Primary Hyperparathyroidism: Heterogenous Imagistic Aspects, a

Complex Journey to Diagnosis

Author: Dan Alexandru Arhire

Co-authors: Bogdan-Andrei Mazureac, Ioana Purice
Scientific coordinator: Oana Arhire MD

Introduction: Hyperparathyroidism is the result of overproduction of parathyroid hormone

(PTH) leading to abnormal calcium homeostasis, thus the increased osteoclastic activity. It can
be primary, secondary or tertiary. There are many characteristic imaging features
predominantly involving the skeletal system.

Materials and methods: A 55-year-old female patient, presented to Rheumatology

Department of Rehabilitation Clinical Hospital Iai for left hip arthralgia, gait difficulties,
hyperkyphosis, height loss, non-specific bone pain, abdominal pain and bowel sounds,
persistent diarrheic syndrome, as well as hypoanabolic syndrome. Multiple radiological and
imagistic investigations, such as hands, spine and pelvic X-Ray, thoraco-abdominopelvic CT
scan, cervical US, osteodensitometry and scintigraphy guided towards the diagnosis.

Results: The pelvic X-Ray showed massive osteolysis on the left ilium and shape
abnormalities of the pelvis. The spine X-ray indicated the specific rugger-jersey sign, which
raised high suspicion of hyperparathyroidism. In order to exclude other causes of the osteolysis,
a thoraco-abdominopelvic CT scan was performed. The CT excluded any malignant visceral
lesion, but revealed many resorbtion sites in almost all bones. Further cervical US confirmed
two tumoral solid mases on the parathyroid topography with benign characteristics. Finally, X-
Ray of the hands and skull revealed the specific signs of HPT such as areas of osseous
resorbtion, respectively the salt and pepper aspect. The abdominal groans were explained by
the enlargement of the small bowel and vigurous peristaltic movements, both seen with
ultrasound examination. The laboratory tests revealed: raised levels of serum PTH, alkalin
phosphatase and calcium. The osteodensitometry confirmed the osteoporosis and the nuclear
medicine highlighted the parathyroid tumors.

Conclusion: The diagnosis of hyperparathyroidism requires multidisciplinary team-work. The

radiologic and imaging approaches represent a useful tool to demonstrate the proper
manifestations of the disease when the results of the clinical investigations are not specific
enough to prompt a diagnosis.

Keywords: Hyperparathyroidism, Rugger-Jersey, Osseous Resorbtion

A Retrospective Sequential Study of the Risk Factors and the Incidence
of the Endometrial Cancer

Author: Mihai-Vlad Valu

Scientific coordinator: Professor Toma Ovidiu MD PhD

Introduction: This article is made up of a retrospective study for 5 months, including

the patients diagnosed with endometrium cancer.

Materials and methods: This article is made up of a retrospective study for 5

months, including the patients diagnosed with endometrium cancer, hospitalized in
the Radiotherapy Clinic from within the Regional Institute of Oncology Iasi, during
the period 01.07.2015 01.12.2015, in which I assessed the incidence of different risk
factors. The data collection was done based on the medical record available in the
hospital archive. There were taken into consideration the patients from whom there
could be extracted from the medical record the following information: personal data
(age, environment, risk factors). After the selection process, resulted a lot of 60 cases
who were present at the Oncology Regional Institute from Iasi (IRO Iasi), with an
observation of endometrial cancer.

Results: The origin environment of the female patients with uterine body cancer
(CCU) hospitalized in the clinic is predominantly urban. Out of those 60 female
patients who were included in the study, associations of these risk factors were met,
the most frequently, (45%), followed by HTN in a percentage of 27%. In the studied
lot, there were two cases of ovarian cancer before, 1 case in which the treatment with
tamoxifen was followed, and 2 cases of breast cancer, out of which, 1 was synchronic
with endometrial cancer.

Conclusion: Endometrial cancer is a disease characteristic for the postmenopausal

period, the majority of the female patients of the studied lot, having the age between
51-60 years old.

Keywords: Risk Factors, Age at Diagnosis, Tamoxifen

The Challenges of Diagnosing and Treating ANCA Systemic Vasculitis-
Case Presentation

Author: Maria Manaila

Scientific coordinator: Valentina Esanu MD

Introduction: The primary systemic vasculitides are heterogeneous, multi-system

disorders characterized by inflammation and necrosis of small and medium blood vessels.
Their aetiology is unknown and they are often associated with anti-neutrophil cytoplasmic
antibodies (ANCA). Studies from various countries show that the overall annual incidence
of primary systemic vasculitis is approximately 20 cases per million.

Materials and methods: A 48-year-old woman reported to the Pneumology Hospital with
dyspnea, asthenia, fatigue, joint aches, dry cough. Chest examination revealed basal
crackles in the right lung and the chest radiography revealed nodular opacities, varying in
size, with a confluence tendency, some excavated. Blood tests showed an important
inflammatory syndrome and anemia. The patient was diagnosed with right pneumonia for
which she received treatment. Dyspnea and joint pain persisted. X-Ray performed after
treatment showed a stationary radiological aspect. A chest CT highlighted bilateral
multiple nodules, some ground glass opacities, others with peripheral contrast
enhancement. Both bronchoscopic examination and bronchial aspirate revealed no
abnormalities. Bronchial biopsy showed reduced chronic inflammatory infiltrate.
Corroborating the results of laboratory investigations with the clinical symptoms, the
probability of vasculitis was high and the patient was sent to Rheumatology for special
investigations. In evolution, the patient presented external popliteal sciatic nerve paresis
and subcutaneous nodules. Perinuclear ANCA were present, cytoplasmic ANCA were
absent.

Results: The patient started treatment with oral corticosteroid and cyclophosphamide.The
treatment resulted in favorable development of the respiratory, neurological and articular
symptoms, decreased levels of p-ANCA. The peculiarity of the case is represented by the
complications of the corticosteroid therapy: the patient developed Cushing's syndrome and
diabetes.

Conclusion: Although it is a rare disease which is treated by rheumatologists, due to

affecting multiple systems vasculitis should not be forgotten in the differential diagnosis
by physicians from various specialties: pulmonology, dermatology, nephrology,
neurologyand otorhinolaryngology.

Keywords: ANCA Systemic Vasculitis, Ground Glass Opacities, Anti-Neutrophil Cytoplasmic

Antibodies (ANCA)
The Relationship between Obesity and Plasminogen Activator Inhibitor 1
Type Plasma Levels in Patients with Traumatic Brain Injury

Author: Iryna Tereshchenko

Scientific coordinator: Kmyta O.P. MD

Introduction: Plasminogen activator inhibitor 1 type (PAI-1) is a serine protease

inhibitor that act as the principal inhibitor of tissue plasminogen activator and
urokinase and hence fibrinolysis. The production of PAI-1 by adipose tissue could be
an important contributor to the elevated PAI-1 plasma levels. Our study was aimed to
analyze the relationship between obesity and PAI-1 plasma levels in patients with
traumatic brain injury (TBI).

Materials and methods: Totally 295 subjects have been examined in this study.
They were grouped into two categories: 1st contained 81 patients with mild (MTBI)
and 119 severe (STBI) TBI, 2nd (control) group 95 almost healthy individuals.
Subjects were sub grouped using their body mass index and waist-hip ratio.

Results: During the 1st day study, higher plasma PAI-1 levels were reported to have
association with obesity and MTBI (75.76.81, normal body weight (NBW)
54.13.31 ng/ml, p=0.015) and with obesity and STBI (119.12.51, NBW
111.71.45 ng/ml, p=0.042). In the control group higher PAI-1 level were recorded in
obese subjects (52.30.86, NBW 25.41.0 ng/ml, p=0.0001). Analyzing plasma
PAI-1 level on the 14th day, it was recorded that in the patients with MTBI and NBW
the PAI-1 came within normal limits; the patients with obesity and overweight still
had high values PAI-1 was 1.2 times higher than that in the control group
(61.87.22 ng/ml, p=0.0001). In the patients with STBI and NBW the PAI-1
(56.23.98 ng/ml) was 2 times higher; the patients with obesity and overweight still
had high values (87.98.0 ng/ml) PAI-1 was 1.7 times higher than that in the
control group (p=0.004).

Conclusion: According to the results of the study, we can make a conclusion as for
the association between changes in the plasma PAI-1 levels and body weight: PAI-1
values were significantly higher in the patients and control with obesity and STBI
than in the patients with normal body weight.

Keywords: irishca1996
Giant Mediopalmar Lipoma - Rare Benign Tumora. Case Report

Author: Adina Georgiana Para

Co-author: Stefania Gherghe-Moise
Scientific coordinator: Lecturer Mihaela Perea MD PhD

Introduction: The purpose of this paper is to highlight the rarity of lipoma

localization in the hand (represents only 5% of benign tumor of the hand), especially
the ones with big dimensions localized in the palm (giant lipoma over 5 cm), the
importance of IRM exam in establishing the positive and differential diagnostics, as
well as the importance and the necessity of the surgical treatment regarding the
functional rehabilitation of the hand.

Materials and methods: We are reporting a case of a 47 years old patient, which for
about two years has shown changes in the palm relief. About 6 months ago a marked
increase in the volume of thenar eminence followed by the appearance of paresthesias
in the first four fingers was detected. Clinical examination revealed the presence of an
elastic consistency tumor formation, painless spontaneous or on palpation across the
entire palmar surface, with larger size at the thenar eminence level, exceeding 5 cm in
diameter. The most relevant way to determinate the local extension is MRI.
Differential diagnosis is primarily made with liposarcoma. The treatment is surgical
and consists in complete removal of the tumor (135 g). Recurrences are very rare.

Results: The surgical treatment was successful, the patient is socio-professional

fully reintegrated with no functional or sensory sequelae.

Conclusion: We emphasize the rarity of the location, the tumor size, the importance
of the MRI in the differential and positive diagnosis as well as the necessity of
surgery to cancel the symptoms and restore normal function of the hand.

Keywords: Lipoma, Giant Tumor, Hand

A Very Rare Case of Trigeminal Neuralgia Caused By Arteriovenous
Malformation of the Posterior Fossa Treated With Gamma Knife
Surgery

Author: Raul Alexandru Jigoranu

Co-author: Diana Gabriela Scriminti,
Scientific coordinator: Constantin Tuleasca, MD, Chief resident, MD-PHD
candidate; Neurosurgery Service and Gamma Knife Center, Marc Levivier, MD,
PHD, Professor and Chairman,Neurosurgery Service and Gamma Knife Center

Introduction: Trigeminal neuralgia (TN) is a facial pain syndrome, characterized by a severe,

electric shocklike aching. The leading cause of the so-called idiopathic TN in a vast majority
of cases (80-90%) is a vascular compression of the root entry zone (artery or vein). Rare causes
include multiple sclerosis, tumors, or vascular compression. Extremely rare is acknowledged
the compression of the nerve by an arteriovenous malformation (AVM) (0.4-1.8% of cases).

Materials and methods: We report the unusual case of 78 years old patient, diagnosed with
drug-resistant, right TN, 10 years back. MRI and digital substraction angiography (DSA)
revealed a posterior fossa, Spetzler-Martin grade III AVM (arterial supply- vertebro-basilar
trunk, branches from the right superior cerebellar artery; profound venous drainage- Galiens
vein, torcular and straight sinus). She initially underwent Linear Accelerator radiosurgery (RS),
with a dose of 14 Gy at the 90% isodose line. However, 3 years later, after a short relief period,
symptoms reappeared and DSA displayed no signs of obliteration. Gamma Knife surgery
(GKS) was decided and performed on target volume of 0.250 cc, dose of 20 Gy at the 50%
isodose line. The volume of the 12 Gyisodose line was 0.815 cc.

Results: TN disappeared 4 months latter and never relapsed, at a follow-upperiod of 5 years.

Patient underwent DSA 4 years after GKS, confirming complete obliteration of the nidus,
without any adverse radiation effects.

Conclusion: TN caused by pulsatile compression of the feeders of an AVM is rare. The

therapeutic alternatives are microsurgical excision, endovascular treatment or RS. Due to the
angioarchitecture of our particular case, we decided to perform GKS, which was safe and
effective. Large series are needed to make a more comprehensive report about the safety and
efficacy of GKS in these procedures.

Keywords: Trigeminal Neuralgia, Gamma Knife Radiosurgery, Arteriovenous Malformation

Dramatic Facial Nerve Schwannoma Functional Recovery after Combined
Management of Radiosurgery and Intensive Facial Reeducation

Author: Raul Alexandru Jigoranu

Co-author: Diana Gabriela Scriminti, Beatrice Goncalves Matoso- Logopedist,
Department of ENT surgery
Scientific coordinator: Constantin Tuleasca, MD, Chief resident, MD-PHD
candidate; Neurosurgery Service and Gamma Knife Center, Marc Levivier, MD,
PHD, Professor and Chairman,Neurosurgery Service and Gamma Knife Center

Introduction: Facial nerve schwannomas are rare tumors, accounting for less than 2% of
intracranial neurinomas. The optimal management is currently under debate and includes
observation, microsurgical resection, radiosurgery (RS) and fractionated radiotherapy. While
surgery has the advantage of quick mass relief, functional preservation of the facial nerve
remains challenging. In symptomatic patients and/or presenting with tumor growth, RS and
particularly Gamma Knife surgery (GKS) might be a valuable alternative.

Materials and methods: We report the unusual case of 36-year-old woman, who presented
with right, progressive, complete (House and Brackmann grade VI) facial palsy. Hearing was
normal. Brain CT and later MRI showed a partially calcified mass, occupying right geniculate
ganglion area, with bone erosion. Nerve conduction study revealed absence of responses on the
right, with presence of fibrillation potentials in right facial muscles. Most likely diagnosis was
facial schwannoma. The patient did not agree for ENT surgery, and underwent GKS. The
prescribed marginal dose was 12 Gy at the 50% isodose line.

Results: Three months later, a training program with facial reeducation was settled up,
including techniques from Neuromuscular-Retraining (Diels-Combs), and specific
massages for facial palsy (Gatignol). Six months after GKS (and 3 months after
reeducation), there was already slight clinical improvement. Within following
months, facial palsy passed gradually to grade II, which persisted up to 3 years. The
electromyography showed an improvement, both in speed motor conduction and
voluntary contraction. Last MRI, 3 years after GKS, displayed dramatic shrinkage of
the tumor.

Conclusion: In our experience, GKS appear to be an appropriate therapeutic option in the

management of these rare and invalidating tumors. However, it should be also accompanied by
a rehabilitation program, in the frame of a combined management, so as to give the patients the
best chances for recovery.

Keywords: Functional Recovery, Gamma Knife Radiosurgery, Facial Schwannoma

Peritoneal Carcinomatosis Treatment with Hyperthermic
Chemotherapy Associated With TumoralCytoreduction

Author: Diana-Elena Iov

Co-author: Andreea-Roxana Ciobanu, Cristina-Maria Florea
Scientific coordinator: Teaching Assistant. Ionut Hutanu MD

Introduction: Peritoneal carcinomatosis (PC) is a disease with a severe prognosis for which
chemotherapy and palliative surgical interventions had been the standard treatment for a long
time. In the last 30 years, intraperitoneal hyperthermic chemotherapy (HIPEC) associated with
optimal tumoralcytoreduction has become the preferred treatment for PC with apendicular
origin and for diffuse peritoneal mesothelioma. Recent studies have proven the efficiency of
this complex procedure in the treatment of PC with other origins: colon, ovary and stomach.

Materials and methods: 53-year-old female patient was admitted to the Regional Oncology
Institute Iasi with a presumptive diagnosis of pseudomyxomaperitonei following abdomino-
pelvic CT examination. The patient presented significant weight loss in the previous 2 months,
abdominal enlargement and inferior limb edema. Laboratory tests revealed increased levels of
tumoral markers (CEA- 17.60ng/ml, CA19-9: 260 U/ml, CA125: 16.30U/ml). The endoscopy
showed sliding hiatal hernia esophagitis, biliary reflux and pangastritis.

Results: Through surgical approach, bilateral ovarian masses which formed a pelvic block
including the uterus and rectum, diffuse peritoneal carcinomatosis and abundant ascites were
identified. Total hysterectomy with bilateral anexectomy, the Hartmann procedure with
complete mesorectal excision, anterograde colecistectomy, splenectomy, apendicectomy, total
and bilateral diaphragmatic peritonectomy, partial hepatic glisonectomy, total epiploonectomy
and HIPEC (42.5 C Oxaliplatin 900 mg) were performed. Post-treatment evolution was
favorable with resumption of per os alimentation and no fever. Histopathology of the resection
pieces established the diagnosis of low grade aggresivitypseudomyxomaperitonei (DPAM
Disseminated Peritoneal Adenomucinosis) of probable appendicular origin. Clinical and
radiological examination performed after 6 months showed no signs of tumoral relapse.

Conclusion: PC is a disease with a grim prognostic, for which optimal tumoralcytoreduction

associated with HIPEC have become increasingly popular.At a fairly high price, acceptable
morbidity and mortality rates and improved postoperative quality of life, this complex
technique is the sole healing option for PC patients.

Keywords: PeritonealCarcinomatosis, HIPEC, PseudomyxomaPeritonei

The Role of Immunohistochemistry in the Diagnosis of an Anal
Malignant Melanoma

Author: Miruna-Lorelei Bitca

Co-author: Lidia Sanduleac
Scientific coordinator: Teaching Assistant Loredana Ungureanu MD, Assistant
ProfessorDelia Ciobanu MD PhD

Introduction: Anal melanoma represents about 1 % of all anorectal melanoma with

an aggressive behavior and a very short survival. Being sometimes an achromic lesion
it can be mistaken frequently for hemorrhoids.

Materials and methods: We report a case of a 86 years old male, who underwent
endoscopic resection of an anal canal polyp. For histopathological and
immunohistochemical examination, the harvested fragment was fixed with 10%
buffered formalin and stained with hematoxilin-eosin, cytokeratin AE1/3, Melan A,
S100, HMB45, ki67.

Results: The macroscopic examination of the specimen revealed a polypoid mass

2.6/2.5/1.1 cm having the color similar to normal anal mucosa. The histopathological
examination indicated a malignant tumor with cellular pleomorphism, a high mitotic
index (4 mitosis/HPF) and a reduced melanic pigment. The tumor was invasive in
submucosa with Breslow index of about 10 mm. The immunohistochemical
examination have shown an intense positivity of tumoral cells for Melan A, HMB45,
S100. Mitotic index was high of about 80%. The final histopathological dignosis was
spindle cell malignant melanoma.

Conclusion: Since the anorectal melanoma is sometimes very difficult to diagnose,

the immunohistochemical techniques are all the time of real help.

Keywords: Anal Melanoma, Histopathology, Immunohistochemistry

Atypical Metastases of a Case of Colon Cancer

Author: Sabrina-Mihaela Balasa

Co-author: Loredana-Sorina Smarandache, Daniela Bulancea
Scientific coordinator: Emil Moraru MD

Introduction: Colon cancer is a major cause of mortality and morbidity worldwide

and the second cause of decease by cancer in Europe.The systemic extension of this
neoplasm leads especially to hepatic metastases.It is well known that breast
metastases occur more frequently in lymphoma,metastatic melanoma and bronchial
carcinoma.Regarding the colon cancer,only 19 cases of breast metastases have been
described until 2010.

Materials and methods: We presented the case of a 52 years old female patient,who
had come to Craiovas EmergencyCounty Hospital in 2010,one year after she
underwent a right hemicolectomy and chemotherapy for right colonic tumor.After
clinical and paraclinicalexaminations,we had discovered a left breast tumor and an
anterior abdominal tumor.The evolution was dramatic,the patient developing left
breast metastasis,abdominal parietal metastasis and recurrent colon cancer in the
anastomosis site,invading the abdominal wall.It has been performed left breast tumor
excision, abdominal tumor ablation with large parietal excision,with synthetic mesh
emplacement.The case evolved with right breast metastasis, abdominal parietal
recurrence,involving the abdominal synthetic mesh,with invasion of the gastric wall,
andright inguinal parietal metastasis.Palliative surgical treatmentwasapplied.Due to
numerous abdominal tumor recurrences leading to multiple digestive fistulas,the
decline of patients general status occurred after approximately 3 years after being
diagnosed with colon cancer and the patient deceased.

Results: The particularity of our case consists in the presence of breast metastases
following right colon carcinoma without the presence of any hepatic metastases
during the entire postoperative evolution. Local evolution was explosive with
numerous abdominal parietal metastases and recurrences leading to the patients
decease.

Conclusion: Emplacement of synthetic parietal mesh after parietal ablation for cancer
may consist into a hotspot for cancerous cell invasion.

Keywords: Colon cancer, Breast metastases, Local recurrence

Bilateral Amaurosis after Endogenous Endophthalmitis with Fulminant
EvolutionCase Report

Author: Loredana-Sorina Smarandache

Co-author: LiorUziel, Sabrina-Mihaela Balasa
Scientific coordinator: Alin-Stefan Stefanescu-Dima MD; Andreea Corici MD

Introduction: Endogenous endophthalmitis is a relatively rare disease characterized by

intraocular infection due to a microorganism hematogenous spread from a distant
infectious collection.It represents a major emergency due to the high risk of irreversible
eye damage and reserved prognosis.From the 44 cases reported in the literature since
1981, 61% had diabetes, 68% had suppurative liver diseases and 16% had urinary tract
infections.

Materials and methods: We present the case of a 56 years old male patient who had
come to Craiovas Hospital Emergency Department accusing fever,decreased visual acuity
in the right eye and ocular pain in the left eye.The patient was hospitalized in the intensive
care unit with the diagnosis of endogenous bilateral endophthalmitis.From the patients
history we took into consideration insulin-dependent type 2 Diabetes and chronic Viral
type C Hepatitis.In the absence of the etiologic diagnosis the patient was treated with
antibiotics and anti-inflammatory drugs and after 14 days of favorable evolution,he was
discharged.Three days later,the patient came back to the Emergency
Department,presenting a septic state,being hospitalized immediately in the Intensive Care
unit.After the 3rd urology investigation,it was discovered the presence of a left prostatic
lobe abscess.Atransrectal abscess drainage was performed and the bacteriology
examination showed the presence of Proteus.The prognosis was reserved,with loss of
patients visual acuity in the right eye and evisceration of the left eye.

Results: The unfavorable evolution of this patient was determined by the late discovery of
the main site of infection.In the presented case,the usage of the correct antibiotic before
finding the endogenous infectious site made it even harder to be found.

Conclusion: In spite of the correct treatment and many clinical, laboratory,imaging and
interclinicalexaminations,the etiologic diagnosis was established with great difficulty and
in a very late state

Keywords: Endophthalmitis, Abscess, Amaurosis

Rare Case Study: Gastrointestinal Stromal Tumor

Author: Ayesha Rahman

Scientific coordinator: Elmi Gielan MD

Introduction: Gastrointestinal stromal tumors (GISTs) are a type of sarcoma which

arises from mesenchymal neoplasms of the gastrointestinal tract. However, they are
extremely rare; accounting for less than 1% of tumors found in the gastrointestinal
tract.

Materials and methods: A 76 year old female was admitted in the Internal Medicine
department complaining of severe epigastric pain with tenderness, heartburn and an
impaired general condition. Importantly, the initial onset of symptoms began with the
presence of Melena (3-4/day) three days prior to hospitalization.
Endoscopic examination revealed a large mass with a pedunculated shape. The
diameter of the peduncles neck was 12mm and the heads was 20mm. Unusual for
GISTS which appear on the lesser and greater curvature of the stomach as a sessile
mass, this tumour appeared in the pyloric antrum region extending to the duodenum.
The accumulating data had led to the diagnosis of an Atypical Polyp. However, after a
histological study, the diagnosis was found to be a gastrointestinal stromal tumour.
Due to the rarity of GISTs the initial diagnosis was incorrect.

Results: Treatment of the GIST was endoscopic resection. After the resection, the
patient was placed on proton pump inhibitors and was
additionally called for a routine endoscopy six months later.

Conclusion: Due to the rarity of GISTs occurrence and the shape of the mass, it was
initially thought as an atypical polyp. Nevertheless, endoscopic resection had
successfully removed the whole GIST. Furthermore, aftercare treatment of proton
pump inhibitors had proven to be a successful management to prevent relapse.

Keywords: GIST, Sarcoma, Gastrointestinal

Anaplastic Thyroid Cancer, Atypical Presentation and Evolution: Case
Study

Author: Gabriela Paduret

Co-author: Petruta-Dumitrita Mutescu
Scientific coordinator: Assistant Professor Maria-Christina Ungureanu MD PhD,
Teaching Assistant Alexandru Florescu MD

Introduction: Anaplastic thyroid carcinoma (ATC) is the rarest and most aggressive form
of thyroid cancer. According to scientific data, ATC constitutes approximately 1% of all
types of thyroid malignancies. At the time of diagnosis 40% of patients present with
cervical lymphadenopathy and up to 43% of patients have distant metastases. Treatment
includes surgery, radiation, and chemotherapy. They have an average median survival of 5
months, and less than 20% are alive 1 year after diagnosis.

Materials and methods: The development of this case report was based on a thorough
anamnesis, clinical examination, investigation results, as well as past discharge letters.

Results: Male patient, age 60, with a neglected multinodular goiter for over 20 years
presents to the clinic accusing enlargement of the cervical mass, hoarseness and difficult
breathing. According to clinical examination, the biochemical profile and the ultrasound,
the presumptive diagnosis suggested a benign origin. Taking into account the effect on the
patients quality of life it was decided to perform a total thyroidectomy. The macroscopic
aspect of the resection piece was in line with the hypothetical benign aetiology. However,
histological examination (in two different hospitals) revealed anaplastic thyroid carcinoma
in association with folliculo-papillary carcinoma. Furthermore, the patient undertook
radioiodine therapy and a cerebral and cervico-thoracic CT-scan showed no secondary
lesions. In addition, treatment with high dose of Levothyroxine was initiated. At the yearly
evaluation, the ultrasound unveiled remnants of thyroid tissue for which the patient
pursued External Beam Radiotherapy.

Conclusion: The distinctiveness of this case consists in the deceiving clinical,

echographic and macroscopic features, the scarcity of the histological aspect the
undifferentiated carcinoma correlated with the more differentiated forms, and the
challenging management decisions that followed. Even if with ATC long term survival is
rare, the patient is among the very few survivors two years after the diagnosis.

Keywords: Anaplastic Thyroid Carcinoma (ATC), Incidence, Prognosis

Laparoscopic Circumcaval Ureter Ablation

Author: Alexandru-Dan Costache

Co-author: Nicoleta Dumitrescu, Iulia-Georgiana Axinia
Scientific coordinator: Teaching Assistant Bogdan Novac MD, PhD

Introduction: A circumcaval ureter, more commonly described as a retrocaval ureter

is a congenital abnormality of the inferior vena cava, although it is often considered
as being caused by an improper ureteral development. There are two types described,
with a high loop or a low loop, both being mainly asymptomatic, with patients
developing, depending on the degree of compression, either a partial right ureteral
obstruction or recurrent urinary tract infections due to urinary stasis.

Materials and methods: Such is the case of a 57 year old patient who was admitted
in the Urology Department of the Parhon Teaching Hospital, complaining for three
months of right lumbar pain with antero-inferior radiation. Imaging investigations
revealed a right retrocaval ureter, causing an obstruction which explained the lumbar
pain and the third degree right hydronephrosis and hydroureter. The therapeutical
procedure consisted of a laparoscopic uncrossing of the congenital malformation,
consisting of the relocation of the ureter anteriorly to the inferior vena cava,
accompanied by pyeloplasty.

Results: After the procedure, the preoperative symptoms have subsided and the
postoperative period was uneventful. The patient was discharged with a right self-
retaining ureteric catheter in situ for the next three months.

Conclusion: This case is a strong argument for the importance of performing

minimally invasive surgery and underlines the excellent outcome of these procedures,
despite the small number of cases recorded in medical literature.

Keywords: Circumcaval Ureter, Third Degree Hydronephrosis

De Novo Nasopharynx Carcinoma after Total Laryngectomy - Case
Report

Author: Thomas-Gabriel Schreiner

Co-author: Ana-Maria Padurariu, Oliver Daniel Schreiner
Scientific coordinator: Teaching Assistant Catalina Pintilie MD

Introduction: Recurrence is common after total laryngectomy for advanced laryngeal

carcinoma, more than 50% of the patients developing recurrences 18 to 24 months
after the first therapeutic approach at the pharynx, tracheostome, neck lymph node, or
distant sites. The aim of this study is to present a case where no recurrence emerged,
but after 8 years a de novo nasopharyngeal carcinoma was detected in an uncommon
location, on the lateral wall of the nasopharynx, near the opening of the Eustachian
tube.

Materials and methods: We present a clinical case of a 69 years old male who came
for his regular follow-up in the ENT Clinic of Sf. Spiridon County Hospital with
nasal obstruction, right earache, tinnitus and dizziness, dysphagia and odynophagia,
symptoms which began one month before and worsened. He was known with an
operated laryngeal squamous cell carcinoma in 2009, after the total laryngectomy, he
neglected the follow-up check-ups that must have been conducted every 6 months. He
denied smoking and alcohol consumption. An inflammation starting from
nasopharynx and extending towards hypopharynx was first suspected, while clinical
examination revealed no lymph node enlargement

Results: Investigations showed leukocytosis and mild levels of C-reactive protein. On

nasopharyngoscopy, a mass arising in the fossa of Rosenmller was visible, therefore
biopsies were taken. The pathological exam confirmed a nonkeratinizing carcinoma.
Radiotherapy was chosen as the optimal method, a dose of 66 Gray was used. Regular
CT or MRI check-ups are required every 3 months during the first year and every 6
months during the second and third years after treatment.

Conclusion: The singularity of the case consists of the absence of the recurrence after
laryngectomy and the detection in an early stage of development of a nasopharyngeal
carcinoma that imitated an inflammation without lymph node enlargement.

Keywords: Nasopharynx Carcinoma, Laryngectomy, Squamous Cell Carcinoma

Chronorhythmic Profile of Quercetin Impact on the Antioxidant System
under the Conditions Of The Experimental Acute Kidney Injury

Author: Anastasiia Adamchuk

Co-author: Oleksandra Horoshko, Volodymyr Zeleniuk
Scientific coordinator: Volodymyr Zeleniuk MD

Introduction: Renal function has a marked circadian periodicity. The study of

renoprotective properties of drugs within their impact on the kidneys circadian
rhythms is highly relevant. Thus, the aim of our work was to investigate the influence
of quercetin containing drugs on the diurinal antioxidant profile of rats under the
conditions of acute renal injury (AKI).

Materials and methods: In vivo studies were carried out using 28 nonlinear white
laboratory rats. Glycerol-induced AKI was modeled after 50% glycerol solution
injected intramuscularly (10 ml/kg). Quercetin containing drugs lipoflavon and
corvitin (8 mg/kg of quercetin equivalent) were administrated i/p 40 min after
glycerol injection 4 times a day: at 8.00, 14.00, 20.00 and 2.00.

Results: As has been found in our experiments, throughout the day malondialdehyde
(MDA) content in the kidney tissues of untreated animals reached a minimum rate at
14.00 and the maximum at 2.00 and was averagely higher by 80% than in controls.
The most significant reduction of MDA content by 20% was observed at 2.00 in both
corvitin and lipoflavon groups. Animals with AKI showed an increase in oxidatively
modified proteins (OMP) level by 31%, with acrophase at 20.00. Meanwhile, corvitin
administration caused the decline in the OMP formation intensity by 23% (acrophase
at 20.00) and lipoflavon by 16% (acrophase at 2.00). Glutathione peroxidase (GPx)
activity in the kidney tissue of untreated rats with AKI decreased significantly (by
1.57 times, as compared to intact control). Meanwhile quercetin-treated rats featured
improvements in the amelioration of the GPx activity averagely by 72% at 20.00 and
2.00.

Conclusion: The antioxidant protection during the AKI progression in rats via
corvitin and lipoflavon intensifies mostly in the evening (20.00) and at night (2.00),
respectively. Thus, the administration of quercetin containing drugs with the purpose
of renoprotection should be adjusted to the renal circadian clock.

Keywords: Quercetin, Circadian Rhythms, Acute Kidney Injury

NOT ACCEPTED

Spontaneus Hepatic Subcapsular Hematoma

Author: Iulia AncaBota

Scientific coordinator: RalucaLupusoru MD

Introduction: Spontenoussubcapsular liver hematoma is often reported in preeclampsia-

in HELLP syndrome and rarely in gross anatomical lesions or coagulopathy(1). Usually
the developement of a hepatic subcapsular hematoma is associated with trauma.

Materials and methods:A 63 years-old-male, presented to the emergency room 7 days

after an acute episode of fever, dyspnea, fatigue and pain in the right upper abdomen. The
pain worsened by body movements. On physical examination, no pallor, examination of
the heart was normal, examination of the lungs revealed crackles rales and right basal the
vesicular murmur was abolished. Tender hepatomegaly and a distended abdomen was
noted. Laboratory results revealed a hemoglobin of 10 g/dl, a white blood cell count of
30.300/l, a platelet count of 564.000/l. PT was 11.4 seconds. Increased liver function
test: AST=334 U/L , ALT=669 U/L, T.bil=1.7 mg/dl, ALP=182 U/L, GGT=546 U/L. On
abdominal ultrasound an inomogen, transonic hepatic mass of 15/5 cm that followed the
liver structure from the anterior face to the inferior one was found. Contrast enhanced
ultrasonography (CEUS) revealed the presence of an unenhancing collection under the
liver capsule suggestive for a subcapsular liver hematoma. CT scan confirmed the
subcapsular hematoma around all liver segments, and in segment V it revealed a rupture of
the liver capsule, and also intraparenchymal bleeding. Patient was referred to surgery,
were drainage was made.

Results:

Conclusion: A subcapsular hematoma of the liver is an accumulation of blood between

Glisson's capsule and the liver parenchyma. Rupture into the peritoneum has a 75%
mortality rate if the intervention is not performed immediatly(2). Subcapsular liver
hematoma occures usually in case of trauma. Spontaneous liver bleeding occures in case
of coagulopathy, gross anatomical lesions or in case of HELLP syndrome. The
particularity of this case is that the patient presented at the emergency room for a banal
pneumonia and he was diagnosed with the rupture of a large spontaneous subcapsular
hematoma. The patient did not fit in any category, being without a visible trauma, without
coagulopathy or anatomical lesions.

Keywords: Liver, Hematoma, Ultrasound

Secretory Breast Carcinoma: A Rare Subtype of Cancer with a
Favorable Prognosis

Author: Iulia Hutanu

Co-author: Lorena Vatra, Amalia Ilasoaia
Scientific coordinator: Professor Florin Mitu MD PhD

Introduction: Breast cancer is the most common cancer in women, causing nearly
373.000 deaths each year worldwide. Secretory breast carcinoma is a rare subtype of
neoplasm, accounting for only 0.15% of all invasive breast cancers. In scientific
journals, most cases were reported in women, while only 27 cases were found in men.
This abstract focuses on the significance of breast clinical examinations and the
importance of cancer prevention through screening programs.

Materials and methods: We report the case of a 49 year old female patient, known
with multiple cardiovascular risk factors, who is admitted to Hospital of Recovery
Iai. Clinical examination reveals a tumefaction and rashes on the right breast, pain
during palpation, skin thickening (orange peel skin) and nipple inversion.
Laboratory investigations reveal markers of inflammation, as well as high levels of
carcinoembryonic antigen. Breast ultrasound confirms the presence of a voluminous
tumoral formation with a non-homogeneous structure.

Results: The biopsy shows a malignant cell proliferation with secretory granules. The
result of the biopsy, combined with the clinical and the laboratory investigations
support the diagnosis of secretory carcinoma. Since hormonal treatment is not
effective for this type of cancer, chemotherapy treatment is established and surgery is
recommended. The prognosis is favorable, but the chances of metastastatic axillary
lymph nodes or distant metastases required immediate treatment. Recent data from
literature shows that the tumor is associated with a mutation of the ETV6-NTRK3
gene, which can pave the way for new targeted molecular therapies.

Conclusion: Secretory breast carcinoma is a rare tumor with a favorable prognosis.

Detection through screening methods is particularly important due to the number of
over 1 million new cases of breast cancer each year and increased mortality among
women. Since secretory carcinoma can mimic benign tumors, biopsy is essential to
the diagnosis and the establishment of proper treatment.

Keywords: Secretory Breast Carcinoma, ETV6-NTRK3, Mutation

Clostridium Difficile Admissions, Identifying Trends Using the Atlas
Score: Infectious Diseases Hospital Iasi

Author: Afeefa Anwar

Co-author: Rabeea Anwar, Saad Ali Maqsood
Scientific coordinator: Associate Professor Catalina Luca MD PhD

Introduction: Infection with Clostridium difficile has in recent years become

increasingly more frequent. It is currently one of the most common aetiology for
nosocomial diarrhoeal disease. Clostridium difficile has the capability to produce
toxins and can lead to enterocolitis. The prognosis of patients admitted with this
infection vary, however when spread throughout hospitals to patients who are
admitted for other reasons, can lead to deterioration and complications of their
conditions.
Our objectives include identifying trends in C. diff. and the regional patterns in
admissions of patients to the hospital.

Materials and methods: The ATLAS score (Miller 2010), which is a 5 criteria
bedside scoring system to gather information about the prognosis and severity of a
patient admitted with C.difficile infection. Data was collected using a patient data
form outlining information about previously prescribed antibiotics, duration and
pathology. Overall 30 patients were studied over a two month period.

Results: There has been an increasing trend in the number of cases in the last year,
particularly among the immunocompromised patients. Metronidazole, vancomycin
and a combination of both are the most commonly used in our hospital. Fidaxomicine
was used in 5 cases and the faecal transplant in 8 cases previously. Our scientific co-
ordinator has found that 48 of the cases occurred in patients with previous surgery and
52 cases came from medical services. The results of our study are still being
processed and are ongoing. 26% of patients that were admitted had an ATLAS score
of 3 on admission which indicates moderate-severe prognosis.

Conclusion: Analysis of these cases gives us an insight into regional trends of

hospital acquired Clostridium difficile infection; our results aim to conclude how
these trends are influenced by other risk factors.

Keywords: DiarrhoealAetiology, Nosocomial Infection, Clostridium difficile

Gist in a Neonate with Jejunal Atresia and Stenosis - Case Presentation

Author: Midhun Mathew

Co-author: Nidhiya Kadampattu Jonh, Sandra Susan Roy
Scientific coordinator: Teaching Assistant George AlinStoica MD
Introduction: Intestinal atresia (IA) is a common small bowel malformation
encountered in 1 out of 1000 live births. Gastrointestinal stromal tumors (GISTs) are
the most frequent mesenchymal tumors of the gastrointestinal tract. Their overall
incidence is between 1020 per million people; they are usually seen in adulthood and
occur very rarely in neonates.

Materials and methods: We will present the case of a 5 days old male, with
intestinal stenosis and atresia (type II) operated for peritonitis. The newborn was
vaginally delivered five days before admission, birth weight was 2950 g, APGAR
score 8/10 and, apparently, normal stooling was reported in the first two days. After
feeding attempts, repeated vomiting episodes occurred, but with clinically normal
abdomen. In the last day before presentation to our hospital emergency, severe belly
distension, vomiting, increasing volumes of gastric aspirate on the nasogastric tube,
and lack of meconium passage, developed progressively.

Results: At laparotomy, we found an intestinal obstruction complicated by small

bowel diastatic perforations. The source of perforation was an over-distended jejunal
loop with necrosis and perforation, between a proximal stenotic bowel and a distal
atresic area. On the resected specimen, the histopathologic examination revealed a
small gastrointestinal stromal tumor of 8 mm. The imunohistochemical analysis
indicated a low malignant potential. He is currently under pediatric oncology follow-
up.

Conclusion: The peculiarity of our case was the association of three events in a
newborn: intestinal stenosis followed by an intestinal atresia distally and the
occurrence of a small gastrointestinal stromal tumor. To our knowledge, the presence
of a GIST on the resected specimen of the small bowel for an obstructive
malformation was never reported before in the medical literature.

Keywords: Intestinal Atresia, Intestinal Stenosis, Gastrointestinal Stromal Tumor

Patient with Sheehan Syndrome and Dyselectrolytemia

Author: Karina Boiagian

Co-author: Luana-AndreeaBosoteannu, Alexandra Ana Mateescu
Scientific coordinator: Assistant ProfessorIrina Tica MD PhD

Introduction: In Sheehan syndrome, the affected organ is the pituitary gland. When
the blood supply to the hypophysis is reduced, the symptoms and signs of its
hypofunction affect almost any part of the body. Hyponatremia is the most frequent
electrolytic disorder of this syndrome, being present in approximately 33-69% of the
patients.

Materials and methods: We studied the case of a 78 year-old female patient,

suffering from pituitary insufficiency and multiple comorbidities (type 2 Diabetes,
Essential Arterial Hypertension, first-degree atrioventricular block, Heart Failure,
stage 2 of Chronic Renal Disease). The medical example we present is characterized
by hyponatremia, secondary to an extended diarrheic syndrome, affecting the patient
following a substitutive treatment with Euthyrox and Prednison. Moreover, the patient
suffered from bronchopneumonia, diagnosed with clinical, microbiological and
radiological methods which imbalanced even more the electrolytic panel
(hypopotassemia).

Results: Due to the two-stage evolution of the medical condition (diarrheic

syndrome, hyponatremia and, successively, hypopotassemia, bronchopneumonia with
bilateral pleurisy) the patient followed multiple antibiotic treatment and she was
stabilized as far as the hydro-electrolytic disorder is concerned. As soon as the
sufferers general state of health improved, the discharge was permitted.

Conclusion: Dyselectrolytemia, associated with pituitary insufficiency and with a

substantial third-age pathology, poses significant challenges for diagnosis and
treatment, often with poor prognosis.

Keywords: Sheehan Syndrome, Hyponatremia, Hypopotassemia

NOT ACCEPTED

THORACOSCOPIC APPROACH IN A CASE OF MULTI-

LOCULATED EMPYEMA

Author: Nithiya Kadampattu John

Co-author: Sandra Susan Roy
Scientific coordinator: Stoica Alin MD, Dumitru Loredana MD, Fruntelata Radu
MD

Introduction: Pleural empyema is a rare but redoubtable pathology in childhood. In

our case, we intended to evacuate the encysted collection from the right hemithorax in
order to solve the acute respiratory failure and to eradicate the infectious outbreak.

Materials and methods: We used two- port thoracoscopic approach and working
pressure of 6 mmHg. The pleural cavity presented false membranes delimitating
pseudo-cavities successively addressed by thoracoscopy. The pus and false
membranes are collected for microbiological and histo-pathological examination.

Results: The postoperative clinical outcome was very good - the infectious syndrome
disappeared without respiratory failure. The radiological findings showed the
resolution of the initial aspects.

Conclusion: In our child, the thoracoscopic approach is as effective as the classical

intervention (the thoracotomy) which is a more laborious maneuver.

Keywords: Two Port Thoracoscope, Respiratory Distress, Infectious Syndrome

Metallic Body Voluntary Ingestion by a 16 Year Old Teenager

Author: Dim Gabriela

Co-author: Dabuleanu Ana Maria
Scientific coordinator: Gabriela Paduraru MD

Introduction: A patient aged 16 years was admitted in emergency for voluntary

ingestion of a metal foreign with an increased risk of intestinal perforation and
obstruction.

Materials and methods: The patient shows a foreign body in the intestines which the
patient ingested voluntarily. On clinical examination to the skin a postoperative keloid
scar in the supra-ombilical region and a keloid scar on the front and back of the left
forearm after burn and a painful abdomen on a superficial and deep palpation. The
patient also declares the absence of stool for the past 6 days.
Radiological finding show the existence of the two metallic objects located on the
topography of the small intestine, with dimensions of 10 cm/1.9 cm and 6.8 cm/0.5
cm and another thread like structure in the rectal topography. The intestines show no
sign of perforation or obstruction.

Results: Following admission, the patient has ingested other metallic objects (2
spoons, needles) which showed no obstruction or perforation and expects an eventual
evolution: a favorable one by removing the objects naturally or an unfavorable
(obstruction, perforation) indication for surgery.

Conclusion: This patient is remarkable for his many hospitalizations (10 till now) for
the same reason-metallic body ingestion. Metal bodies and sharp objects ingested can
cause very serious complications at any age but especially in children who requires
careful monitoring and appropriate therapeutic approach, according to the state of the
patient. In this case the patient requested a psychological checkup given the number
of repeated hospitalizations.

Keywords: Metal Body, Obstruction, Perforation

Multimodal Therapy of Nefrolithiasis

Author: Melissa Madalina Mihalas

Co-author: Stelian Adrian Ritiu
Scientific coordinator: Assistant Professor AlinCumpanas MD PhD

Introduction: Renal lithiasis is in top three most common urological pathology.

Today thanks to progress of medical techniques there are many surgical treatment
methods that can be used presenting the benefits of a less invasive technique with a
better and quicker recovery and a lower chance of infection. The 70s brough an
elective method in surgery of nephrolithiasis percutaneous nephrolithotomy (PCNL)
and later retrograde intrarenal surgery (RIRS) was introduced.

Materials and methods: The retrospective cohort study included 112 patients
hospitalised at the Urology Clinic in Timisoara County Emergency Clinical Hospital
between January 2013 December 2013 diagnosed with renal lithiasis. PCNL,
pielolitotomy, nephrolitotomy and nephrectomy were performed, assessing : age and
gender, background, associated pathology, size and location of the lithiasis and its
components, time of hospitalisation post-surgery, placement of JJ stent and the reason
to do so and postoperative complications.

Results: Study shows the most commonly affected by renal lithiasis patients are 40 to
69 years old (66%) while patients above 70 years are not so frequently diagnosed
(11%). Gender distribution is almost equal (44% males, 56% females) with
predominance in patients coming from urban area (66%). Most subjects had
associated hypertension (49%), diabetes (18%) and ischemic cardiomyopathy (17%).
PCNL was mostly used (96 patients 87%) out of which 14 patients (15%) presented
minor postoperative complications.

Conclusion: According to our study patients between 40 and 69 years old, females
with previously diagnosed hypertension coming from urban area are mostly
diagnosed with nephrolithiasis. PCNL is frequently used and with a low chance of
postoperative complications.

Keywords: Nephrolithiasis, Percutaneous Nephrolitotomy, Minimally Invasive

Surgery
NOT ACCEPTED

Congenital Bronchial Atresia

Author: Ruxandra-Maria Hartan

Co-author: Ion-Andrei Hurjui
Scientific coordinator: Tesloianu Anda MD, Albu Andra MD

Introduction: Bronchial atresia is a rare congenital disorder characterized by

localized atresia or stenosis of a segmental bronchus. We present a case of congenital
bronchial atresia with unique features in a forty one years old asymptomatic, non-
smoker female who presented to the Emergency Room after experiencing extremities
shaking, lipothymia and asthenia

Materials and methods:

Results: After taking an X-ray chest, it revealed a flattened diaphragm and bilateral
pulmonary hypertransparency, so it was mandatory to take a thoracic CT to get more
information. The scan showed pathological modifications of the left lower lobe
among with decreased vascularization and hypertransparency and a tubular formation
filled with mucus.

Conclusion: After being under medication with 2 antibiotics at the same time, the
clinical evolution of the pacient was favorable and the symptoms remitted. She was
discharged from the hospital and she was sent to the Thoracic Surgery Clinic for a
thorough consult.

Keywords: Atresia, Congenital, Pulmonary

Bronchiolitis Complicated With Severe Sepsis, Acute Multiple Organ
Failure in an 8 Months Down Syndrome Male Infant

Author: Dabuleanu Ana-Maria

Co-author: Dim Gabriela, Ciubotariu Mihaela Alina
Scientific coordinator: Paduraru Gabriela MD, Assistant Professor Valeriu V. Lupu
MD

Introduction:Down syndrome, the 21 trisomy, represents a major cause of infantile

morbidity and mortality. In Iai the medium incidence of Down syndrome was 1/769
new-born. Children with Downs syndrome suffer more often and more severely from
respiratory tract infections.

Materials and methods: We are presenting the case of an infant coming from a
disfavored environment who hasbeen diagnosed with Down Syndrome, dystrophy and
who presented a bronchopneumonia complicated with cardio respiratory failure,
diarrhea, acute dehydrated, sepsis and convulsive syndrome. The infant accused
productive cough, dyspnea, diarrhea and the clinical examination revealed respiratory
effort, dyspnea, polypnoea and a pathologic pulmonary auscultation specific to a
bronchopneumonia. To study the gravity of his disease we ordered paraclinic
examinations such as biochemical and cellular evaluation of the blood, electrolytes,
thoracic x-rayand echography of the abdomen, heart and fontanels. As a result we
noticed the severe sepsis and the multiple organ failure syndrome.
The patient was transferred to an ICU where we started the treatment in order to
sustain his vital functions and to treat the infectious cause.

Results: The evolution was positive under our treatment. The prognostic remains
reserved because in this case the Down syndrome which associate multiple organ
dysfunctions is associated with the dystrophy and the poor environment.

Conclusion: As studies reveal RSV bronchopneumonia is a major health issue in

children with Downs syndrome, as it accounts for 17.6% of all Down Syndrome
admissions to hospital and it can also associate bacterial overgrowth. Treating
bronchopneumonia in infant patients consist of maintaining the oxygen saturation,
hydro-electrolytic and nutritional rebalancing, Ephedrine instillations, antibiotics, non
assisted and assisted ventilation.

Keywords: Bronchopneumonia, Acute multiple organ failure, Down Syndrome

The Role of Radiolabeled Nanoparticles in Medical Imaging Diagnosis

Author: Eusebiu Petru Irina

Co-author: Patricia Richter, Radu Cristian Tataru
Scientific coordinator: Lecturer Irena Cristina Grierosu MD PhD; Professor
Cipriana Stefanescu MD PhD

Introduction: The lymphatic system is difficult to visualize imagistically. It is well-

known that the lymph is one of the dissemination ways in neoplasia. The identification of
the first drainage lymph node (the sentinel node), followed by the target biopsy and
anatomo-pathologic diagnosis helps in the adaptation of the therapeutic conduct according
to the diseases stage. Also, there are non-oncological pathologies whose consequence is
represented by lymphatic obstruction, with the dilatation and deformation of the lymph
ducts, followed by the formation of lymph collaterals and clinical occurrence of the
edema. The visualization of lymph anomalies in these cases could be extremely useful in
both diagnosis and therapy.

Materials and methods: The nanoparticles (particles between 5 and 300 nm in diameter)
marked by 99mTc can be used in scintigraphic imaging: in localization and identification
of the sentinel node, and in making lymph maps in oncologic and non-oncologic patients.
These are acquired with a double headed gamma-camera (dynamic images immediately
after injection), as well as static images (30 minutes or a few hours after the injection).
The gamma-camera captures the gamma rays emitted by the patient after the intradermic
administration of the radiotracer. According to the diameter of the radiolabeled
nanoparticles, the moment of acquisition and the pathology localization, the lymph
channels can be viewed, as well as the drainage nodes or the position of the lymph
obstruction.

Results: This is a very high sensitivity method (> 98 %). In all 25 cases we identified
sentinel node from breast cancer and malignant melanoma, as well the lymphatic channels
in cases of lymphedema. These images was extremely helpful for surgery localization,
occupying also an important place in the therapeutic algorithm.

Conclusion: Our findings support the literature data that the lymphoscintigraphy (with or
without sentinel node identification) proved to be extremely useful in diagnosing of lymph
pathologies, both in oncologic and non-oncologic cases.

Keywords: Sentinel Node, Nanoparticles, Lymphoscintigraphy

A Challenging Diagnosis of a Two-Year-Old Patient with Early Signs of
Virilisation- Case Report

Author: Giorgia Pastiu

Co-author: Octavian Peuna, Sorana Maria Pascalau
Scientific coordinator: Anamaria Baldean MD, Professor Carmen E. Georgescu
MD PhD

Introduction: Congenital adrenal hyperplasia (CAH) represents a group of autosomal

recessive disorders caused by deficient adrenal corticosteroid biosynthesis. 90% of
CAH are caused by 21-hydroxylase deficiency. However, the diagnosis may be
challenging due to possibility of another enzymes deficiencies implicated in
corticosteroid synthesis.

Materials and methods: A two-year-old male patient came in our attention last year
after accusing early development of external sexual organs (macropenis), pubic hair
growth, face acne and accelerated linear growth (+3.8SD). Clinical manifestations
were suggestive of precious puberty. The hormonal profile revealed normal values for
age of LH and FSH and high levels of testosterone (=2.26 ng/ml), hypocorticism
(basal cortisol=1.80 g/dl) associated with high level of ACTH so that the next step
was dosage of 17-OH-progesterone which had higher levels than normal. The most
accurate diagnosis was 21-hydroxylase deficiency. Skeletal age assessment indicated
precocious bone maturation (bone age of 6 years). The patient also underwent
testicular and abdominal echography, which excluded a testosterone-secreting tumor.
Pituitary MRI excluded a central etiology of precious puberty. Treatment consisted in
oral administration of Hydrocortisone 7.5 mg/day. Two months following
diagnosis,patient presents a good disease control, but frequent episodes of
hypertension.

Results: The reported case illustrates an aparent case of 21-hydroxylase deficiency in

simple virilizing form. Though, the association virilisation-hypertension leads us to a
more probable diagnosis: 11--hydroxylase deficiency.

Conclusion: Early signs of virilisation in our patient indicate mostly a peripheral

etiology, which has been confirmed by the hormonal profile. Once the laboratory
values for aldosterone and plasmatic renine will come out, it will be possible to
establish rather the hypertension is caused by11--hydroxylase deficiency or not.

Keywords: 11--hydroxylase, Hypertension, Virilisation

Giant Malignant Peripheral Nerve Sheath Tumor in a Patient with Type
1 Neurofibromatosis

Author: Teodora Rotaru

Co-author: Ioana Mare, Elena Iftimi
Scientific coordinator: Teaching Assistant Monica Panzaru MD

Introduction: One of the most common genetic disorders is type 1 neurofibromatosis (NF-1),
also known as von Recklinghausen disease, with a prevalence of one case in 3500 births. The
gene for NF-1 is located on the long arm of chromosome 17 and encodes neurofibromin, a
peptide that acts as a tumor suppressor.NF-1 is an autosomal dominant disease and almost 50%
of cases are the result of de novo mutations. The most frequent symptoms include caf-au-lait
spots, cutaneous neurofibromas and Lisch nodules (pigmented hamartomas of the iris), but the
disease can have various manifestations.

Materials and methods: We present the case of a 16-year-old patient with a giant tumor
located in the right gluteal region, multiple caf-au-lait spots and axillary and inguinal freckles,
all of which suggested NF-1. The tumor was surgically removed, with a favorable outcome
post-surgery. Histopathological examination revealed a malignant peripheral nerve sheath
tumor, which confirmed the suspected diagnosis. Familial anamnesis revealed a sister with
multiple caf-au-lait spots and a brother who died of a brain tumor.The parents do not have
clinical signs that could indicate NF-1.The patient presented for reevaluation and
chemotherapy, complaining of irritating dry cough and intermittent mild thoracic pain, but the
clinical evaluation was within normal limits.

Results: Thoraco-abdomino-pelvic CT showed an abdominal mass and pulmonary

metastases/multiple pulmonary nodules, disseminated in both pulmonary areas, located
intraparenchymal and subpleural. Palliative care was recommended, the patient being
monitored by an oncologist.The patients sister was examined and diagnosed with NF-1
(multiple caf-au-lait spots, axillary and inguinal freckles, optic glioma). Further data on the
deceased brother could not be obtained

Conclusion: NF-1 has various clinical manifestations, the stand out in this case being the size
of the tumor and its unfavorable evolution. Familial anamnesis points at either
germlinemosaicism or two de novo mutations, both cited in literature.

Keywords: Neurofibrimatosis 1, Germlinemosaicism, Tumor

Morphological Profile of a Borderline Serous Ovarian Tumor

Author: Iuliana Stefanuca

Co-author: Paula-Georgiana Plaiasu, Stefana-Eugenia Moldovanu
Scientific coordinator: Associate. Professor Raluca Balan MD. PhD; Professor
Cornelia Amalinei MD. PhD

Introduction: Borderline ovarian epithelial tumors are defined by WHO (World

Health Organization) as tumors with no obvious invasion of the stroma, which have
mitotic activity and nuclear abnormalities intermediate between benign and malignant
tumors of similar cells. Ovarian serous borderline tumors (SBT) represent a disputed
heterogeneous histological group in terms of terminology and behavior.

Materials and methods: We report a case of serous borderline ovarian tumor with
micropapillary pattern and foci of microinvasion, in a 31 year old woman. The patient
presented with metrorrhagia and lower abdominal pain. The ultrasound diagnostic
revealed a left adnexal cystic tumor, with intracysticvegetations and the pelvic
examination detected enlarged left adnexa, which was sensitive to palpation. The
surgical treatment resulted in left salpingo-oophorectomy.

Results: The surgical specimen was formalin-fixed, paraffin-embedded, and routinely

stained with H&E. The histopathologic examination revealed a serous borderline
ovarian tumor with micropapillary pattern, with foci of microinvasion, and
periovarian isolated areas highly suggestive for low grade serous carcinoma.

Conclusion: The correct assessment of the histologic subtype and pattern of serous
borderline ovarian tumor, as well as the presence of poor prognostic featureshave
great importance, as the final tumor staging has impact on therapeutic management
and prognostic of the patient.Conservative surgery represents an option for young
patients with serous ovarian borderline tumors with microinvasion, for fertility
preservation, studies revealing that limited salpingo-oophorectomy does not affect
disease-free survival.

Keywords: Borderline Tumor, Micropapillary Pattern, Ovary

Iatrogenic Cushings Syndrome: Not So Rare

Author: Silvia Cristina Strat

Co-author: Andra Maria Mircea, Elena Diana Nafureanu
Scientific coordinator: Professor Carmen Vulpoi MD, PhD; Georgiana
Constantinescu MD, PhD-student

Introduction: Glucocorticoids are widely used for the treatment of various diseases, often
in high doses that may lead to the development of severe hypercortisolism. Iatrogenic
hypercortisolism leads to several complications secondary to the excess of potent
glucocorticoids and the suppression of the hypothalamic-pituitary-adrenal axis.

Materials and methods: We present the case of a 44 year-old female patient with a
history of psoriasis vulgaris (initially treated with Methotrexate), psoriatic arthritis and
sarcoidosis. The patient underwent prescribed treatment with Prednisone 15mg/day for the
last 2 years in association with Betamethasone for more than 6 months, for which she had
no prescription. Addressed to the Endocrinology Clinic, she accused important weight
gain (more than 30 kg in 2 years) with predominant abdominal distribution, moon face,
facial plethora, dorsocervical and supraclavicular fat pads, violaceous striae, hirsutism and
well-defined psoriasis plaques on the extremities, thorax and abdomen. She associated
high blood pressure values, corrected under antihypertensive treatment, high cholesterol
and blood sugar levels. Secondary hypertension and diabetes were later on confirmed with
introduction of specific treatment. Dual X Ray densitometry (BMD DXA) revealed
moderate bone loss. Prednisone was slowly decreased before withdrawal.

Results: Biological findings revealed: high cortisol levels with suppressed ACTH levels
prior to glucocorticoid withdrawal. 1 week after Prednisone withdrawal, morning cortisol
levels were normal, as well as ACTH, signs of regaining the adrenal function.

Conclusion: Iatrogenic Cushings Syndrome represents a problematic condition as the

oral corticosteroid therapy remains the main line of treatment in many inflammatory and
autoimmune disorders. Having this into consideration, a balance must be reached between
treatment of the underlying disorder and monitoring the adverse effects. Therefore,
ongoing patients education and surveillance remain mandatory in avoiding any extra self-
administrated drugs and prompt diagnosis of corticoid induced secondary effects.

Keywords: Cushings syndrome, Iatrogenic, Glucocorticoids

A Rare Case Of Autoimmune Polyglandular Syndrome

Author: Andra-Maria Mircea

Co-author: Silvia Cristina Strat
Scientific coordinator: Professor Carmen Vulpoi, MD, PhD; Georgiana
Constantinescu, MD, PhD-Student

Introduction: Autoimmune polyglandular syndromes (APS) are a heterogeneous

group of rare diseases characterized by autoimmune activity against more than one
endocrine organ, although non-endocrine organs can also be affected.
APS is divided into 2 major subtypes based on age of presentation, pattern of disease
combination and mode of inheritance. APS type I usually manifests in early infancy
or adolescence. It is characterized by multiple endocrine deficiencies with
mucocutaneous candidiasis and ectodermal dystrophy. APS type II usually manifests
in 3rd or 4th decade of life with female preponderance and commonly includes
autoimmune thyroid disease, type 1 diabetes, and Addisons disease.

Materials and methods: We present the case of a 68 year-old female patient with a
history of coronary heart disease with artery bypass graft surgery and deep vein
thrombosis addressed to the Clinic of Endocrinology for impaired general condition,
diarrhea and important weight loss. Clinical examination and laboratory blood tests
revealed positive anti-gliadin antibodies consistent with celiac disease in association
with positive anti thyroid peroxidase antibodies characteristic for autoimmune
thyroiditis, low free thyroxine with high TSH, consistent with hypothyroidism. She
also associated osteoporosis (T score= -5.1). Under gluten free diet, the patients
general condition was improved.

Results: The association of autoimmune thyroiditis and celiac disease is a rare type of
autoimmune polyglandular syndrome, especially in the absence of Addisons disease.
The challenge is to detect the possible occurrence of any other autoimmune
endocrinopathies.

Conclusion: In this particular case, the patient is known with Type II autoimmune
polyglandular syndrome but has no features of Addison's disease.

Keywords: Autoimmune Polyglandular Syndrome, Hypothyroidism, Celiac Disease

THE USE OF NEGATIVE PRESSURE WOUND THERAPY IN
COMPLICATIONS OF SURGICAL INTERVENTIONS. CASE
REPORT.

Author: Vunvulea Vlad

Scientific coordinator: Associate Professor Mircea Muresan MD PhD

Introduction: The foreign body reaction is an inflammatory response generated by

the interaction between macrophages and foreign body giant cells on synthetic
surfaces. These kinds of reactions form due to the abnormal presence of a medical
device, prosthesis, or biomaterial. Even with todays modern biomaterials, physically
and chemically inert; generally stable, non-immunogenic and non-toxic. Despite this,
they are not biologically inert. A foreign body reaction is triggered by their presence
being fairly uniform. Such cases are the implantation of Polypropylene or Polyester
mesh such as the surgical treatment of hernias and eventration.

Materials and methods: We present the case of a 59 year old female, smoker, with
generalized Atherosclerosis, who developed an eventration of the abdominal wall
after an Aortobifemural bypass surgery for Leriches syndrome. One week after the
plasty of the abdominal wall with Prolene mesh using onlay repair as a mesh location,
the results were unfavorable with foreign body reaction and suppuration of the
wound.We decide to re-intervene in order to extract the mesh and to treat the open
abdomen. As per International Expert Panel on Negative Pressure Wound Therapy
(NPWT-EP) recommendations, NPWT should be considered to prepare the wound for
surgical closure as part of a clinical pathway if first line therapy is not efficacious, in
our case we used Vivano abdominal kit.

Results: The results were favorable, granular tissue started to appear over the
intestinal loop and the signs of infection were reducing. Therefore we inserted a dual-
mesh (Polyester-Silicone) having a favorable evolution with primary closure of the
wound.

Conclusion: Therefore the Negative Pressure Wound Therapy is indeed a life saver in
cases of complications of surgical treatment of abdominal hernias.

Keywords: NPWT, Eventration, Dual-Mesh

An Accidental Diagnosis of Coffin-Lowry Syndrome in Pediatric Patient
Case Report

Author: Ana-Maria Padurariu

Co-author: Silvia-Mihaela Bulai, Thomas-Gabriel Schreiner
Scientific coordinator: Professor Ingrith Miron MD PhD, Teaching Assistant
Adriana Mocanu MD PhD

Introduction: Coffin-Lowry Syndrome is a rare X-linked dominant genetic disorder that is

characterized by mental retardation, hypertelorism, abnormalities of growth, skeletal
abnormalities like kyphoscoliosis and pectus carinatum, as well as cardiac abnormalities. The
syndrome is caused by mutations in the RPS6KA3 gene, which encodes RSK2, a growth-
factor-regulated protein kinase. De novo mutations are responsible for the majority of Coffin
Lowry syndromes diagnosed in boys, only 20-30% have one additional affected family
members.

Materials and methods: We report the case of a 3-year old boy who came at Iasi Countys
Emergency Hospital for Children Sf. Maria with specific symptoms of a viral tonsillitis. The
boy showed in previous medical history the followings: premature birth, malnutrition, therefore
required prolonged hospitalization for nutritional status recovery and chronic infantile
encephalopathy. Physical examination revealed: dysmorphic facies, hypertelorism, broad nose,
full everted lips, kyphoscoliosis, pectus carinatum,broad, tapering fingers, intense systolic
murmur, neuro-motor retardation and lack of temporal-spatial orientation.

Results: Coffin-Lowry Syndrome was suggested by the characteristic phenotype of the patient
and a positive family history (his mother and sister who showed mild features of the
syndrome). Molecular Genetic Tests conducted by the Genetic Laboratory of rare diseases are
expected to show structural modifications in the region of the RPS6KA3 gene. Supportive
therapy and genetic counseling is required, as no curative treatment is available.

Conclusion: The particularity of the case consists of both the unconventional way of diagnosis
during a respiratory tract inflammation and the rarity of the syndrome (1/100.000 incidence),
the only case reported in the clinic during the last 20 years.

Keywords: Coffin-Lowry Syndrome, Pediatric patient, RPS6KA3 gene

Hypertension As A Hallmark For A Rare Genetic Disease - Case Report

Author: Sorana-Maria Pascalau

Co-author: Irina-Elena Nechita, Giorgia Pastiu
Scientific coordinator: Madalina Chiriac MD; Professor Carmen Georgescu MD,
PhD

Introduction: Pheochromocytomas are cathecholamines secreting tumours which arise

from the chromaffin tissue of the adrenal medulla. These tumors may appear either as
sporadic neoplasms or in multiple endocrine neoplasia (MEN) syndromes, involving
malignancies of the endocrine organs that can develop synchronously or metachronously.
MEN 2A, one of the subtypes, is associated with medullary thyroid carcinoma,
pheochromocytoma and primary hyperparathyroidism.

Materials and methods: On admission in 2012, a 47-year-old male patient presented with
palpitations, headache, diaphoresis and severe fatigability. The physical examination
revealed facial flushing, high blood pressure and tachycardia. The patient comes from a
family with numerous cases of medullary thyroid cancer, pheochromocytoma and even
sudden death. The diagnosis of bilateral pheochromocytoma was reached based on highly
increased metanephrines serum levels, two suprarenalian adenomas detected by the CT
scan and the already established diagnosis of grade 3 hypertension. Moreover, elevated
calcitonin levels correlated with pheochromocytoma and positive family history raised the
suspicion of MEN2A. Although in 2015 the CT disclosed a considerable enlargement of
the adenoma, the patient refused the surgical intervention. However, he was readmitted to
the Endocrinology Unit due to several paroxysmal hypertensive crises.

Results: Laboratory tests showed twelve times elevated serum metanephrines (1085.6
pg/ml) and calcitonin threefold higher than reference (27.5 pg/ml). Last CT scan revealed
two heterogenous, iodophilic masses of 4.3/2.3 cm (right) and 2.7/2.1 cm (left) in
diameter. Although patient's genetic testing is ongoing, another family member was found
positive for codon 634 exon 11 mutation in the RET proto-oncogene.

Conclusion: The case of such a patient represents a major concern to the physician, due to
the complex family history of MEN2A extended on more than four generations and also
because of the unpredictable evolution of the disease in the absence of a proper surgical
treatment.

Keywords: Pheochromocytoma, MEN 2A, Hypertension

NOT ACCEPTED
Risk Factors in Wound Infections after Gynecological Laparotomy

Author: Eliza Bradescu

Co-author: Diana Badiu, Dan Navolan
Scientific coordinator: Dragos Nemescu MD PhD

Introduction: Postoperative wound infection represents a higher importance in

clinical practice. In spite of the modern surgical devices and techniques, it still
represents common complications. The objective of the study is to recognize the main
risk factors in postoperative wound infections after gynecological laparotomy and
further developing an infection surveillance program.

Materials and methods: We search the MEDLINE database system. All the studies
which imply the gynecological laparotomy were screening in order to achieve their
eligibility for meta-analysis.

Results: The main factors achieved after wound infections were longer hospital
admission, antibiotics and even resutures.

Conclusion: In order to reduce the risk factors which appear after gynecological
laparotomies, an infection surveillance program should be implemented for better
increasing the preventive measures and raising the quality of life.

Keywords: Infection, Risk Factors, Gynecology

A Rare Cause of Dyspeptic Syndrome: Familial Adenomatous Polyposis

Author: Mihaela Cornelia Robu

Co-author: Georgiana Catalina Robu MD, Livia Elena Iordache
Scientific coordinator: Associate professorMariana Jinga MD PhD

Introduction: Familial adenomatous polyposis (FAP) is an autosomal dominantly

inherited intestinal polyposis syndrome which accounts for about 1% of all colorectal
cancer. Nonspecific symptoms such as rectal bleeding, diarrhea or abdominal pain in
young patients may be suggestive for FAP.

Materials and methods:We report the case of a 48- years old woman who presented
at the Gastroenterology Department for epigastric pain and bloating. From her
familial history we mention that her mother was diagnosed with colorectal cancer and
her sister underwent colonoscopy which revealed numerous polyps. Her biological
tests showed only a lower level of hemoglobin. We performed an upper
gastrointestinal endoscopy which revealed gastritis. It was prescribed a therapy with
pump inhibitors. After a few months she came back because of a diffuse abdominal
pain. We decided to perform a colonoscopy, which revealed more than 100 polyps. It
was taken biopsies from polyps and sent to the pathology.

Results: We tried to establish the diagnosis of familial adenomatous polyposis. It was

recommended genetic tests before undergoing surgery.

Conclusion: Familial adenomatous polyposis can have nonspecific symptoms and

thats why it is important to take into consideration also the familial history. As FAP
is a cause of colorectal cancer it is recommended screening of the relatives.

Keywords: Epigastric Pain, Colonoscopy, Genetic Tests

SHOULD BE IN INTERNAL MEDICINE

The Estimation of Glomerular Filtration Rate in Kidney Transplant

Patients

Author: CovicAndreea
Co-author: Andronic-Niculescu Bogdan, Starica Alexandra
Scientific coordinator: Angelica Gramaticu MD

Introduction: Kidney graft function can be determined using the creatinine clearance (CrCl),
or estimated from serum creatinine using mathematical equations like CKD-EPI, MDRD and
Cockroft Gault. However, these equations were derived from non-transplant populations.

To evaluate the correlation and agreement between measured CrCl and eGFR in kidney
transplant recipients (KTR).

Materials and methods: We estimated GFR using MDRD, CKD-EPI and Cockroft Gault in
135 KTR (86 males, median age 58 years. CrCl was measured from 24-hour urine output.

Results: CrCl (median 64.0 ml/min) was significantly higher than CKD-EPI (median 52.9,
p<0.05), but similar to MDRD (median 53.6) and Cockroft Gault (median 56.2).
Mathematical equations are correlated to CrCl (r = 0.768 for CKD-EPI, 0.760 for MDRD and
0.781 for Cockroft Gault; p<0.001). However, the Bland-Altman plot showed that neither of
these methods has a good agreement with CrCl and demonstrated a higher discrepancy between
these methods with increasing GFR values. Out of the 14 outlier patients in the Bland-Altman
plot with CrCl well above MDRD values, we observed urinary creatinine >1.5 g/day in 7 (50%)
and an untrustworthy urine collection in one. From the 3 outlier patients with CrCl well below
MDRD, we found one patient with urinary creatinine <0.5 g/day, but no apparent explanation
could br found for the other outliers.
In patients with a measured CrCl 90 ml/min we found that there is a good agreement between
the methods, with no additional proportional bias.

Conclusion: In general, mathematical equations correlate with CrCl although they provide
lower value estimates for GFR than measured CrCl. The highest correlation coefficient
corresponds to the Cockroft-Gault equation. We found an agreement between the methods only
in patients with a calculated CrCl 90 ml/min. 24h urinary creatinine excretion may identify
some outliers in whom high or low muscle mass interferes with eGFR by equations.

Keywords: Kidney Draft, GFR, Transplant

NOT ACCEPTED
Resuscitated Cardiac Arrest in HIV Late Presenter Patient

Author: Loredana-Sorina Smarandache

Co-author: Lior Uziel, Daniela Bulancea
Scientific coordinator: Assistant Professor Florentina Dumitrescu MD PhD;
Cristina Roskanovic MD

Introduction: HIV/AIDS,pandemic on the rise,occupies the fourth leading cause of death

globally.In Western Europe,about 50% of newly diagnosed HIV-positive individuals are late
presenters(CD4 below 350 cells/mL or presenting with an AIDS-defining event, regardless of
the CD4 cell count).HIV-positive subgroup of patients with cardiac disease is increasing,up to
24% of cases being reported at autopsy.Causes of cardiac disease are controversial,among them
being the direct HIV effect on the heart,the presence of opportunistic infections and the effect
of HAART on the heart.

Materials and methods: We present the case of a 36 years old female patient who was
hospitalized in July 2016 at the Clinical Infectious Disease and Pneumology Victor Babes
Hospital,Craiova for diarrhea,astheniaand significant weight loss.Epidemiological investigation
discover numerous hematologic treatments in 2000(for thrombocytopenia),pulmonary
tuberculosis in 2008 and multiple unprotected sexual intercourse.Following numerous
investigations,the patient was diagnosed with lung tuberculosis (reactivated),polyserositis,
severe anemia(Hb=6.9g/dl),thrush,tricuspid insufficiency,HIV stage C3(CD4=196 cells/ml;
HIV RNA=1.120.000 copies/ml)initiating antibacillary,antifungal treatment and rebalancing
electrolytes.The evolution was dramatic by the occurrence of a cardiac arrest due to sever
hypokalemia(K=1.6mmol/L).Following the administration of Adrenalin and applying
resuscitation protocol,ventricular fibrillation was converted to sinus rhythm with the patients
subsequent takeover by SMURD.After rebalancing,the patient returned to Victor Babes
Hospital,currently being under antibacillary and antiretroviral treatment (Kivexa+Efavirenz)
with immune reconstruction(CD4=396cel/ml)and HIV viral load undetectable, with good
adherence to treatment.

Results: Challenge of the case may be supported by the data cited in literature regarding HIV
infection and cardiac disease,in this case trying to explain the appearance of cardiac arrest due
to pericarditis(possible tuberculosis etiology),due to non-bacterial endocarditis with tricuspid
valve damage and the appearance of an embolism or due to hypokalemia, being cited in
literature also the fact that the value of CD4 lymphocytes under 200 cells/ml causes a higher
risk of endocarditis and a grim prognosis.

Conclusion:

Keywords: HIV, late presenter, AIDS

Involvement of a New Rutin Derivative in Experimental Induced
Hyperhomocysteinemia in Rats

Author: Ioana-Irina Rezus

Scientific coordinator: Assistant Professor Nina Filip MD PhD

Introduction: Hyperhomocysteinemia is considered to be involved in many diseases

from cardiovascular to neurological illnesses. It is generally agreed that two
mechanisms cause hyperhomocysteinemia: one is low vitamins (B12, B6, folic acid)
supplies and second the main enzymes deficiencies (cystathionine -synthase
deficiency and methylenetetrahydrofolate reductase deficiency).
Hypehomocysteinemia is today considered a severe risk factor in vascular illnesses.
Thus three risk factors have been identified in vascular disease: hyperlipemia,
hyperhomocysteinemia and the imbalance of oxidation-reducing status. We intend to
research the effect of the new drug on hyperhomocysteinemia. The new drug
synthesized was coded as L3. We have investigated the influence of L3 on the levels
of the following parameters: cholesterol, homocysteine and the total antioxidant
status.

Materials and methods: Hyperhomocysteinemia was experimentally induced

through metionine administration, in rats, 2 g/ kg body/day, per os, for two weeks.
Concentrations of plasma homocysteine in rats were determined before and after
metionine administration using a Diazyme kit. TAS in plasma and cholesterol
concentrations were measured using a Randox kit for manual use.

Results: Homocysteine concentration was 11.08 1.03 M/ml initial and more than
50 M/ml at final. TAS level was 0.7320.021 mM/L initially, 0.6110.011 mM/L
after methionine administration and 0.7020.014 mM/L after methionine and L3
administration for two weeks. The cholesterol concentration determined in rat plasma
initially was 48.29 6.95 mg/dl and remained the same in both groups at final.

Conclusion: Our data show that installed hyperhomocysteinemia decreases the total
antioxidant capacity. In high homocysteine conditions, L3 succeeds to prevent the
decrease of the total antioxidant status, keeps cholesterol level within normal range
but has no effect on homocysteine level, meaning that two of the risk factors are
diminished.

Keywords: Homocysteine, Oxidative Stress, Cholesterol

Hydrocephalus Vs Hydrocephalus

Author: Jeethu Ann Jose

Co-author: Jeeva Rose Jose, Ruban Idiculla Chacko
Scientific coordinator: Simona Blessen MD

Introduction: Hydrocephalus is one of the most common birth defects. Each year
one out of every 500 births results in hydrocephalus. One of the most common causes
of hydrocephalus is spina bifida, a birth defect in which the spinal canal and the
backbone dont close before the baby is born. Around 15-25% of the children will
develop hydrocephalus from myelomeningocele, a type of Spina Bifida.

Materials and methods: A comparative case study between two Patients born with
lumbo-sacral myelomeningocele and their evolution into hydrocephaly. In this study,
I will compare and evaluate the outcomes of Patients A and B. Patient A without
surgery and Patient B who underwent surgery. The mortality rate is 50-60%
without surgery since there is no medical therapy to treat hydrocephalus. The
mortality rate can decrease drastically from 50-60% to 5-10% with surgery. However,
Patient A without any surgery survived 10 years equivalent to Patient B. Patient B
was treated with intraventricular stent whereas patient A was left with symptomatic
medication management. Patient B also had to undergo a second surgery as he grew
up.

Results: Both patients lived for more than 10 years. Patients A went through slow
and progressive physical impairment whereas Patient B, still showing no severe signs
of impairment or physical disabilities.

Conclusion: Although both patients lived for more than 10 years, Intraventricular
stenting gave a very good prognosis with no signs of relapse with minimal mental or
physical impairment.

Keywords: Myelomeningocele, Spina Bifida, Intraventricular stent

NOT ACCEPTED
Minimally Invasive Treatment of the Femoral Essential Cyst and Bone
Marrow Transplantation from the Sternum

Author: Jeethu Ann Jose

Co-author: Jeeva Rose Jose, Ruban Idiculla Chacko
Scientific coordinator: Alin Stoica MD

Introduction: The author is presenting a case of a 16 years old girl diagnosed on

MRI with the essential cyst of the left femur of about 3.5 cm in the proximal
metaphyseal part. Essential bone cyst occurs more commonly in children and
adolescents. They are painless and discovered incidentally.

Materials and methods:According to the dimensions of the cyst and the age of the
patient the minimally invasive treatment was preferred. Two bone trocars were
inserted at the proximal and the distal poles of the cyst cavity and the fluid content of
the cyst was evacuated and gathered for cytological examination. Washout of the
cavity was provided using Betadine solution and saline solution. Bone marrow from
the sternum was extracted through a bone puncture needle and transplanted into the
cyst. All maneuvers were performed under C-arm X-ray control.

Results:The postoperative clinical outcome was very good - the infectious syndrome
disappeared without any further complications. The radiological findings showed the
resolution of the initial aspects.

Conclusion:Compared to open surgery minimally invasive surgery with x-ray image

intensifier proved to be effective with reduced complications and time of recovery.

Keywords: Bone Cyst, X-Ray Image Intensifier, Transplantation

DIAGNOSTIC DIFFICULTIES - TUBERCULOSIS OF SYMPHYSIS
PUBIS - A CASE REPORT

Author: Daniela Bulancea

Co-author: Ionela Popescu, Lior Uziel
Scientific coordinator: Dan-Nelu Anusca, Raul-Filip Muresan

Introduction: Despite the progress made during the last decade, tuberculosis is still a
worldwide medical problem, being the first cause of decease by infectious diseases in
the world next to HIV/AIDS. Approximately 10% of the extra pulmonary tuberculosis
patients show osteoarticular forms, where the spine is the most affected. Pubic
symphysis tuberculosis is an uncommon condition, especially after the introduction of
chemotherapy in the TB management. There were reported only nine cases during the
last three decades.

Materials and methods We present the case of a male patient, aged 55, who was
addmited in the Orthopedics Service of the Craiova Emergency County Hospital with
lumbar region and pubic symphysis pain with irradiance on the right lower limb. The
symptoms increased during walking, when the Trendelenburg walk was observed.
The negative pelvic X-ray and laboratory investigations indicated an osteitis pubis,
but the lumbar spine X-ray raised the suspicion of tuberculous sacroiliitis and the CT
scan raised it even more . A CT-guided puncture of the pubic symphysis was
performed, followed by the Tuberculin test. The results were positive for TB.

Results: The patient went under surgical intervention to drain the collection using
curettage and wedge resection after the psoas muscle was opened. Based on the
diagnosis, the patient started a strictly supervised treatment with Rifampicin,
Izoniazid, Ethambutol, Pyrazinamide for nine months along with B and C vitamins, a
strict diet and repose. The evolution was favorable with complete healing.

Conclusion: Pubic symphysis tuberculosis is an extremely rare form of extra

pulmonary TB, reason why the differential diagnosis is often made with osteitis and
osteomyelitis pubis. The difficulty of this case was created by the posibility of
different interpretation, lack of urogenital affect, that lead to the assumption of a
nonspecific osteitis.

Keywords: Pubic symphysis tuberculosis, Extrapulmonary tuberculosis, Pubis

osteitis
DIAGNOSTIC CHALLENGE OF HYPERINSULINEMIC
HYPOGLYCEMIA Case Report

Author: Lior Uziel

Co-authors: Loredana-Sorina Smarandache; Sabrina-Mihaela Balasa
Scientific coordinator: Simona Georgiana Popa MD, Adina Popa MD,
Maria Moa MD

Introduction: Insulinomas are pancreatic neuroendocrine tumors which are a

common cause of hyperinsulinemic hypoglycemia.

Material and Methods: We present the case of a 33-year-old female patient who had
episodic neuroglycopenic hyperinsulinemic hypoglycaemic symptoms associated with
upper body flushing for 2 years. Laboratory data during the symptoms episode:
insulinemia = 21.36 U/ml (normal range: 317 U/mL), glycaemia = 33 mg/dl, -
hydroxybutyrate = 0 mmol/L (normal range: <0.6 mmol/L), anti-insulin antibodies,
chromogranin A, urinary levels of 5-hydroxyindoleacetic acid (5-HIAA) and
serotonin were in normal range. HbA1c was 5.7% (normal range 45.6%).
Endoscopic ultrasound and 3 Tesla magnetic resonance imaging identified a 18.3/16.3
mm tissue mass in the uncinate process of the pancreatic head, which was completely
surgically removed. Histological analysis indicated only tumoral invasion of the
conjunctive capsule, without mitotic activity in the tumoral cells, cytological atypia,
perineural or angioinvasion. Immunohistochemical staining indicated a Ki67 index of
3% and positivity for synaptophyisin and chromogranin A.

Results: At the nine months follow-up the patient was asymptomatic and had normal
insulinemia and glycemia.

Conclusions: The challenge of the hyperinsulinemic hypoglycaemia diagnosis in our

case was represented by the association of atypical symptoms (neuroglycopenic, but
not autonomic hyperinsulinemic hypoglycemic symptoms and carcinoid syndrome
symptoms) with normal serum chromogranin A and serotonin and also a small size
tumor that made difficult its localization.

Keyword: diabetes, insulinomas, neuroendocrine tumor

PSEUDOEXFOLIATION SYNDROME WITH CLOSED-ANGLE
GLAUCOMA AND NUCLEAR CATARACT IN EVOLUTION: CASE
REPORT

Author: Lior Uziel

Co-authors: Loredana-Sorina Smarandache; Alexandru-Ionel Talaban
Scientific Coordinators: Alin-Stefan Stefanescu-Dima MD, Andreea Corici MD

Introduction: Pseudoexfoliation syndrome is a systemic disease, primarily having

ocular manifestations, which produces an accumulation of white-gray protein in eyes
structure, determining the most common form of secondary open angle glaucoma.
Prevalence in Europe was found to be 5.5% in France and 6.3% in Norway,
comparing to 8.2% in South Africa and 7.4% in India. Because of the increased mean
age of population, pseudoexfoliation syndrome may become more prevalent in the
future.

Material and methods:We present the case of a 81 years old female

patient,diagnosed in 2002(9 years before)with pseudoexfoliative syndrome and open-
angle glaucoma in both eyes, for which she was under treatment with Xalatan until
March 2007, when an intraocular pressure of 40mmHg and myopia were determined,
requiring immediate hospitalization. The right eye was prepared preoperative by
adding Cosopt and Pilocarpine, followed by an YAG iridotomy. We mention
accidentally instillation of Pilocarpine in the left eye. Three hours postoperative, was
observed a tendency to angle closure in miosis in the left eye, requiring immediate
YAG iridotomy. Evolution was favorable, with patient discharge. In January 2008,
due to nuclear cataracts and myopia in both eyes,it was observed an angle closure by
phacomorphic mechanism, which required phacoemulsification with foldable IOL in
the right eye, 3 months later observing the appearance of zonular dehiscence with
anterior vitreous body migration. In 2008-2010, progressive deterioration of
intraocular pressure appeared, with the need of reintervention in the right eye
(phacoemulsification+foldable IOL+stabilizing the cristalinian bag using a capsular
tension ring), with no intraoperative incidents.

Results: Within 1 month after surgery, refractive and presional status are stable under
treatment.

Conclusions: Particularity of the case lies in identifying the complex mechanism of

developing open-angle pseudoexfoliative glaucoma and also the mechanisms of angle
closure (phacometric, phacotopic or after administrating Pilocarpine) and the existent
blurring therapeutic decision (role of lens extraction in management of
pseudoexfoliative glaucoma, uncompensated narrow-angle glaucoma under maximal
medical therapy) involving the necessity to turn to data cited in literature.

Keywords: Pseudoexfoliation syndrome, glaucoma, cataract