytic extramedullary component which extended on the right posterolateral side up to C7 . A diffuse craniospinal leptomeningeal thickening was also present . A total-body CT scan ruled out lesions outside the CNS and cerebrospinal fluid (CSF) analysis excluded infection. Corticosteroid therapy was administered with no clinical improvement. After a week, the neurological status deteriorated rapidly with paraparesis worsening and onset of hydrocephalus with headache, emesis, and lethargy. The patient, therefore, underwent external ventricular drain positioning, once again, cultural and cytologic CSF analysis was not diagnostic. A C7-D4 laminectomy was subsequently performed. Intraoperatively, the spinal cord appeared swollen and distorted, with difficult to identify the apparent exophitic nodule. The tumor was then approached with intraoperative ultrasound and functional mapping with direct electrical stimulation with a monopolar probe.[,] The procedure was interrupted due to sudden deterioration of the motor evoked potentials; then, to decompress the spinal cord, a duraplasty was completed using a dural patch and a pedicled multifidus muscle flap was performed to decrease the risk of CSF leakage.[,]\nPostoperatively, the patient showed an immediate mild worsening of the lower limbs deficit. After a few days, severe further neurological deterioration occurred with progressive motor deficit to the upper limbs and ultimately respiratory failure. Mechanical ventilation was necessary and the patient was, therefore, transferred to the Intensive Care Unit. During the following weeks, he developed tetraplegia and underwent surgery for ventriculoperitoneal shunt positioning. By the time, the histological diagnosis was available; the clinical status would not allow radiotherapy (RT) or chemotherapy (ChT). The patient deceased approximately 90 days after hospitalization due to respiratory complications.", "summary": "A 21-year-old male presented with mild paraparesis and hypoesthesia with a D2 level. MRI scan of the brain and spine showed a dorsal intramedullary lesion; a diffuse craniospinal leptomeningeal thickening was also present. After a week, the neurological status deteriorated rapidly with paraparesis worsening and onset of acute hydrocephalus. The patient underwent external ventricular drain positioning; a C7-D4 laminectomy was subsequently performed with partial tumor resection. Histological examination revealed a DLGNT with aggressive aspects (Ki67 30%). Postoperatively, the patient showed an immediate mild worsening of the lower limbs deficit. After a few days, severe further neurological deterioration occurred with progressive motor deficit to the upper limbs and ultimately respiratory failure. Mechanical ventilation was necessary and the patient was transferred to the ICU; during the following weeks, he developed tetraplegia and underwent ventriculoperitoneal shunt positioning. By the time, the histological diagnosis was available, the clinical status would not allow radiotherapy or chemotherapy. The patient deceased approximately 90 days after hospitalization due to respiratory complications.", "subclaim_evaluations": [ { "subclaim": "The patient is a 21-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had mild paraparesis.", "support_label": "supported" }, { "subclaim": "The patient had hypoesthesia.", "support_label": "supported" }, { "subclaim": "The neurological deficit was at the D2 level.", "support_label": "supported" }, { "subclaim": "MRI showed a dorsal intramedullary lesion.", "support_label": "supported" }, { "subclaim": "MRI showed diffuse craniospinal leptomeningeal thickening.", "support_label": "supported" }, { "subclaim": "The neurological status deteriorated rapidly after one week.", "support_label": "supported" }, { "subclaim": "The patient developed acute hydrocephalus.", "support_label": "supported" }, { "subclaim": "The patient underwent external ventricular drain positioning.", "support_label": "supported" }, { "subclaim": "A C7-D4 laminectomy was performed.", "support_label": "supported" }, { "subclaim": "Partial tumor resection was performed.", "support_label": "supported" }, { "subclaim": "Histological examination revealed a DLGNT.", "support_label": "not_supported" }, { "subclaim": "The DLGNT had aggressive aspects.", "support_label": "not_supported" }, { "subclaim": "The Ki67 index was 30%.", "support_label": "not_supported" }, { "subclaim": "Postoperatively, the patient had an immediate mild worsening of the lower limbs deficit.", "support_label": "supported" }, { "subclaim": "Severe further neurological deterioration occurred after a few days.", "support_label": "supported" }, { "subclaim": "The motor deficit progressed to the upper limbs.", "support_label": "supported" }, { "subclaim": "The patient developed respiratory failure.", "support_label": "supported" }, { "subclaim": "Mechanical ventilation was necessary.", "support_label": "supported" }, { "subclaim": "The patient was transferred to the ICU.", "support_label": "supported" }, { "subclaim": "The patient developed tetraplegia.", "support_label": "supported" }, { "subclaim": "A ventriculoperitoneal shunt was positioned.", "support_label": "supported" }, { "subclaim": "The histological diagnosis was available.", "support_label": "supported" }, { "subclaim": "The clinical status did not allow radiotherapy.", "support_label": "supported" }, { "subclaim": "The clinical status did not allow chemotherapy.", "support_label": "supported" }, { "subclaim": "The patient died approximately 90 days after hospitalization.", "support_label": "supported" }, { "subclaim": "The cause of death was respiratory complications.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2798_en.txt", "fulltext": "A 28-year-old healthy man sustained injury to the left lower leg due to a traffic accident. He was admitted to the local hospital and received a DR/CT examination . The patient suffered a left ankle fracture, clavicle fracture and dislocation. He underwent debridement followed by Vacuum Sealing Drainage (VSD) cover and fibula plate fixation surgery. He was moved to the ICU postoperatively. One week later, he underwent open reduction and internal fixation of clavicle fracture surgery. Postoperative healing of the left shoulder wound was satisfactory, but the left lower leg showed poor wound healing and a large-area skin defect, and the long bone remained exposed. The patient returned to our hospital for further treatment.\nThe patient presented with stable vital signs and absence of any cardiopulmonary abnormalities; the wound covering the VSD had good negative pressure. There was a weak dorsalis pedis artery, toes showed restricted movement, the shoulder wound healed completely, dorsalis pedis pulse improved, the posterior tibial artery pulse remained unchanged, and the lateral margins of the left foot felt numb. General physical examination results were without exception.\nThe blood test results of the patient showed white blood cell count of 12.36 * 109/ L, neutrophil percentage of 80.3 %, C-reactive protein of 53.66 mg/L, and calcitonin of 0.115 (0–0.05 ng/mL).\nSevere open wound to the left calf, Large skin defect on left calf, Extensive bone exposure in the left calf, Left medial malleolar defect Positive after admission to cephalosporins anti-infection treatment, 7 Ye Zao nucleoside detumescence, low molecular heparin calcium sodium anticoagulation. Four days after admission and debridement surgery, the patient had a large left leg skin defect, the tibia was exposed (area: 23 cm * 10 cm), the ankle area had defects, and the medial malleolus osseous was absent . Ankle joint debridement take part of the training for the inflammatory tissue + drug susceptibility, after thorough debridement, will narrow rear to lift ahead of soft tissue wound, finally use the VSD cover the wound. After 4 days of germiculture, results revealed the presence of enterococcus, and the patient received levofloxacin to fight infection. After 7 days, the VSD was dismantled, the wound and exposed bone area had become smaller, and the surrounding granulation tissue was fresh. The medication of the patient was changed . After 14 days, the patient underwent a second surgery, where intraoperative debridement was carried out on the wound again; ipsilateral thigh skin transplantation was undertaken and covered with VSD. The skin graft grew well, leaving the long bone exposed . After 4 weeks, the skin graft area was observed to be healing well. The exposed bone was ground intraoperatively and subjected to micropower drilling such that each hole was spaced 5 to 10 mm apart . Gentamicin bone cement (DuPuy Synthes, USA) was mixed with powder bone cement (40 g); polymethyl methacrylate reagent (DuPuy Synthes, USA) was added and fully mixed. The cement dough was placed to cover the bone shape and fixed with sutures . The bone cement was removed, and the tissue showed no signs of necrosis . Using an external fixator with the fibula plate, the fibula segment and trim were removed. The fibula ankle bone graft showed fusion and wound healing. The patient was followed up 1 month after discharge, and the affected area showed no infection, indicating recovery .", "summary": "A 28-year-old healthy man was injured in a car accident and presented to the local hospital with a large skin defect and exposed left lower leg long bone. After transfer to our hospital, the patient underwent repeated debridement and skin graft, a cortex borehole combined with bone cement cover, and ankle fusion. The patient achieved full recovery.", "subclaim_evaluations": [ { "subclaim": "The patient is a 28-year-old man.", "support_label": "supported" }, { "subclaim": "The patient was injured in a car accident.", "support_label": "supported" }, { "subclaim": "The patient had a large skin defect on the left lower leg.", "support_label": "supported" }, { "subclaim": "The patient had exposed left lower leg long bone.", "support_label": "supported" }, { "subclaim": "The patient underwent repeated debridement.", "support_label": "supported" }, { "subclaim": "The patient underwent skin grafting.", "support_label": "supported" }, { "subclaim": "The patient had a cortex borehole procedure.", "support_label": "supported" }, { "subclaim": "The patient had a bone cement cover applied.", "support_label": "supported" }, { "subclaim": "The patient had ankle fusion.", "support_label": "supported" }, { "subclaim": "The patient achieved full recovery.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1678_en.txt", "fulltext": "A previously healthy 48-year-old woman, with no significant past medical history and no family history of colorectal diseases, presented to the emergency room with abdominal distension, colicky pain, and a history of repeated episodes of lower gastrointestinal hemorrhage for as long as couple of months. She also complained of 8 kg weight loss in the last 2 months. She denied taking any prescription or over-the-counter medications. Clinical examination revealed a malnourished woman in severe distress due to diffuse abdominal tenderness. Signs of colonic obstruction were apparent. Digital rectal examination was indicative for rectal bleeding. Her vital signs were temperature 38°C, pulse 118/min, blood pressure 105/60 mmHg, and respiratory rate 20/min. Blood counts showed Hb 7.4 g/dl and a white blood count of 16.000. Serum electrolytes, liver function tests, and urinalysis were unremarkable. A plain abdominal X-ray and abdominal CT scan confirmed the signs of large bowel obstruction, along with a polypoid mass fully occluding the lumen of the terminal sigmoid colon. The patient was taken to the operating room where a standard left hemicolectomy was performed because of the malignant appearance of the mass and the extensive lymph node involvement that was found intraoperatively .\nHistological examination revealed a branching polypoid lesion characterized by mucosa projections with a central muscular core . Additionally, misplaced mucosa was encountered within the submucosa forming cystic structures, while partly preserved continuity with the polypoid part of the lesion could be demonstrated . The colonic epithelium both of the exophytic and the endophytic component showed extensive adenomatous transformation with high-grade dysplasia . A lesion-restricted transmural Crohn-like inflammation with prominent lymphoid aggregates was also present. The final diagnosis was consistent with a solitary hamartomatous polyp of Peutz-Jeghers type characterized by an inverted component, analogous to colitis cystica profunda, and by extensive high-grade dysplastic changes. The patient had an uneventful postoperative recovery and complete resolution of her symptoms. Follow-up colonoscopy 3 months after surgery showed no abnormal findings. The patient remains free of symptoms.", "summary": "Herein, we describe a unique case of colitis cystica profunda in the setting of Peutz-Jeghers-type polyp of the sigmoid colon, associated with high-grade dysplasia of the overlying epithelium in a 48-year-old female patient, who presented to the emergency room with signs of intestinal obstruction. To the best of our insight, this is the first manifestation ever reported in the literature regarding the coexistence of solitary Peutz-Jeghers-type polyp, colitis cystica profunda, and high-grade dysplasia of the epithelium of the colon.", "subclaim_evaluations": [ { "subclaim": "The patient is a 48-year-old female.", "support_label": "supported" }, { "subclaim": "The patient had a Peutz-Jeghers-type polyp of the sigmoid colon.", "support_label": "supported" }, { "subclaim": "The patient had colitis cystica profunda.", "support_label": "supported" }, { "subclaim": "The patient had high-grade dysplasia of the overlying epithelium.", "support_label": "supported" }, { "subclaim": "The patient presented with signs of intestinal obstruction.", "support_label": "supported" }, { "subclaim": "The case involves the coexistence of a solitary Peutz-Jeghers-type polyp, colitis cystica profunda, and high-grade dysplasia.", "support_label": "supported" }, { "subclaim": "This is the first reported case in the literature of this specific combination of findings.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2076_en.txt", "fulltext": "A 51-year-old Caucasian left-handed housewife lady (weight 61 kg, height 159 cm) was admitted to our institution because of severe sudden onset headache followed by transient loss of consciousness and vomiting. On examination she was fully conscious and oriented and complained of severe headache. Nuchal rigidity was evident. No focal neurological deficit was found. Temperature was 38°C and other vital signs were stable. Past medical history was negative and she did not consume any medication.\nCT scan of the head revealed acute subarachnoid hemorrhage prominently occupying the right sylvian fissure. CT angiography was performed . The cerebral vasculature was found to harbor three saccular aneurysms at: (1) right MCA trifurcation, (2) left ICA bifurcation, and (3) distal basilar artery. The right MCA aneurysm was presumed to be the ruptured aneurysm due to location of subarachnoid clot and irregular shape of the aneurysm.\nA right pterional craniotomy was performed with the patient in the supine position and head rotated 30 degrees to left. After elevation of the craniotomy flap, the sphenoid ridge was drilled flush with the orbital roof to facilitate exposure of the basilar tip aneurysm. After duratomy, gentle frontal lobe retraction allowed CSF drainage from the optic and carotid cisterns. Right optic nerve and right ICA were identified and the Sylvian fissure was opened from medial to lateral, following the bifurcation of right ICA to MCA trifurcation. A saccular aneurysm was found in the MCA trifurcation projecting inferolaterally. After dissection of the neck it was clipped. Next, opening the membrane of Liliequist, let to the distal basilar aneurysm from the corridor between the right optic nerve and right ICA. The aneurysm was located between the right PCA and right SCA with a wide neck, and its dome projected laterally to right. Successful clipping was achieved. The left ICA bifurcation aneurysm was identified after following the right A1, anterior communicating and left A1 arteries with minimal brain retraction, and gaining benefit from favorable neuroanesthesia. The aneurysm projected superiorly and was also clipped .\nThe patient experienced an uneventful post-operative period and was discharge within 5 days of surgery. A follow-up CT angiography confirmed successful obliteration of all lesions and preservation of normal cerebral vasculature .", "summary": "A 51 year-old Caucasian right handed housewife lady (weight 61 kg, height 159 cm) presented with a headache of acute onset which proved to be caused by acute subarachnoid hemorrhage. Cerebral computed tomographic angiography revealed multiple aneurysms. The patient underwent a right pterional craniotomy to obliterate right middle cerebral, distal basilar and left carotid bifurcation aneurysms. The post-operative course was uneventful.", "subclaim_evaluations": [ { "subclaim": "The patient is a 51 year-old woman.", "support_label": "supported" }, { "subclaim": "The patient is right-handed.", "support_label": "not_supported" }, { "subclaim": "The patient is a housewife.", "support_label": "supported" }, { "subclaim": "The patient's weight is 61 kg.", "support_label": "supported" }, { "subclaim": "The patient's height is 159 cm.", "support_label": "supported" }, { "subclaim": "The patient had a headache of acute onset.", "support_label": "supported" }, { "subclaim": "The headache was caused by acute subarachnoid hemorrhage.", "support_label": "supported" }, { "subclaim": "Cerebral computed tomographic angiography revealed multiple aneurysms.", "support_label": "supported" }, { "subclaim": "The patient underwent a right pterional craniotomy.", "support_label": "supported" }, { "subclaim": "The right pterional craniotomy was performed to obliterate right middle cerebral aneurysms.", "support_label": "supported" }, { "subclaim": "The right pterional craniotomy was performed to obliterate distal basilar aneurysms.", "support_label": "supported" }, { "subclaim": "The right pterional craniotomy was performed to obliterate left carotid bifurcation aneurysms.", "support_label": "not_supported" }, { "subclaim": "The post-operative course was uneventful.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1775_en.txt", "fulltext": "A 5-year-old girl initially presented to our department due to worsening pain in the left proximal thigh. Osteosarcoma was suspected radiographically . Open biopsy revealed a high-grade conventional osteosarcoma. The tumor was initially staged as IIB (T2b N0 M0), and neoadjuvant chemotherapy was commenced in accordance with the NECO-95J protocol . After three cycles of neoadjuvant chemotherapy, the pain was alleviated, the extra-osseous mass was dramatically reduced, and limb-salvage surgery was planned. As the tumor had already invaded the epiphyseal plate and epiphysis of the left distal femur at initial presentation, osteo-articular resection was thought necessary so as to obtain a negative surgical margin. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion was performed . Both medial and lateral meniscuses were preserved. The spacer was hand-made, using an intramedullary nail of 7 mm in diameter and molded polymethylmethacrylate (PMMA). Because there were no commercially available molds fitting the distal femur of such a young child, we made the spacer by hand, imitating the original distal femur of the patient that had been just removed. After surgery, the left leg was externally fixed in a cast for 4 weeks. Partial weight bearing on the affected leg, supported by a hinged knee brace, was thereafter commenced ; however, the spacer was dislocated at 7 months post-operatively, preventing the patient from bearing weight and leading to bone atrophy in the left leg .\nAt 7 years and 8 months old, secondary surgery was performed with the aim of enabling weight bearing on the affected leg. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer (Kyocera Corp., Japan) with a smooth straight stem of 8 mm in diameter had been ordered 3 months prior to the surgery . Intra-operatively, after the removal of the initial spacer, a 1-cm length of the distal edge of the residual femur was removed, but the periosteum and reactive membrane around the molded PMMA was preserved. The junction between the residual femur and the ceramic spacer was fixed with PMMA, and then covered with the preserved periosteum and membrane . After surgery, the left leg was placed in a cast for 4 weeks, after which the patient re-started partial weight bearing using a hinged knee brace as with the first spacer. The bone atrophy in the left leg was gradually resolved. At 18 months after the second surgery, the cortexes of the femur and tibia had thickened sufficiently for expandable mega-prosthesis; however, loosening of the stem and varus deformity was observed . A third surgical intervention was, therefore, planned.\nAt 9 years and 7 months old, the second spacer was removed, and the knee joint was reconstructed using a custom-made growing femoral prosthesis (Stryker Corp., Germany) with a curved porous stem of 8.5 mm in diameter fixed to the residual femur with two screws . Intra-operatively, the PMMA around the junction was already loosened, and the stem was easily removed. The residual femur was carefully reamed, and the stem was inserted. Cancellous bone chips from the proximal tibial epiphysis were grafted around the bone-prosthesis junction and then wrapped with the preserved periosteum and pseudo-periosteum membrane. The proximal surface of the tibia was also replaced, but the growth plate was preserved. Immediately after surgery, range of motion (ROM) exercise was started. Six weeks after surgery, partial weight bearing was permitted. Ten months after the third surgery, the patient was able to walk unsupported, and a radiograph showed further thickening of the cortex of the residual femur . At 10 years and 7 months old, the growing femoral prosthesis was extended by 1.1 cm. At the latest follow-up, at 11 years and 1 month old, the patient was 143 cm in height with a limb length discrepancy (LLD) of 5 cm and was able to walk unsupported using a 2.5 cm shoe lift (Video ). The Musculoskeletal Tumor Society (MSTS) score was 24 out of 30 points . The muscle strength of quadriceps recovered to manual muscle test (MMT) level 3, and active straight leg raising became possible without extension lag. The ROM of the left knee was 0–90°. The patient was receiving a second extension of growing femoral prosthesis.", "summary": "A 5-year-old girl with high-grade conventional osteosarcoma in the left distal femur underwent a series of surgeries. After three cycles of neoadjuvant chemotherapy, limb-salvage surgery was planned because femoral rotationplasty had been refused. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion using a 7-mm-diameter intramedullary nail and molded polymethylmethacrylate was performed. At 7 years and 8 months old, secondary surgery was performed because the first spacer had been dislocated and the residual femur became atrophic. The distal end of the residual femur was removed by 1 cm, but the periosteum and induced membrane around polymethylmethacrylate was preserved. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer with a smooth straight 8-mm-diameter stem was utilized. The bone-spacer junction was fixed with polymethylmethacrylate and then covered with the preserved periosteum and induced membrane. After surgery, the bone atrophy improved. At 9 years and 7 months old, the second spacer was removed because it had loosened, and the knee joint was reconstructed using a custom-made growing femoral prosthesis with a curved porous 8.5-mm-diameter stem. Cancellous bone tips from the proximal tibia were grafted around the bone-prosthesis junction underneath the induced membrane. At 10 years and 5 months old, the patient was able to walk unsupported and a radiograph showed further thickening of the cortex of the residual femur without any stress shielding. Although having 5 cm of limb length discrepancy, the patient and her mother were satisfied with the function. The MSTS score was 24 out of 30 points. Repeated limb length extensions are planned.", "subclaim_evaluations": [ { "subclaim": "The patient is a 5-year-old girl.", "support_label": "supported" }, { "subclaim": "She has high-grade conventional osteosarcoma in the left distal femur.", "support_label": "supported" }, { "subclaim": "She underwent three cycles of neoadjuvant chemotherapy.", "support_label": "supported" }, { "subclaim": "Limb-salvage surgery was planned.", "support_label": "supported" }, { "subclaim": "Femoral rotationplasty had been refused.", "support_label": "not_supported" }, { "subclaim": "At 6 years and 2 months old, distal femoral resection was performed.", "support_label": "supported" }, { "subclaim": "A 7-mm-diameter intramedullary nail was used.", "support_label": "supported" }, { "subclaim": "Molded polymethylmethacrylate was used as a temporary spacer.", "support_label": "supported" }, { "subclaim": "At 7 years and 8 months old, secondary surgery was performed.", "support_label": "supported" }, { "subclaim": "The first spacer had been dislocated.", "support_label": "supported" }, { "subclaim": "The residual femur became atrophic.", "support_label": "supported" }, { "subclaim": "The distal end of the residual femur was removed by 1 cm.", "support_label": "supported" }, { "subclaim": "The periosteum and induced membrane around polymethylmethacrylate was preserved.", "support_label": "supported" }, { "subclaim": "A custom-made ceramic spacer with an 8-mm-diameter stem was utilized.", "support_label": "supported" }, { "subclaim": "The bone-spacer junction was fixed with polymethylmethacrylate.", "support_label": "supported" }, { "subclaim": "The bone atrophy improved after surgery.", "support_label": "supported" }, { "subclaim": "At 9 years and 7 months old, the second spacer was removed because it had loosened.", "support_label": "supported" }, { "subclaim": "The knee joint was reconstructed using a custom-made growing femoral prosthesis.", "support_label": "supported" }, { "subclaim": "The prosthesis had a curved porous 8.5-mm-diameter stem.", "support_label": "supported" }, { "subclaim": "Cancellous bone tips from the proximal tibia were grafted around the bone-prosthesis junction.", "support_label": "supported" }, { "subclaim": "The graft was placed underneath the induced membrane.", "support_label": "supported" }, { "subclaim": "At 10 years and 5 months old, the patient was able to walk unsupported.", "support_label": "not_supported" }, { "subclaim": "A radiograph showed further thickening of the cortex of the residual femur.", "support_label": "supported" }, { "subclaim": "There was no stress shielding observed.", "support_label": "not_supported" }, { "subclaim": "The patient had a 5-cm limb length discrepancy.", "support_label": "supported" }, { "subclaim": "The patient and her mother were satisfied with the function.", "support_label": "not_supported" }, { "subclaim": "The MSTS score was 24 out of 30 points.", "support_label": "supported" }, { "subclaim": "Repeated limb length extensions are planned.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1175_en.txt", "fulltext": "A 38-year-old male complained of palpitation and exertional dyspnea on his first visit to a local hospital in February. He never had a fever, arthralgias, weight loss or fatigue, nor did he have a personal or relevant family history of cardiovascular disease or neoplasms. A grade II/6 pansystolic heart murmur was heard during physical examination. Transthoracic echocardiography (TTE) revealed a large mass in the left ventricle, attached to the anterolateral papillary muscle and chordae tendineae. The local doctor made a preliminary diagnosis of suspected intracardiac fibroelastoma or myxoma, and suggested surgical resection for this intracardiac neoplasm through conventional median sternotomy. However, the patient was deterred by the invasiveness of sternotomy, and refused to have surgery in his local hospital. In May, as he learned about our experience in minimally invasive cardiac surgery, he came to our center.\nWe reexamined the patient. The TTE confirmed a mobile round cystic mass inside the left ventricle. The mass had a hyperechogenic wall and hypoechogenic content and was attached to the anterior mitral leaflet . In systole, the mass prolapsed into the left ventricular outflow tract (LVOT) with accelerated peak velocity (2.5 m/s), which led to mitral regurgitation . The LVOT appeared normal without subvalvular ridge or asymmetric septal hypertrophy. Complementary thoracic and abdominal computed tomographic (CT) scans did not show any evidence of the existence or potential spread of noncardiac neoplasms. All laboratory examinations including tumor markers were unremarkable.\nNon-invasively distinguishing aggressive from non-aggressive intracardiac tumors is an important clinical challenge. Preoperative biopsy for histopathological diagnosis is inapplicable to intracardiac tumors. In this case, fortunately, the TTE provided significant information on morphology, localization, biological characteristics, as well as tumor vascularity-perfusion. The mass had a smooth surface, clear border, and low echodensity. No imaging evidence showed any features of malignancy like vascularity-perfusion, invasion or filtration into the cardiac structure, permeation to the great vessels, or pericardial effusion. So, there was a fairly high probability that this mass would be benign. We made a diagnosis of a primary intracardiac cystic tumor according to the obtained information, and decided to resect the tumor.\nGenerally, a benign intracardiac tumor in this location and size can be accessed via trans-aortic or mitral orifice approach through mini-thoracotomy. Since we have enough experience of totally endoscopic mitral surgery, we decided to perform the operation in a totally thoracoscopic approach, and manage the possible deformation and dysfunction of the cardiac structure if necessary.\nTumor resection was planned and performed through a totally endoscopic, video-assisted approach with thoracoscopy and femoral cannulation (Supplemental Video). The cardiopulmonary bypass and the surgical approach were established as the conventional endoscopic mitral surgery . A 35-mm working port was made in the fourth interspace, lateral to the midclavicular line. After deflation of the right lung, two additional ports were then placed: a camera port through the anterior axillary line in the fourth interspace, and an 8-mm port in the lateral fifth interspace for a transthoracic Chitwood clamp (Scanlan International, Minneapolis, Minn). We used the Chitwood clamp to occlude the ascending aorta and administrated the antegrade cardioplegia. A left atriotomy was performed, and the atrial retractor was applied. The mitral orifice and the mass were then clearly visualized . The mass was oval and reddish, partly attached to the chordate structure of anterior papillary muscle and A1 area of anterior mitral leaflet via two pedicles . We completely excised the mass through the roots of the pedicles, and then carefully cauterized the margin of excision. The size and structure of the mitral leaflets and subvalvular apparatus appeared to be normal. No surgical injuries were found during further exploration . The saline test showed no mitral regurgitation.\nThe excised mass was 25 mm*20 mm*20 mm in size . Pathologic diagnosis confirmed a simple blood cyst, consistent with blood-filled space lined with a single layer of endothelium. The patients had an uneventful recovery. He was able to walk on the first postoperative day and was discharged three days after the operation. The patient was symptom-free and working full time during follow-up.", "summary": "An apparently healthy 38-year-old male presented to his local hospital with six months history of palpitation and exertional dyspnea. Transthoracic echocardiography showed a mobile round cystic mass inside the left ventricle, attached to the anterolateral papillary muscle and chordae tendineae of the mitral valve. The local doctor diagnosed an intracardiac tumor and suggested a surgical resection through median sternotomy. However, the patient refused to have a sternotomy. He was then referred to us seeking minimally invasive surgery. We assessed the location, appearance and relationship to nearby structures of the tumor with echocardiography, and made a diagnosis of a suspected primary cystic intracardiac tumor. Since we had enough experience of totally endoscopic mitral surgery, our surgical plan was to resect the tumor in the aid of thoracoscopy, and manage the possible deformation and dysfunction of the cardiac structure if necessary. Using femoro-femoral cannulation and cardiopulmonary bypass, we successfully resected the tumor through a thoracoscopic approach in a closed chest, and well preserved the subvalvular structure and valvular function. Postoperative recovery was quick and uneventful. Pathologic diagnosis confirmed a simple blood cyst.", "subclaim_evaluations": [ { "subclaim": "The patient is a 38-year-old male.", "support_label": "supported" }, { "subclaim": "He had six months of palpitation.", "support_label": "not_supported" }, { "subclaim": "He had exertional dyspnea.", "support_label": "supported" }, { "subclaim": "Transthoracic echocardiography showed a mobile round cystic mass inside the left ventricle.", "support_label": "supported" }, { "subclaim": "The mass was attached to the anterolateral papillary muscle.", "support_label": "supported" }, { "subclaim": "The mass was attached to the chordae tendineae of the mitral valve.", "support_label": "supported" }, { "subclaim": "The local doctor diagnosed an intracardiac tumor.", "support_label": "supported" }, { "subclaim": "The local doctor suggested surgical resection through median sternotomy.", "support_label": "supported" }, { "subclaim": "The patient refused sternotomy.", "support_label": "supported" }, { "subclaim": "The patient was referred for minimally invasive surgery.", "support_label": "supported" }, { "subclaim": "The tumor was diagnosed as a suspected primary cystic intracardiac tumor.", "support_label": "supported" }, { "subclaim": "The surgical plan was to resect the tumor using thoracoscopy.", "support_label": "supported" }, { "subclaim": "The surgery used femoro-femoral cannulation.", "support_label": "not_supported" }, { "subclaim": "The surgery used cardiopulmonary bypass.", "support_label": "supported" }, { "subclaim": "The tumor was resected through a thoracoscopic approach.", "support_label": "supported" }, { "subclaim": "The subvalvular structure was preserved.", "support_label": "supported" }, { "subclaim": "Valvular function was preserved.", "support_label": "supported" }, { "subclaim": "Postoperative recovery was quick.", "support_label": "supported" }, { "subclaim": "Postoperative recovery was uneventful.", "support_label": "supported" }, { "subclaim": "Pathologic diagnosis confirmed a simple blood cyst.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1672_en.txt", "fulltext": "Patient is a 90-year-old Caucasian female with a past medical history of gastroesophageal reflux disease symptomatically managed with pantoprazole 40 mg daily, hypothyroidism, depression, anxiety, and peripheral neuropath; who presented to the emergency department (ED) with nausea, vomiting and abdominal pain. She also had a fever of 101.5 F and was complaining of chills. She initially went to a local ED where laboratory evaluation revealed a urinary tract infection. She was found to have elevated serum amylase (890 U/L) and lipase (3500 U/L) levels as well. Her white blood cell count was 11,000/mcL. Total bilirubin, alanine aminotransferase and aspartate aminotransferase levels were normal. Her blood cultures grew Gram-negative rods and Gram-positive cocci for which she was started on vancomycin [1250 mg every 12 h] and Zosyn® [3.375 gm every 6 h].\nA computed tomography (CT) scan of the abdomen and pelvis without intravenous contrast was performed which showed a very large hiatal hernia compressing and deforming the heart amongst other structures. The majority of the stomach along with the body and tail of the pancreas were herniated into the mediastinum. There was a large amount of free fluid in the mediastinum. There was dependent cholelithiasis and a distended gallbladder with signs of acute cholecystitis. A right upper quadrant ultrasound (RUQ US) showed intra and extra-hepatic biliary ductal dilation with possible echogenic material within the common bile duct. There was gallbladder wall thickening and peri-cholecystic fluid, these findings were thought to represent either acute cholecystitis or secondary to pancreatitis. The patient underwent an echocardiogram which showed left ventricular ejection fraction of 74%. There were no regional wall motion abnormalities.\nBased on the findings of RUQ US, an endoscopic retrograde cholangiopancreatogram (ERCP) was performed which showed a normal esophagus, large hiatal hernia with most of the stomach above the diaphragm and a duodenal diverticulum. The major papilla was located entirely within the diverticulum. The entire main bile duct was dilated. Choledocholithiasis was found.\nA repeat CT scan of the chest, abdomen and pelvis with intravenous contrast was performed. The body and tail of the pancreas was found to be herniating into the mediastinum .\nThe patient was continued on vancomycin and Zosyn®. The bacteria were found to be ampicillin-sensitive Enterococcus durans and a pan-sensitive E. coli. She was switched to ampicillin [2 g every 6 h] for the next 2 days and finally to oral amoxicillin PO [500 mg every 8 h]. Given the findings of large hiatal hernia, General Surgery was consulted. Given the chronicity of the patient’s symptoms, her age and relatively good symptom control with proton pump inhibitors, a conservative approach to therapy was recommended with no surgical consideration for hiatal hernia repair. An elective cholecystectomy was offered to the patient and she elected to discuss this at a clinic visit in the upcoming weeks. On the day of discharge, the patient was tolerating a diet, had no pain or nausea, and was feeling well.", "summary": "We report an unusual case of pancreatic herniation into the mediastinum in a 90-year-old Caucasian female. This patient initially presented with nausea and vomiting associated with abdominal pain. Serum lipase and amylase both were elevated. Computed tomography scan of the chest, abdomen and pelvis revealed a large hiatal hernia with pancreas herniation into the mediastinum, with superimposed acute pancreatitis likely due to gallstone. Because of its unusual location, the patient also developed acute mediastinitis. The patient was management conservatively and did well. On the day of discharge; she was tolerating a diet, had no pain or nausea and was back to her baseline health.", "subclaim_evaluations": [ { "subclaim": "The patient is a 90-year-old Caucasian female.", "support_label": "supported" }, { "subclaim": "The patient had pancreatic herniation into the mediastinum.", "support_label": "supported" }, { "subclaim": "The patient presented with nausea and vomiting.", "support_label": "supported" }, { "subclaim": "The patient had abdominal pain.", "support_label": "supported" }, { "subclaim": "Serum lipase was elevated.", "support_label": "supported" }, { "subclaim": "Serum amylase was elevated.", "support_label": "supported" }, { "subclaim": "Computed tomography scan showed a large hiatal hernia.", "support_label": "supported" }, { "subclaim": "Computed tomography scan showed pancreas herniation into the mediastinum.", "support_label": "supported" }, { "subclaim": "The acute pancreatitis was likely due to gallstone.", "support_label": "supported" }, { "subclaim": "The patient developed acute mediastinitis.", "support_label": "not_supported" }, { "subclaim": "The patient was managed conservatively.", "support_label": "supported" }, { "subclaim": "On the day of discharge, the patient was tolerating a diet.", "support_label": "supported" }, { "subclaim": "On the day of discharge, the patient had no pain or nausea.", "support_label": "supported" }, { "subclaim": "On the day of discharge, the patient was back to her baseline health.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3256_en.txt", "fulltext": "The parents of a previously healthy 2-year-old child came to our hospital with complaints of malaise, lethargy, vomiting, loose stools, yellowing of the sclera and skin, dark urine and white stools, which have been observed in the child for 4 days. Possible contact with infectious patients, use of drugs and other potentially toxic substances was not detected. The objective status of the child during hospitalization was characterized by elevated body temperature (37.7°C), marked lethargy, icteric coloration of the skin and mucous membranes, hepatomegaly. Heart rate (HR) – 123/min., respiratory rate – 24/min., SpO2-98%. The examination revealed an increase in total bilirubin to 129.6 μmol/l, direct fraction to 116.24 μmol/l, increased levels of transaminases: ALT - 4.5 mmol/l/h, AST - 3.3 mmol/l/h. Taking into account the clinical data, viral hepatitis was suspected, an appropriate examination and symptomatic therapy were prescribed.\n\nSpecific studies revealed positive titers of IgM HAV and IgM EBV (VCA), negative results of examination for markers of HBV (HBsAg), HCV (IgM+G), cytomegalovirus (IgM) and leptospirosis (PCR). An ultrasound examination revealed an increase in the size and increased echogenicity of the liver. Taking into account the detected markers, the disease was considered to be viral hepatitis A with EBV co-infection.\n\nDuring the first three days of inpatient treatment, the child’s condition remained stable, vital functions were within normal limits. In laboratory tests, there was a tendency to decrease the elevated levels of bilirubin and transaminases. On the fourth day of stay, a disturbance of consciousness appeared in the form of stupor (on the Glasgow coma scale (GCS) - (E3V4M5)=12b). The appearance of neurological symptoms was associated with deterioration of coagulation hemostasis indicators (Prothrombin index (PI), Activated partial thromboplastin time (APTT)), a decrease in the concentration of protein in blood serum. The worsening of the condition was considered as ALF. The treatment included antibacterial therapy (cefotaxime 50 mg/kg/day), corticosteroids (dexamethasone 0.6 mg/kg/day), parenteral nutrition, replacement therapy (fresh-frozen plasma), albumin 20%, glutargin 80 mg/day, thioctic acid 10 units/kg/day, canavit up to 5 mg/day, respiratory support (ventilation). Over the next two days, the child’s condition worsened due to ALF. Disturbances of consciousness progressed to severe coma (according to the FOUR (E0M0B0R1) scale = 1 point, without drug sedation), peripheral edema developed, hemorrhagic contents appeared through the nasogastric tube, intestinal peristalsis was suppressed, oligo-anuria developed, laboratory tests showed progression anemia, an increase in the level of indirect bilirubin, indicators of coagulation hemostasis worsened (Table 1). On the 6th day of hospital stay, the child had a cardiac arrest (asystole), which did not recover after resuscitation measures.\n\n", "summary": "A 2-year-old child was hospitalized on the 4th day of the disease with manifestations of jaundice and general intoxication. The examination revealed markers of active hepatitis A virus infection and Epstein-Barr virus infection. From the seventh day of the disease, the child's condition began to progressively deteriorate due to manifestations of ALF. Despite the use of immunomodulatory and replacement therapy, the disease ended fatally on the 9th day. Pathohistological examination revealed manifestations of viral necrotic hepatitis on the background of autoimmune sclerosing cholangitis.\n\nOn the 4th day of inpatient treatment, a liver biopsy was performed. The pathohistological study revealed changes in the liver, which were characterized by the following changes: the beam structure is absent, the parenchyma with disturbed architecture due to widespread massive necrosis. When carrying out a histochemical reaction with Azan, soft-fibrous fibrosis in the parenchyma is noted. In immunohistochemical reactions with cytokeratin, the expression of biliary epithelium in the parenchyma in the form of false bile ducts is noted. Immunohistochemical reaction with CD45 and CD68 – diffuse expression of lymphocytic and macrophage cells in the parenchyma.\n\nThe results of histological examination were considered as manifestations of viral necrotic hepatitis against the background of autoimmune sclerosing cholangitis.", "subclaim_evaluations": [ { "subclaim": "The child was hospitalized on the 4th day of the disease.", "support_label": "supported" }, { "subclaim": "The child had manifestations of jaundice.", "support_label": "supported" }, { "subclaim": "The child had manifestations of general intoxication.", "support_label": "supported" }, { "subclaim": "Markers of active hepatitis A virus infection were present.", "support_label": "supported" }, { "subclaim": "Markers of Epstein-Barr virus infection were present.", "support_label": "supported" }, { "subclaim": "The child's condition began to progressively deteriorate on the 7th day.", "support_label": "not_supported" }, { "subclaim": "The deterioration was due to manifestations of acute liver failure.", "support_label": "supported" }, { "subclaim": "The disease ended fatally on the 9th day.", "support_label": "not_supported" }, { "subclaim": "A liver biopsy was performed on the 4th day of inpatient treatment.", "support_label": "not_supported" }, { "subclaim": "The beam structure of the liver was absent.", "support_label": "not_supported" }, { "subclaim": "The liver parenchyma had disturbed architecture due to widespread massive necrosis.", "support_label": "not_supported" }, { "subclaim": "Soft-fibrous fibrosis in the parenchyma was noted with Azan histochemical reaction.", "support_label": "not_supported" }, { "subclaim": "Immunohistochemical reaction with cytokeratin showed expression of biliary epithelium in the form of false bile ducts.", "support_label": "not_supported" }, { "subclaim": "Immunohistochemical reaction with CD45 showed diffuse expression of lymphocytic cells in the parenchyma.", "support_label": "not_supported" }, { "subclaim": "Immunohistochemical reaction with CD68 showed diffuse expression of macrophage cells in the parenchyma.", "support_label": "not_supported" }, { "subclaim": "The histological findings were considered as viral necrotic hepatitis against the background of autoimmune sclerosing cholangitis.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_341_en.txt", "fulltext": "An 8-year-old female presented to the pediatric haematology-oncology department at the Sun Yat-sen Memorial Hospital for scheduled chemotherapy treatment. The child was diagnosed with acute lymphoblastic leukaemia (Pre-B-ALL, BCR/ABL p190 positive) 2 months ago and the risk stratification was set as high risk.\nThe patient commenced the first round of CAM (cyclophosphamide + cytarabine + 6-mercaptopurine) regimen of induction chemotherapy along with oral dasatinib treatment. The child experienced neutropenia and developed a fever (38.5 °C) with occasional cough and pharyngeal discomfort. Chemotherapy was stopped and meropenem was used. Fever repeated with elevated fever peaks. C-reactive protein (CRP) increased to 23.3 mg/dL, while blood and sputum cultures were negative. Computed tomography (CT) scan showed multiple small patchy hyperdense shadows in both lungs with poorly defined borders, mainly in the lower lobes of both lungs . According to the examination results and the agranulocytosis state, teicoplanin combined with trimethoprim-sulfamethoxazole(TMP-SMX) and caspofungin were prescribed. Methylprednisolone (1 mg/kg qd) was also utilised. The patient's temperature did not decrease, and dyspnea gradually developed. The NGS test result indicated a Pneumocystis jirovecii infection, and ticoranine was discontinued.\nThe child's dyspnea significantly worsened, and the PaO2 was 59 mmHg (with an oxygen supplementation via mask at 8L/min). She was transferred to the pediatric intensive care unit (PICU) and intubated. Chest X-ray showed large dense shadows in the middle and lower lungs . The Procalcitonin(PCT) was mildly elevated(0.65 ng/ml). The 1,3-beta-D-glucan test (G test) result was positive (634 pg/mL) while the galactomannan test (GM test) result (0.33 μg/L) was negative. EBV, CMV nucleic acid test, as well as blood and sputum cultures were negative. Considering the severity of pneumonia and neutrophil deficiency after chemotherapy, linezolid was commenced for anti-infection treatment, and granulocyte colony-stimulating factor (G-CSF) (5 ug/kg.d) was administered to promote proliferation and differentiation of the bone marrow granulocyte lineage. Subsequently, the neutrophil count and C-reactive protein (CRP) began to rise rapidly .The sputum mNGS test result also showed a Pneumocystis jirovecii infection 2 days later, and the anti-infective regimen remained unchanged.\nThe patient's temperature decreased, but a gradually increasing ventilator parameter was required to maintain the oxygen saturation. The oxygenation index (OI) was between 14-and 16, implying the existence of moderate acute respiratory distress syndrome, according to the Pediatric Acute Lung Injury Consensus (PALICC). Inflammatory factor levels were significantly increased: sIL-2R (soluble IL-2 receptor, soluble IL-2 receptor) 5049 U/mL, IL-6 1141 pg/mL, IL-10 70.9 pg/mL, and IL-8 1242 pg/mL . The chest X-ray showed multiple speckled, corn-like dense shadows in both lungs with indistinct borders and lattice-like changes , T-SPOT and serological tests of common respiratory pathogens (Mycoplasma pneumonia, adenovirus, respiratory syncytial virus, parainfluenza virus, influenza virus A, influenza virus B, Legionella type 1–7, coxsackievirus A, coxsackievirus B, echovirus IgM) were negative. Meropenem and linezolid were replaced with amikacin and tigecycline. The peak and the frequency of fever decreased, but the ventilator parameters were still high, with OI values between 10 and 13.\nOn the 16th day, the CT scan showed that the patchy hyper-dense shadows were alleviated, but interstitial thickening with grid-like changes and ground-glass opacities appeared in both lungs, suggestive of bilateral interstitial pneumonia . The fibrosis markers significantly increased: collagen type IV (CIV) 140.12 ng/mL, pre-collagen peptide III (PCIII) 151.18 ng/mL, and hyaluronic acid (HA) 1056.81 ng/mL. High-dose methylprednisolone (10 mg/kg.d × 5 d) pulse therapy was given, along with the anti-fibrotic treatment of pirfenidone and acetylcysteine. But the lung function did not improve, and the X-ray showed corn-like high-density shadows in both lungs with unclear borders and grid-like changes . The child's parents opted for withdrawal of medical care, and the girl died after being discharged from the hospital.", "summary": "An 8-year-old girl presented with acute lymphoblastic leukaemia was admitted for scheduled chemotherapy treatment. During chemotherapy, she experienced pancytopenia and Pneumocystis jirovecii pneumonia, which was diagnosed based on the abnormal shadows observed on chest computed tomography, the elevation of serum β-D-glucan, and the positive mNGS results of Pneumocystis jirovecii in both sputum and blood. After treatment with Granulocyte Colony-Stimulating Factor, sulfamethoxazole, and caspofungin, aggravation of lung lesions was discovered and severe interstitial lung disease developed in a short period along with a rapidly increasing leukocyte count. Intravenous methylprednisolone pulse therapy was given, but lung function did not improve, and she finally died after the withdrawal of medical care.", "subclaim_evaluations": [ { "subclaim": "An 8-year-old girl presented with acute lymphoblastic leukaemia.", "support_label": "supported" }, { "subclaim": "She was admitted for scheduled chemotherapy treatment.", "support_label": "supported" }, { "subclaim": "During chemotherapy, she experienced pancytopenia.", "support_label": "not_supported" }, { "subclaim": "She was diagnosed with Pneumocystis jirovecii pneumonia.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on abnormal shadows observed on chest computed tomography.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on the elevation of serum β-D-glucan.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on positive mNGS results of Pneumocystis jirovecii in sputum.", "support_label": "supported" }, { "subclaim": "The diagnosis was based on positive mNGS results of Pneumocystis jirovecii in blood.", "support_label": "not_supported" }, { "subclaim": "She received treatment with Granulocyte Colony-Stimulating Factor.", "support_label": "supported" }, { "subclaim": "She received treatment with sulfamethoxazole.", "support_label": "supported" }, { "subclaim": "She received treatment with caspofungin.", "support_label": "supported" }, { "subclaim": "Aggravation of lung lesions was discovered.", "support_label": "supported" }, { "subclaim": "Severe interstitial lung disease developed in a short period.", "support_label": "supported" }, { "subclaim": "There was a rapidly increasing leukocyte count.", "support_label": "not_supported" }, { "subclaim": "Intravenous methylprednisolone pulse therapy was given.", "support_label": "supported" }, { "subclaim": "Lung function did not improve.", "support_label": "supported" }, { "subclaim": "Medical care was withdrawn.", "support_label": "supported" }, { "subclaim": "She finally died.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_402_en.txt", "fulltext": "A 71-year-old woman with a pancreatic tumor involving the head and uncinate process was referred to our hospital with symptoms of back pain, weight loss, and diabetes. According to imaging, the tumor was approximately 30 mm in diameter. The patient was diagnosed with pancreatic duct adenocarcinoma based on findings from an endoscopic ultrasound-guided fine-needle biopsy specimen. The tumor was in contact with the right side of the SMV at the level where it received the first jejunal vein tributary. The tumor attachment to the SMV had a longitudinal extent of about 20 mm but involved less than half of the vein’s circumference, so the tumor was considered resectable. However, extension of tumor along the retropancreatic nerve plexus (RNP) approached the superior mesenteric artery (SMA; Fig. ), so based upon the results of the PREP-02/JSAP-05 trial , 2 cycles of gemcitabine and S-1 were administered before surgery.\nAlthough no radiologically evident changes of tumor status were recognized after chemotherapy, we planned to carry out pancreatoduodenectomy with SMV resection and reconstruction. The first jejunal vein tributary would be resected, provided that a vein-clamping test produced no jejunal congestion. Then the segment of the SMV caudal to its confluence with the inferior mesenteric vein (IMV) would be resected in continuity with the pancreatic tumor. Reconstruction of the SMV by simple end-to-end suturing without a venous graft would be difficult, considering that both the splenic vein and the IMV were to be preserved.\nOne notable finding from computed tomography (CT) before surgery was dilation of the right ovarian vein to a diameter of about 10 mm, similar to the SMV diameter where resection was planned . Although the patient had no active symptoms of PCS such as chronic pelvic pain, feelings of heaviness, or urinary urgency at the time of surgery, she had experienced severe dysmenorrhea prior to menopause and still had occasional feelings of pelvic heaviness, suggesting that she was at future risk for PCS. We reasoned that use of the dilated right ovarian vein as a graft might prevent or lessen such occurrences while also offering dimensions favorable for grafting.\nNo cancer dissemination was grossly evident at laparotomy; subsequent cytologic examination of abdominal lavage fluid detected no malignant cells. Dissection began with liberal application of the Kocher maneuver to the duodenum and firm retraction of the pancreatic head to the left. The peritoneum at the base of the transverse mesocolon was divided to approach the SMA and SMV, as in the mesenteric approach . When no evident jejunal congestion resulted from clamping the first jejunal vein tributary near the confluence of the tributary and the SMV, the tributary was ligated and divided. We performed the retropancreatic nerve plexus (RNP) hanging maneuver as we previously reported , making sure that the cut end of the RNP was free of cancer invasion. In brief, the RNP hanging maneuver was carried out as follows. The middle colic artery arising from the SMA and the middle colic vein both were ligated and divided, after which the SMA trunk was followed cranially to its origin. The tape for RNP hanging was placed around the RNP, which was divided together with ligation and division of the inferior pancreatoduodenal artery in the plane determined by the hanging tape prior to any division of the pancreatic parenchyma and gastric antrum. A 3-cm minimum length of the dilated right ovarian vein was removed for use as a venous graft. The tumor was removed together with the portion of the SMV that it had invaded. The SMV was reconstructed with no venous bypass, using the right ovarian vein graft. Obvious valves were not recognized within the patient’s graft after harvesting, so we carried out reconstruction in a standard manner: distal end to distal end and proximal end to proximal end. The duration of reconstruction was 38 min , while total duration of the operation was 607 min. Intraoperative blood loss was 390 mL. The pathologic diagnosis was invasive ductal carcinoma; the stage according to the classification of pancreatic carcinoma was pT3pN1b (4/40) M0, pStage IIB, with invasion of the SMV (pPV1). R0 resection status was achieved.\nThe postoperative course was uneventful, and the patient was discharged 25 days after surgery. She has finished adjuvant chemotherapy and was free from disease recurrence at 8 months after surgery. PCS symptoms have not occurred. Patency of the venous graft for SMV reconstruction was confirmed by contrast CT carried out with administration of a direct oral anticoagulant 8 months after surgery .", "summary": "A 71-year-old woman with cancer involving the pancreatic head, uncinate process, and SMV underwent pancreatoduodenectomy with SMV resection. Reconstruction used a portion of the right ovarian vein that was markedly dilated and had placed her at risk for pelvic congestion syndrome (PCS). Graft patency was confirmed 8 months after surgery. She now finished receiving adjuvant chemotherapy and has no symptoms of PCS.", "subclaim_evaluations": [ { "subclaim": "The patient is a 71-year-old woman.", "support_label": "supported" }, { "subclaim": "She has cancer involving the pancreatic head.", "support_label": "supported" }, { "subclaim": "She has cancer involving the uncinate process.", "support_label": "supported" }, { "subclaim": "She has cancer involving the superior mesenteric vein (SMV).", "support_label": "supported" }, { "subclaim": "She underwent pancreatoduodenectomy.", "support_label": "supported" }, { "subclaim": "She underwent SMV resection.", "support_label": "supported" }, { "subclaim": "Reconstruction used a portion of the right ovarian vein.", "support_label": "supported" }, { "subclaim": "The right ovarian vein was markedly dilated.", "support_label": "supported" }, { "subclaim": "The dilated right ovarian vein placed her at risk for pelvic congestion syndrome.", "support_label": "supported" }, { "subclaim": "Graft patency was confirmed 8 months after surgery.", "support_label": "supported" }, { "subclaim": "She has finished receiving adjuvant chemotherapy.", "support_label": "supported" }, { "subclaim": "She has no symptoms of pelvic congestion syndrome.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2802_en.txt", "fulltext": "A 69-year-old Japanese man who sustained an injury in a car collision received first aid at a nearby hospital and underwent craniotomy surgery for traumatic acute subdural hematoma, traumatic subarachnoid hemorrhage, and traumatic localized brain contusion. Conservative treatment was given for left-sided condylar process fracture, axis fracture, right clavicle fracture, and right fracture of the distal radius. After his consciousness disorder improved, 4 months after injury, it became clear that the patient was unable to close his mouth. His TMJ may have been dislocated during intubation. The mouth presented in an open state, with lip closure incapacity . Stenosis of the jaw dentition was demonstrated with labioclination of the front tooth, open bite, and xerostomia. The patient had a tracheostomy and could not evaluate the verbal response, Glasgow Coma Scale (GCS) 11. Traumatic brain injury left paralysis of his right upper extremity. The patient was at high risk of aspiration pneumonia due to diminished swallowing function, so the previous doctor had performed an additional gastrostomy, which recovered his ability to eat.\nPanoramic radiography examination revealed a left condylar process fracture and dislocation of the bilateral mandibular condyles. On computed tomography examination, the left condylar process fracture on the medial side and both mandibular condyles greatly exceeded the articular tubercle .\nWe attempted a manual reduction owing to the existing diagnosis of old left condylar fracture and bilateral anterior dislocation of the TMJ, but reduction was impossible. Therefore, we planned to perform right condylar resection using an intraoral approach. In addition, we evaluated the planned procedure using a three-dimensional model and confirmed that it would not disturb the jaw reposition, because the left condylar process fractures to medial. We confirmed that it was difficult to reduce and fix the old fracture and that it did not interfere with the reproduction of the original occlusion on the three-dimensional model, so we decided to treat it conservatively.\nWe performed right condylectomy with the patient under general anesthesia. Manual reduction was performed again in a state of muscle relaxation, but reduction was not possible. After an incision was made in the buccal mucosa according to the sagittal split ramus osteotomy, the inside and outside of the mandibular ramus was revealed, and the coronoid process and the neck of the mandible were confirmed . The coronoid process obstructed the visual field, so it was cut and resected with a reciprocating saw . Using a saw and osteotome, the base of the condylar was cut and separated from the surrounding soft tissue to remove the condylar head . We confirmed that the mandibular body had moved backward and that the molars could achieve the occlusion, and the wound was closed. Intermaxillary traction was started during the postoperative period using an intermaxillary fixation screw inserted in the alveolar region to improve occlusal deviation. Twenty-one days after the operation, a normal occlusion was obtained, and intermaxillary fixation screw was removed. During the 12-month postoperative follow-up period, no TMJ dislocation recurred, and the occlusion remained stable . After the operation, he was able to open and close the mouth by himself, and the lips could be closed, so that hypersalivation did not occur. His left condylar process was displaced inward owing to a fracture, but the opening and closing movements were possible because the hinge movement centered on the left condylar process.", "summary": "A 69-year-old Japanese man who sustained an injury in a car collision was unable to close his mouth. Owing to the diagnosis of long-standing temporomandibular joint dislocation, intraoral condylectomy was performed. In the case of temporomandibular joint dislocation, it is convenient to reach the condyle from the oral cavity because sufficient opening is maintained. The condyle can be clearly visualized using an approach similar to sagittal split ramus osteotomy, and the operation using surgical instruments can be facilitated by resecting the coronoid process. By separating the surrounding soft tissue and pulling the cut condyle with sufficient visual field, the condyle can be resected while addressing the hemostasis. During the 12-month postoperative follow-up period, no temporomandibular joint dislocation recurred and the occlusion remained stable.", "subclaim_evaluations": [ { "subclaim": "The patient was a 69-year-old Japanese man.", "support_label": "supported" }, { "subclaim": "The patient sustained an injury in a car collision.", "support_label": "supported" }, { "subclaim": "The patient was unable to close his mouth.", "support_label": "supported" }, { "subclaim": "The diagnosis was long-standing temporomandibular joint dislocation.", "support_label": "supported" }, { "subclaim": "Intraoral condylectomy was performed.", "support_label": "supported" }, { "subclaim": "In the case of temporomandibular joint dislocation, it is convenient to reach the condyle from the oral cavity.", "support_label": "supported" }, { "subclaim": "Sufficient opening is maintained in temporomandibular joint dislocation.", "support_label": "supported" }, { "subclaim": "The condyle can be clearly visualized using an approach similar to sagittal split ramus osteotomy.", "support_label": "supported" }, { "subclaim": "The operation can be facilitated by resecting the coronoid process.", "support_label": "supported" }, { "subclaim": "The condyle can be resected while addressing the hemostasis.", "support_label": "supported" }, { "subclaim": "During the 12-month postoperative follow-up period, no temporomandibular joint dislocation recurred.", "support_label": "supported" }, { "subclaim": "The occlusion remained stable during the 12-month postoperative follow-up period.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1952_en.txt", "fulltext": "A 55-year-old Greek woman was referred to our clinic for the management of a cystic lesion located in the tail of the pancreas. The lesion was discovered incidentally during her staging workup with abdominal ultrasound for invasive ductal adenocarcinoma of the left breast 16 months ago. Just after a modified radical left mastectomy had been performed, we further investigated the pancreatic lesion with a magnetic resonance imaging (MRI) scan, which revealed a space-occupying cystic lesion of maximum diameter of 5 cm located in the tail of the pancreas with calcifications of the wall and a central cystic component . Besides the chemo-, radio-, and hormonal therapy she received for her breast cancer, her past medical history also included hypothyroidism under hormone-replacement therapy.\nThe findings in the physical examination were unremarkable. Blood investigation and tumor markers (CEA, CA 15-3, CA 19-9, and CA 125) were within normal limits. The possibility of a mucinous cystic neoplasm of the pancreas was considered, and a laparoscopic distal pancreatectomy and a splenectomy were chosen.\nThe first distal pancreatectomy in pigs was described by Soper et al. in 1994; 2 years later, Gagner reported his first five cases of spleen-preserving laparoscopic distal pancreatectomy for insulinoma.\nIn our case, the patient was placed in a modified lithotomy position, with the surgeon standing between the legs of the patient. We used a five-port technique, placing a 12 mm trocar left paramedian at about the level of the umbilicus, a 10 mm-trocar in the left upper quadrant of the abdomen on the anterior axillary line, a 10 mm-trocar in the subxiphoid region, a 5 mm-trocar in the left hypochondrium on the midclavicular line, and a 5 mm-trocar in the right hypochondrium in the midclavicular line as well . Pneumoperitoneum was established with the open Hasson technique through the 12 mm paramedian port. Exploratory laparoscopy did not reveal macroscopically evident intra-abdominal metastases. We used a 30-degree laparoscope and an ultrasonic dissector (UltraCision; Ethicon, Endosurgery). After entering the lesser sac, we identified the splenic artery at the upper border of the pancreas after its origin from the celiac axis, and we ligated, by using a disposable clip applicator (U.S. Surgical Corp., Norwalk, CT) . The mobilization of the pancreas started at the reflexion of the superior leaf of the transverse mesocolon on the pancreas. The plane at the inferior border of the body of the pancreas was opened with blunt dissection, gradually exposing the posterior surface of the pancreas. The splenic vein was gently dissected by using a right-angle dissector and was ligated with clips. After sufficiently mobilizing the pancreas, this was transected by using an endoGIA (45 × 2.5 mm) . Subsequent mobilization of the spleen from its attachments to the diaphragm, colon, and left kidney was performed. The specimen was retrieved through a vertical extension of the paramedian port site in a retrieval endobag (Autosuture, Norwalk, CT). A drain was placed in the splenic fossa. Estimated intraoperative blood loss was 320 ml, and no blood transfusion was required. The pathology report revealed a pancreatic tumor 5 cm in diameter. The lesion was multiloculated, contained a yellowish fluid and a thick, stiffened wall, consisting of dense fibrotic tissue with hyaline degeneration, calcifications, regions of ossific metaplasia, and microscopic foci of neoplasmatic tissue, compatible with cystic-solid pseudopapillary neoplasm of the pancreas. Seven reactive regional lymph nodes were harvested, and resection margins were free.\nThe postoperative course was complicated by a pancreatic fistula (50 ml/d) grade B and a reactive left pleural effusion. On the fifth postoperative day, a CT scan of the abdomen was performed, and a subdiaphragmatic collection was drained under CT guidance. The patient's clinical condition was improved, and the patient was finally discharged on postoperative day 13. The patient's follow-up (with abdominal CT and biochemical tests yearly) in a time period of 36 months revealed no disease recurrence or development of diabetes.", "summary": "We report the case of a 55-year-old Greek woman with a solid pseudopapillary tumor of the tail of the pancreas. She underwent a laparoscopic distal pancreatectomy and splenectomy. The histopathologic examination finally revealed a cystic-solid pseudopapillary neoplasm of the pancreas. Solid pseudopapillary tumors of the pancreas are rare and affect predominantly young women. These tumors are of unclear pathogenesis and low malignancy, and surgical resection offers an excellent chance for long-term survival.", "subclaim_evaluations": [ { "subclaim": "The patient is a 55-year-old Greek woman.", "support_label": "supported" }, { "subclaim": "The patient had a solid pseudopapillary tumor of the tail of the pancreas.", "support_label": "supported" }, { "subclaim": "The patient underwent a laparoscopic distal pancreatectomy.", "support_label": "supported" }, { "subclaim": "The patient underwent a splenectomy.", "support_label": "supported" }, { "subclaim": "Histopathologic examination revealed a cystic-solid pseudopapillary neoplasm of the pancreas.", "support_label": "supported" }, { "subclaim": "Solid pseudopapillary tumors of the pancreas are rare.", "support_label": "supported" }, { "subclaim": "Solid pseudopapillary tumors of the pancreas affect predominantly young women.", "support_label": "not_supported" }, { "subclaim": "The pathogenesis of solid pseudopapillary tumors of the pancreas is unclear.", "support_label": "not_supported" }, { "subclaim": "Solid pseudopapillary tumors of the pancreas are of low malignancy.", "support_label": "supported" }, { "subclaim": "Surgical resection offers an excellent chance for long-term survival in patients with solid pseudopapillary tumors of the pancreas.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_984_en.txt", "fulltext": "A 46 year-old man with HIV/AIDS (CD4 T-cell 115 × 106/l) presented with two weeks of left 5th digit pain and swelling. He denied any history of recent trauma to the hand, fever, weight loss, or other systemic symptoms, but did note an occasional dry cough. He had traveled repeatedly between his native country Ivory Coast, West Africa and the United States. He was not taking antiretroviral medications at the time of presentation. On physical exam his fifth digit was swollen and erythematous at the proximal intraphalangeal joint [figure ]. His laboratory values on admission were as follows: white blood cell count 5000 cells/mm3, hemoglobin 11.6 grams/dl, hematocrit 33.9%, platelets 280,000 platelets/mm3, eosinophils 9.0%, and erythrocyte sedimentation rate (ESR) of 60 mm/hour. Left hand radiography was significant for soft tissue swelling over the left finger with joint space narrowing and cortical lucencies with cystic degenerative changes in the proximal phalanx [figure ]. Admission chest radiography demonstrated right hilar lymph node enlargement with multiple scattered nodules and a resolving right lower lobe infiltrate. Computed tomography scan of the chest revealed multiple pulmonary nodules [figure ], necrotic lymph nodes, and splenomegaly. The patient underwent incision, drainage, and biopsy of the affected finger. Operative findings were significant for purulent, mottled, soft, yellow bone.\nRare acid-fast bacilli were demonstrated on biopsy of the both phalanx and synovial fluid samples [figure ]. We used the Gen-PROBE® Amplified Mycobacterium tuberculosis Direct Test which employs a transcription-mediated amplification and hybridization protection assay to qualitatively detect Mycobacterium tuberculosis complex ribosomal RNA (rRNA). Several weeks later cultures of all surgical material grew Mycobacterium tuberculosis [figure ]. Multiple Ziehl-Neelsen stains of induced sputum samples were negative for acid-fast bacilli, but all specimens sent for sputum culture grew Mycobacterium tuberculosis. Antituberculous treatment was initiated with rifampin, isoniazid, pyrizinamide, and ethambutol prior to culture results. After 12 weeks of treatment, marked improvement in the finger lesion was noted [figure ].", "summary": "We describe a case of tuberculosis (TB) dactylitis in a patient with AIDS who originated from the Ivory Coast. The diagnosis was established by direct visualization of acid-fast bacilli on joint fluid and bone biopsy of the proximal phalanx. Imaging of the chest revealed multiple bilateral nodules. Confirmation of the diagnosis was made by isolation of Mycobacterium tuberculosis from sputum and bone cultures.", "subclaim_evaluations": [ { "subclaim": "The patient had tuberculosis dactylitis.", "support_label": "supported" }, { "subclaim": "The patient had AIDS.", "support_label": "supported" }, { "subclaim": "The patient originated from the Ivory Coast.", "support_label": "supported" }, { "subclaim": "Acid-fast bacilli were visualized in the joint fluid.", "support_label": "supported" }, { "subclaim": "A bone biopsy of the proximal phalanx was performed.", "support_label": "supported" }, { "subclaim": "Chest imaging showed multiple bilateral nodules.", "support_label": "supported" }, { "subclaim": "Mycobacterium tuberculosis was isolated from sputum.", "support_label": "supported" }, { "subclaim": "Mycobacterium tuberculosis was isolated from bone cultures.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_673_en.txt", "fulltext": "A 45-year-old obese male with Stanford A DeBakey type-II aortic dissection, atrioventricular re-entrant tachycardia, and atrial regurgitation was complaining of chest discomfort accompanied by palpitations, nausea, and cold sweats. Patient had a history of controlled hypertension with nebivolol 2 × 5 mg, as well as pericardial effusion and right bundle branch block 8–10 years prior. Previously, the patient was treated with anticoagulants and anti-arrhythmic medications. The patient was an ex-smoker for 16 years before quitting 6 years ago without any history of cardiac disease in the family. His vital signs on arrival were stable with normal jugular venous pressure, widened pulse pressure 99/59 mmHg similar in both arms, and soft diastolic aortic heart murmur. Laboratory findings were elevated for white blood cells, erythrocyte sedimentation rate, D-dimer, and cardiac marker. Plain chest X-ray showed aorta elongation with cardiomegaly and basal infiltrate on the right lung and middle segment of the left lung. Transthoracic echocardiography (TTE) evaluation revealed aortic root and ascending aorta aneurysm with mild atrial regurgitation secondary to dilated aortic root. Based on the assessments, the patient gave consent for Bentall procedure to replace the dissected aorta.\nAscending and hemiarch replacement Bentall procedure was conducted successfully despite severe adhesion between epicardium and pericardium layer along with resolved complication of sinus bradycardia. The tear started at the level of aortic valve commissure extending to the ascending aorta and middle arch without sign of rupture. Circulatory arrest time was 30 min. Post-intervention, patient was prescribed antibiotics and antifibrinolytic drugs. Anticoagulant medication warfarin for prosthetic valve maintenance was postponed due to concerns of high bleeding risk from aortic dissection and Bentall procedure.\n7 days post-operation, the patient unintentionally strained himself while defecating causing sudden shortness of breath, right chest pain, Visual Analogue Scale (VAS) 5–7, and cold sweats with persistent hypotension (81/51 mmHg) and tachypnea (24 breaths/min), despite fluid support and vasoconstrictors. His electrocardiogram reading was normal. Laboratory tests showed insignificant erythrocyte reduction within predicted value (from 13.1 to 11.1 g/dL in 2 days), raised troponin-T marker (341 pg/mL), hypercoagulable state, and acute kidney injury (estimated glomerular filtration rate 65.9 mL/min/1.73 m2). Transthoracic echocardiography examination showed middle right ventricle free wall hypokinesis with apical sparing. Additionally, chest X-ray evaluation revealed right lung oligaemia and abrupt tapering of the pulmonary artery . All these findings were suggestive of PE for which the patient was prescribed anticoagulant heparin.\nHowever, pulmonary computed tomography (CT) angiography showed an enlarged heart with fluid collection in the right anterolateral-superior pericardial space of density 50–60 Hounsfield unit (HU) pushing the heart laterally while compressing posterior part of superior vena cava, as well as bilateral pulmonary vein and left atrium stenosis due to extraluminal cause indicating cardiac tamponade. Location of the compression at the level of vena cava and pulmonary vein supposedly gave rise to the findings that mimic that of PE. Anticoagulant therapy was immediately ceased, and the patient was scheduled for a surgical pericardiotomy.\nTransoesophageal echocardiography (TEE) evaluations were taken for comparison . Right upper pulmonary vein and pulmonary artery were narrowed due to an external compression compared with after release ( and ). The velocity–time integral (VTI) was also shown to be improved after the clot evacuation.\nDuring the operation, active bleeding was found at the distal anastomosis of the ascending aorta with 600 mL of blood clots pressing against the right ventricle, right atrium, superior vena cava, and main pulmonary artery . After the procedure, his haemodynamics returned to normal and was eventually discharged the following week after close monitoring. At 2 month follow-up, the patient was asymptomatic with improving exercise tolerance. Echocardiography revealed no sign of periaortic leakage from the repaired aorta.", "summary": "A 45-year-old male with aortic dissection DeBakey type-II, 7 day post-Bentall procedure, presented with sudden shortness of breath and persistent shock despite therapy. Initial assessment directed towards pulmonary embolism was supported by hallmark imaging signs from X-ray and transthoracic echocardiography evaluation. However, computed tomography scan results were suggestive of cardiac tamponade mainly accumulating at the right side of the heart, compressing the pulmonary artery and vena cava confirmed by transoesophageal echocardiography, thus mimicking the findings of pulmonary embolism. After clot evacuation procedure, the patient improved clinically and was discharged the following week.", "subclaim_evaluations": [ { "subclaim": "The patient is a 45-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had aortic dissection DeBakey type-II.", "support_label": "supported" }, { "subclaim": "The patient had a Bentall procedure 7 days prior.", "support_label": "supported" }, { "subclaim": "The patient presented with sudden shortness of breath.", "support_label": "supported" }, { "subclaim": "The patient had persistent shock despite therapy.", "support_label": "supported" }, { "subclaim": "Initial assessment was directed toward pulmonary embolism.", "support_label": "supported" }, { "subclaim": "Imaging signs from X-ray and transthoracic echocardiography supported the initial assessment.", "support_label": "supported" }, { "subclaim": "Computed tomography scan results were suggestive of cardiac tamponade.", "support_label": "supported" }, { "subclaim": "The tamponade mainly accumulated at the right side of the heart.", "support_label": "supported" }, { "subclaim": "The tamponade compressed the pulmonary artery.", "support_label": "supported" }, { "subclaim": "The tamponade compressed the vena cava.", "support_label": "supported" }, { "subclaim": "Transoesophageal echocardiography confirmed the findings.", "support_label": "supported" }, { "subclaim": "The findings mimicked those of pulmonary embolism.", "support_label": "supported" }, { "subclaim": "A clot evacuation procedure was performed.", "support_label": "supported" }, { "subclaim": "The patient improved clinically after the procedure.", "support_label": "supported" }, { "subclaim": "The patient was discharged the following week.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1632_en.txt", "fulltext": "A 61-year-old male patient who was operated due to laryngeal carcinoma six months ago. First, MDCT and then, whole body PET-CT scan (643 MBq F-18-FDG i.v.) was performed for the patient due to the lesion monitored on the right apical in PA radiography of the patient, who was followed up stably. The patient’s routine blood test results were within the normal ranges. A lesion of 15x10 mm with radially spiculated extensions, in irregular appearance and containing a few microcalcifications was monitored in the apical region of the right lung in thoracic CT (, ). No lymphadenopathy was detected in the mediastinum. It was observed during the PET-CT that the lesion had a moderate F-18FDG uptake (2.40 SUVmax) . Apart from that, no significant pathologic finding was detected in the chest. In addition, no focus was detected during the PET-CT scan outside the thorax. The patient was first considered to have metastasis in the light of the existing findings. A wedge resection was performed for the patient’s lesion . Microscopic examination of the surgical material showed a group of fungal hyphae, and the patient was diagnosed aspergilloma. The patient was not given any antifungal treatment because the entire region was cleaned within the surgical borders and there was not any other focus.", "summary": "However, in this case report, we presented a case with operated laryngeal carcinoma whom we first had considered to have metastasis and who had received a diagnosis of aspergilloma in CT and Positron emission tomography (PET).", "subclaim_evaluations": [ { "subclaim": "The case report presented a patient with operated laryngeal carcinoma.", "support_label": "supported" }, { "subclaim": "The patient was initially considered to have metastasis.", "support_label": "supported" }, { "subclaim": "The patient received a diagnosis of aspergilloma.", "support_label": "supported" }, { "subclaim": "The diagnosis of aspergilloma was made using CT.", "support_label": "supported" }, { "subclaim": "The diagnosis of aspergilloma was made using Positron emission tomography (PET).", "support_label": "not_supported" } ] } ]