Oğuz Durmuş

Thoracic Outlet Syndrome in a Patient With Poland Syndrome

We report a 20-year-old man with Poland syndrome who suffered from weakness, pain, numbness, and discoloration in the left upper extremity. He was eventually diagnosed as also having thoracic outlet syndrome. The concomitance of these two disorders is discussed with a special emphasis on the underlying mechanisms.

Hepatitis B virus reactivation in a Juvenile Rheumatoid arthritis patient under treatment and its successful management: a complicated case

Juvenile rheumatoid arthritis is a common chronic inflammatory disease in the childhood and it can differentiate rarely into spondiloarthropaties. It is one of the important causes of chronic pain and disability. Some of the drugs used for the treatment have immunosupressive activity. One of the serious side-effects of immunosupressive treatment is activation of opportunistic pathogens. Hepatitis B virus (HBV) is one of these pathogens, and the rate of carriers in the population is considerably high. It can cause liver damage and death if reactivated. Thus, the management of oppotunistic pathogens becomes a complex issue when treating rheumatic diseases with immunosupressive drugs. In this case report, we present a juvenile rheumatoid arthritis patient whose liver enzymes raised while he was under treatment and afterwards HBV reactivation was determined as the cause. When reactivation was detected, we started controlled antiviral therapy. We achieved successful clinical and laboratory results after adding biological agents to the treatment. Careful evaluation of the patients who have indication for immunosuppressive agents and regular follow-up in case of infection may be protective from severe morbidity and/or mortality.

Diffuse Idiopathic Skeletal Hyperostosis as a Cause of Dysphagia in a Young Patient With Metabolic Syndrome

A 42-year-old male patient was admitted to our clinic with neck pain, stiffness, limited range of motion in the neck, and dysphagia upon eating solid foods. The pain had started about 5 years previously and increased over time. The patient had no history of trauma to the neck. He had a history of type 2 diabetes mellitus (for 3 years), hypertension (for 10 years), chronic renal failure, and dyslipidemia. The patient was morbidly obese (body mass index: 41). He had experienced frequent infections of the upper respiratory tract during recent years. Motor, sensory, and other neurologic examinations showed no signs of cervical radiculopathy. Range of motion in the neck was limited in all directions, and widespread cervical paravertebral spasm and tenderness were detected. Radiologic investigations showed contiguous vertebrae, bridging osteophytes (Figure 1). Findings of sacroiliac joint radiography were normal.

Chronic low back pain caused by osteopetrosis type 2

Causes for low back pain usually involve damages in bone, muscle or nerve tissues of spine. Hereditary sclerosing bone disorders are rarely presented with low back pain. This report is intended to remind that osteopetrosis type 2, which is a rare disorder in differential diagnosis of low back pain, should be taken into consideration.

Thoracic outlet syndrome due to an axillary band: what if it ruptures?

A 19-year-old man was seen with pain and paresthesia in his right upper limb especially during overhead activities. He described that his complaints ensued for the last 5–6 weeks. Although he denied any history of major trauma, the patient admitted that he had overused his right upper extremity in the interim. Additionally, he narrated that he had noticed a thread-like structure in his right axilla recently. The medical history was otherwise noncontributory. A thorough neuromusculoskeletal examination of the neck and the upper extremities were unremarkable. The aforementioned complaints of the patient could be elicited during provocative maneuvers for TOS (Roos and hyperabduction tests) on the right side. On palpation, a very thin (but tight) band-like structure was detected, extending between the pectoralis and biceps muscles traversing quite superficially through the axilla. Moreover, during palpation, the patient also suffered pain and paresthesia in his right arm and palm. Cervical X-rays and static/dynamic Doppler imaging were all normal. Eventually, the patient was diagnosed to have disputed neurogenic TOS. Since we considered that the band could easily be excised by a simple approach without need for a major TOS surgery, we referred the patient to Thoracic Surgery Department. Although, the patient refused surgery initially; as his complaints persisted on the 3rd week control visit, he accepted to be operated thereafter. When the patient was seen one day before surgery (as he was planned to be hospitalized), he interestingly declared that the band had probably been ruptured during a strenuous movement at the weekend. Since the band could not be palpated on the repeat physical examination and as the complaints of the patient no more existed, he was called for a control visit with reassurance. Our message in this report is simple and clear; during evaluation for TOS, each and every patient should be examined also with respect to the axillary area. This should be done in patients with and even without relevant signs and symptoms described in that region. Because, unless visible or palpable, the patient may not necessarily be aware of an aberrant structure. Herein, a practical suggestion would be to start this evaluation during Roos test; quite similar to observing for any color change of the upper limbs (i.e. for arterial or venous compromise). In cases with thicker bands, sonographic confirmation would be reasonable and quite convenient as well [1]. In our patient, we were unable to demonstrate the thin band with sonography, and it was thought to be delineated during surgery. However, as the treatment plan was substantially changed after the rupture of the band, we could not classify it into a previously reported category [2, 3] or as a new entity. Finally, although our patient’s thin band was ruptured unintentionally, controversy surrounds the question whether such bands can be manipulated before surgery. L. Ozcakar A. B. Carli O. Durmus M. Z. Kiralp Department of Physical Medicine and Rehabilitation, Gulhane Military Medical Academy Haydarpasa Training Hospital, Istanbul, Turkey