(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

Among patients with hepatitis C viral infection, what role does IL28B polymorphism analysis play in predicting response to standard therapy (pegylated interferon-α and ribavirin), and in individual treatment strategy, if any?

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 57 year old male who presented with chronic abdominal pain, ascites and swelling of both lower limbs. He was also being evaluated for liver transplant for cirrhosis associated with Hepatitis C infection since 1998. At that time he did not seek any treatment and remained relatively asymptomatic until 2002 when he developed swelling of the lower extremities bilaterally along with pruritus. He was then treated with interferon and responded. Investigations at that time revealed:

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient was a 57-year-old male diabetic who was discovered to have a persistent leukocytosis. His past medical history was remarkable for recently diagnosed diabetes mellitus and a 40 pack-year history of smoking cigarettes. A hematologist was following the patient. His white blood cell count increased from 16,700/ul to 63,000/ul during a period of 8 months. The patient underwent two bone marrow biopsies twice in a 2-month period, which were inconclusive for malignancy. Both bone marrow biopsies were negative for bcr/abl gene mutation. He denied any "B" symptoms. The patient was reported to have been treated with hydroxyurea.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An otherwise well 57-year-old man presented with a 6 month history of worsening headaches, hearing difficulties and personality changes. No sensory or motor deficits were found on clinical examination. Computed tomography (CT) and magnetic resonance (MR) imaging showed a dural-based, contrast-enhancing, lobulated left parasagittal mass, associated with mass effect. A clinicoradiologic diagnosis of meningioma was made.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

Patient is a 57 year old male with a medical history of hypertension who was evaluated by a rheumatologist in 1996 for sinus congestion and the presence of lung nodules. Initially, he refused a lung biopsy so he was placed on Cytoxan based on a presumptive diagnosis. From January 2009 till July 2010 he was taking Cytoxan and steroids for his pulmonary disease. At that time, he developed cytopenia and his medications were discontinued. He had one of his lung nodules biopsied which showed a granulomatous vasculitis with alveolar hemorrhage (see Figures 1 and 2). Due to the side effects of his past medicine regimen, he was going to be switched to a new oral agent but was not started on that medicine yet.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 57 year old postmenopausal woman presented with spotting and underwent a routine Papanicolaou test. The patient had no previous medical history or pertinent family history.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 57-year old female with a past medical history of thyroidectomy, hysterectomy, and papillary fibroepithelial hyperplasia of the buccal mucosa. She presented with a three-month history of progressive vertigo, ataxia, and posterior headache. Physical examination revealed lateral nystagmus, dysdiadochokinesis and ataxia.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 58-year old man presented with recent onset headache, speech disturbances and vomiting for last 3 days. On examination, he was conscious with stable vital parameters. There was no other significant neurological deficit. Since his routine investigations and systemic examination was largely within normal limits, he underwent neuroimaging studies. MRI study (Axial, sagittal, coronal, contrast and noncontrast sections) demonstrated a fairly well-defined solid-cystic lesion of size 4×3.2cm in the left temporo-parietal region involving gray and white matter. The mass showed heterogenous enhancement and was predominantly hypointense on T1W image (Fig. 1a). Post-contrast imaging showed a solid component with diffuse enhancement and a cystic area at periphery (Figs. 1b, 1c). Perilesional edema was observed resulting in effacement of adjacent sulci and temporal horn of left lateral ventricle. Patient underwent left temporo-parietal craniotomy with resection of tumor.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 58 year old woman with a history of chronic diarrhea, post-menopausal uterine bleeding, and depression underwent a routine colonoscopy for colon cancer screening which demonstrated a large, nearly obstructing mass extending from the proximal rectum into the distal sigmoid colon. The colonoscopy examination shows a large mass partially occluding lumen of rectosigmoid colon (Fig. 1). The colonoscope could be traversed proximally and the remainder of the examination was normal.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 58 year old Caucasian male presented with weight and appetite loss over 2 to 3 months. He was recently diagnosed with human immunodeficiency virus (HIV) infection. His initial CD4 count was < 20cells/mm3 (7%) with a viral load of 352000 copies/ml. He was commenced on highly active antiretroviral therapy (HAART) and in the third month of therapy, he presented with increasing hallucinations and ataxia. Serologies for hepatitis A, hepatitis B, cytomegalovirus (CMV), toxoplasma, syphilis, tuberculosis (TB) and Cryptococcus neoformans were negative. His cerebrospinal fluid (CSF) profile was negative for Cryptococcus neoformans, TB, herpes simplex virus (HSV), CMV, toxoplasma, varicella zoster virus (VZV) and Epstein Barr virus (EBV) were negative. In addition, his CD4 count rose to 202 cells/mm3 with a viral load of 425 copies/ml.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient was a 58-year-old African American woman with severe static encephalopathy and cerebral palsy both presumptively related to prenatal/perinatal brain injury. Additional neurological diagnoses included an ill-defined seizure history, bipolar affective disorder, and medication-related tardive dyskinesia. The patient's other co-morbidities were non-contributory. She was a permanent resident of a long-term care facility, where she expired unexpectedly. An autopsy was requested.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 58 year old woman with a 3.4 x 2.3 x 1.3 cm solid nodule with some small cystic spaces occupying the mid and lower left pole of the thyroid, as seen on ultrasound imaging (Figure 1A: longitudinal plane, 1B: transverse plane). The patient has noted an increase in size of this nodule and associated dysphagia. TSH and T3 are within normal limits. The patient also has a history of low-grade lymphoma diagnosed 8 years ago, after presenting with cervical lymphadenopathy, for which she has received intravenous immunoglobulin (IVIG) treatments.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 59 year-old man with a past medical history significant for a renal transplant, secondary to hypertensive nephrosclerosis and diabetes, presented with a 3-4 week history of progressive mental status changes, including confusion, somnolence and personality changes. He also had 1-2 weeks of low-grade fevers and chills, with associated weight loss. One to two months prior to his presentation to the emergency room, he was diagnosed with monomorphous post-transplant lymphoproliferative disorder (PTLD) on an axillary lymph node biopsy. Focal areas compatible with diffuse large B-cell lymphoma were seen. His original PET scan revealed extensive lymphadenopathy both above and below the diaphragm.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 59-year old man presented with metastasizing adenocarcinoma of the lung. Within the scope of staging analysis, brain imaging was performed and showed an enlarged posterior fossa with separated cerebellar hemispheres. The cerebellar vermis was absent and instead, a tumor was attached to the meninges at the occipital part of the posterior fossa (Figure 1, Axial T2 weighted cranial MRI). The patient received radiochemotherapy, but finally died of respiratory insufficiency with diffuse alveolar damage.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 59-year old female referred to our hospital because of a cranial trauma following an episode of loss of consciousness. Clinical history was unremarkable expect for a headache of ten-days-duration. CT scan showed a retrosellar, rounded mass, isodense with the brain parenchyma, which measured 2,8 cm in maximum size. By MRI, the mass was likely extra-axial, showed intense and heterogeneous contrast enhancement. The mass compressed, though not infiltrated, the third ventricle (Figure 1). CT angiography showed close anatomical relationship with posterior cerebral arteries as well as with the apex of the basilar artery. At surgery, the lesion was reddish, highly vascularized and it infiltrated the hypothalamus. Due to close anatomical relationship with vital nervous and vascular structures, the lesion was submitted to only partial surgical resection.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 59 year old female with a history of hypertension and depression presented to the Emergency Department with a one week history of nausea, bloody vomiting, and vertigo. She was not taking any anticoagulants and had no history of bleeding disorders. She was noted to have coffee ground emesis, but after having resolution of her nausea with antiemetic medication, opted to return the following morning for a scheduled upper gastrointestinal endoscopy. That evening while at home she developed altered mental status with sudden neurologic decline and EMS was notified. She was intubated on the scene and upon arrival to the Emergency Department, was following commands in all four extremities but demonstrated anisocoria with ophthalmoplegia and left facial weakness.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 59-year-old female presented with a severe headache for 3 weeks and was admitted to another hospital for evaluation. Magnetic resonance image (MRI) of the brain revealed a well-delineated homogeneous contrast-enhancing mass lesion within the infundibular recess. Basal pituitary hormones were within normal limits. A combined pituitary hormone test showed only a slightly decreased fT4 (0.7ng/dL). Because she was postmenopausal, LH (1.76mIU/mL) and FSH (1.02mIU/mL) levels were subnormal. Other endocrinological laboratory tests were not remarkable. Clinicians decided to observe the patient due to the risk of the tissue diagnosis. She was discharged without any treatment recommended for follow up at an outpatient clinic of another hospital. During follow up at an outpatient clinic, she visited our emergency room due to headache and an episode of syncope. The patient was referred to the neurosurgical department for evaluation of a mass lesion in the pituitary stalk and infundibular recess. MRI demonstrated a suprasellar mass measuring about 1 x 1 cm in size. The lesion showed iso-signal intensity on precontrast T1-weighted image with strong homogeneous enhancement by gadolinium (Figure A and B). Initially, we were highly suspicious of lymphoma or metastasis. We performed endoscopic biopsy because the tumor was located within the infundibular recess of the third ventricle. After the tumor wall was coagulated with unipolar coagulator, biopsy of multiple pieces was performed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 59 year old male teacher developed symptoms of pan-hypopituitarism. MRI revealed a solid homogeneously enhancing mass in the sella measuring 1.8 cm extending into the suprasellar cistern causing mild compression of the optic chiasm (Fig 1). Neurological exam was normal other than a small bitemporal visual field defect. The lesion was suspected to be a pituitary adenoma, and a transsphenoidal resection was performed. Intra-operatively, the lesion was noted to be posterior to the anterior pituitary gland. Post-operatively, a small amount of residual tumour was present which has been stable on follow-up neuroimaging. No adjuvant therapy was given.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 59 year-old man with no significant past medical history presented to our neurosurgery clinic with progressive vision loss. He initially noted partial loss of vision in his right eye four years prior to being seen at our institution; this subsequently progressed to complete unilateral blindness over the following year and a half. During this time he had seen a physician at an outside hospital with an unclear work-up and no treatment. His visual loss was then stable for two and a half years until he noticed transient loss of vision in his left eye at which point he was referred to our institution. Magnetic resonance imaging of his brain revealed a 3.3 cm x 3.3 cm x 3.4 cm suprasellar mass (Figure A). Transcranial resection was recommended; however, the patient initially deferred treatment. Two months later he presented to our emergency department with further visual disturbances in his left eye including longer periods of blindness and episodes of color distortion. He was admitted to our neurosurgical service for surgical resection of the mass.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 59-year-old woman presented with an 8-year history of generalized malaise, neck and arm pain and hearing impairment. Six months prior to admission she developed night sweats and a 4 kg weight loss. These symptoms progressed to include headaches, gait instability and the appearance of a painful retroauricular mass. Laboratory analysis showed the following results: haemoglobin, 12.7 g/dl; mean corpuscular volume (MCV), 78.7 fl; thrombocytes count, 483x103/ l; white blood cell count, 15.84x103/ l; neutrophiles count 13.46x103/ l; lymphocytes count, 1.34x103/ l; 4.8% microcytic erythroblasts; sodium, 131 nmol/L. Cranial computed tomography (CT) revealed an osteolytic mass lesion measuring 5 cm in diameter that, extended from the right mastoid to the medial and posterior cerebral fossae. On cranial magnetic resonance imaging (MRI, Figure 1) the 6.8x5.3x4.8cm, poorly circumscribed, extra-axial mass with progressive perifocal edema was noted to extend into the cerebellum, with compression of the IV ventricle and the brainstem. On T1-weighted images, the lesion appeared iso- to hypointense, with solitary intratumoral vessels and haemorrhagic components. T2-weighted images of the mass showed low-signal intensity with inhomogeneous contrast-enhancement. The preoperative differential diagnosis included osteosarcoma, hemangiopericytoma, and metastatic disease. Preoperative fine needle aspiration biopsy (FNA) of the extracranial retroauricular mass was performed. Thorax/abdomen CT performed as part of a metastatic workup did not reveal evidence of other mass lesions. The patient underwent complete surgical resection of the lesion following embolisation.