Signs and symptoms associated with synthetic cannabinoid toxicity: systematic review

Aims: Use of synthetic cannabinoids is associated with significant physical and psychological harms. This research quantified reported toxicities from published reports and assessed the influence of size of the reported study population on rates of symptom reporting. Methods: Systematic review of published case reports and case series of toxicity associated with use of synthetic cannabinoids. Results: Symptoms associated with synthetic cannabinoid toxicity were reported for 3695 individuals, predominantly young males. Symptoms included physiological (e.g. tachycardia, hypertension, nausea/vomiting), emotional (e.g. agitation, irritability, paranoia), behavioural (e.g. drowsiness, aggression) and perceptual (e.g. hallucinations) domains. Most common symptoms were tachycardia (30.2% of cases), agitation (13.5%), drowsiness (12.3%), nausea/vomiting (8.2%) and hallucinations (7.6%). Death or serious medical complications were uncommon (e.g. death 0.2%, stroke 0.1%, myocardial infarction 0.09%). Case reports/smaller case series ( n<10) reported statistically significantly higher rates for 29/34 symptoms than larger case series ( n≥10), which could represent selection bias. Conclusions: Symptoms of synthetic cannabinoid toxicity are variable and cover a number of physical and psychological domains. Symptom reporting varies by study population size. Due to the variable presenting symptoms of synthetic cannabinoid toxicity, clinicians in emergency services should consider synthetic cannabinoid toxicity when evaluating young adult male patients presenting with unexplained agitation or cardiovascular symptoms.

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Myocarditis associated with Covid-19 disease: a systematic review of published Case reports and Case series

10.22541/au.161219538.89676033/v1 ◽

2021 ◽

Author(s):

Sawai Singh Rathore ◽

Gianpier Alonzo Rojas ◽

Manush Sondhi ◽

Suveenkrishna Pothuru ◽

Reshma Pydi ◽

...

Keyword(s):

Systematic Review ◽

Case Reports ◽

Acute Myocarditis ◽

Case Series ◽

Cardiac Biomarkers ◽

Pulmonary Tissue ◽

Mortality And Morbidity ◽

Presenting Symptoms ◽

St Segment ◽

Inflammatory Infiltrates

Background: Covid-19 is an extremely contagious illness caused by the severe acute respiratory syndrome (SARS-CoV-2) virus. Although this disease primarily involves pulmonary tissue, rapidly advancing research has established cardiac involvement in Covid-19 patients. Objective: This systematic review article aimed to compile and illustrate clinical characteristics, diagnostic findings, management, and outcomes manifesting in myocarditis linked with Covid-19. Methods: A literature search was accomplished for published eligible articles with MEDLINE/PubMed and Embase databases. All eligible case reports and case series were included from around the world without any language restrictions. For this review, inclusion criteria were laboratory-confirmed SARS-CoV-2 infection cases reporting a diagnosis of acute myocarditis. Results: Data from 41 studies describing myocarditis in 42 Covid-19 patients was obtained. The median age of these patients was 43.4 years, with 71.4% of them being male. Fever was the most prevalent presenting symptoms seen in 57% of patients. Hypertension was the most pervasive comorbidity accompanying these patients. Cardiac biomarkers troponin and Brain natriuretic peptide (BNP) were raised in almost 90% and 87% of patients, respectively. Electrocardiogram findings were Non-specific and included ST-segment and T-wave changes. The most prevalent histopathological feature appreciated was diffuse lymphocytic inflammatory infiltrates. Antivirals and corticosteroids were the most frequently used medications. About 38% of patients also needed vasopressor assistance. Out of 42 patients, 67% recovered, and eight died. Conclusion: Due to the risk of a sudden worsening of patients conditions and myocarditis association with considerable mortality and morbidity, a knowledge of this cardiac complication of Covid-19 disease is crucial for healthcare professionals.

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Medically important trombiculids: a systematic review of the global distribution and clinical consequences of their bites

Revista Peruana de Investigación en Salud ◽

10.35839/repis.5.2.908 ◽

2021 ◽

Vol 5 (2) ◽

pp. 67-76

Author(s):

Julián F. Porras-Villamil ◽

Mario Javier-Olivera

Keyword(s):

Systematic Review ◽

Human Health ◽

Case Reports ◽

Clinical Signs ◽

Case Series ◽

Clinical Importance ◽

Signs And Symptoms ◽

Publication Date ◽

Rickettsial Infections ◽

Clinical Consequences

Background: Mites are among the smallest arthropods that can be seen without magnification, were the use of dermatoscopy is an invaluable tool. They are a cosmopolitan pest, and at the moment more than 250 species have been shown to produce problems for humans and animals alike. These mites are capable of producing a wide array of clinical signs and symptoms, from local to systemic, from mild to severe, as well as transmitting pathogens. This study aimed to provide an update to the clinical impact on human health, the distribution and species involved in the clinical conditions produced by trombiculids through a systematic review. Background: Mites are among the smallest arthropods that can be seen without magnification, were the use of dermatoscopy is an invaluable tool. They are a cosmopolitan pest, and at the moment more than 250 species have been shown to produce problems for humans and animals alike. These mites are capable of producing a wide array of clinical signs and symptoms, from local to systemic, from mild to severe, as well as transmitting pathogens. This study aimed to provide an update to the clinical impact on human health, the distribution and species involved in the clinical conditions produced by trombiculids through a systematic review. Methods: A systematic literature review was conducted in Medline, Lilacs, Redalyc, Scopus, SciELO and Google Scholar, were we use as a threshold of publication date the year 2008. We limited the search strategy to articles published in Portuguese, French, English and Spanish. Eligible studies were case reports and case series that reported outcomes in humans caused by trombiculid bites. Patient-level and study-level information was extracted. Results: The literature search yielded 832 studies; 13 were case reports, 4 case series and 2 descriptive studies reporting a total of 49 cases. Most patients were male, and the median age was 33.7±6.4 years old. The most frequently reported symptoms were local erythema, pruritus and papules. No deaths were documented. Trombiculids from the genera Trombicula, Eutrombicula and Leptotrombidium appear to be the most commonly reported. Discussion: Trombiculiasis is an infestation caused by the larval stage of various types of mites, known as chiggers, they belong to the class Arachnida and the family Trombiculidae. This systematic review provides an overview of the trombiculids of clinical importance, their distribution and effects of the bite on human health. Our results show that there are different species of mites that can have important consequences for human health. No fatal cases owere registered.Even so, the transmission of scrub typhus is important and remains one of the most life-threatening rickettsial infections in some regions of Asia. Conclusions: The bite of different species of trombiculids around the world can cause a wide array of clinical consequences to human health. Even as mortality appear to be nonexistent, trombiculid bites must be adequately diagnosed and treated properly: A systematic literature review was conducted in Medline, Lilacs, Redalyc, Scopus, SciELO and Google Scholar, were we use as a threshold of publication date the year 2008. We limited the search strategy to articles published in Portuguese, French, English and Spanish. Eligible studies were case reports and case series that reported outcomes in humans caused by trombiculid bites. Patient-level and study-level information was extracted. Results: The literature search yielded 832 studies; 13 were case reports, 4 case series and 2 descriptive studies reporting a total of 49 cases. Most patients were male, and the median age was 33.7±6.4 years old. The most frequently reported symptoms were local erythema, pruritus and papules. No deaths were documented. Trombiculids from the genera Trombicula, Eutrombicula and Leptotrombidium appear to be the most commonly reported. Discussion: Trombiculiasis is an infestation caused by the larval stage of various types of mites, known as chiggers, they belong to the class Arachnida and the family Trombiculidae. This systematic review provides an overview of the trombiculids of clinical importance, their distribution and effects of the bite on human health. Our results show that there are different species of mites that can have important consequences for human health. No fatal cases owere registered.Even so, the transmission of scrub typhus is important and remains one of the most life-threatening rickettsial infections in some regions of Asia. Conclusions: The bite of different species of trombiculids around the world can cause a wide array of clinical consequences to human health. Even as mortality appear to be nonexistent, trombiculid bites must be adequately diagnosed and treated properly.

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Uneventful delivery of two pregnancies in a woman with severe factor XII deficiency: case report and systematic review

Case Reports in Perinatal Medicine ◽

10.1515/crpm-2017-0035 ◽

2018 ◽

Vol 7 (1) ◽

Author(s):

Stamatios Petousis ◽

George Karavas ◽

Chrysoula Margioula-Siarkou ◽

Themistoklis Dagklis ◽

Paraskevi Karapavlidou ◽

...

Keyword(s):

Systematic Review ◽

Case Reports ◽

Case Series ◽

Signs And Symptoms ◽

Factor Xii ◽

Case Presentation ◽

Severe Deficiency ◽

Pubmed Database ◽

Increased Risk

Abstract Background Deficiency of factor XII (FXII) is widely considered to have a detrimental effect on pregnancy. Several reports underline the increased risk for antenatal complications with few published case reports of uncomplicated deliveries. The main objective of our article is to perform a systematic review to highlight pregnancies with severe deficiency of FXII that have been delivered uneventfully, along with presenting our relative case of a woman with severe deficiency of FXII. Materials and methods A systematic review was performed in the Pubmed database. Inclusion criteria were considered to be case reports and case series presenting delivery of uncomplicated pregnancies in women with severe FXII deficiency. Medical records of our patient were also reviewed in terms of signs and symptoms, laboratory and imaging examinations and neonatal outcomes. Results There were 62 abstracts derived while 44 were assessed for eligibility. There were finally three case reports of women with FXII deficiency delivering live newborns and one case series of 12 women with a final outcome of 19 deliveries. Regarding our case presentation, the woman with FXII levels <12%, after a neonatal death because of extreme prematurity (24 weeks + 4 days), was set in regular follow-up and treatment with bemiparin natriate, 3.5 mg/kg and acetylsalicylic acid, 100 mg/day. She finally managed to have her second pregnancy delivered at 38 weeks + 3 days, her third pregnancy ended up as a miscarriage and her fourth pregnancy was also delivered at 37 weeks + 4 days. Conclusion Despite the increased risk for antenatal complications, appropriate follow-up of pregnancies with severe FXII pregnancy may finally lead to an uneventful delivery.

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Lactation Ketoacidosis: A Systematic Review of Case Reports

Medicina ◽

10.3390/medicina56060299 ◽

2020 ◽

Vol 56 (6) ◽

pp. 299

Author(s):

Abdullah M. Al Alawi ◽

Asma Al Flaiti ◽

Henrik Falhammar

Keyword(s):

Systematic Review ◽

Metabolic Acidosis ◽

Case Reports ◽

Case Series ◽

Anion Gap ◽

Precipitating Factors ◽

Presenting Symptoms ◽

Child Weight ◽

Balanced Diet ◽

Relevant Case

Background and Objective: Lactation ketoacidosis is a rare cause of high anion gap metabolic acidosis affecting breastfeeding mothers. We aim to review and analyze all cases of lactation ketoacidosis reported. Materials and Methods: A systematic search of PubMed/MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL), identifying relevant case reports published from 1 January 1970 to 31 December 2019. We extracted the following data: the first author, country, year of publication, age of the mother, age of the child, weight/body mass index (BMI) of the mother, precipitating factors, presenting symptoms, biochemical results, treatment, breastfeeding, and time from presentation to the resolution of ketoacidosis. Results: Sixteen case reports and 1 case series reporting 18 cases of lactation ketoacidosis were found. Presenting symptoms were nausea (72%, 13/18), vomiting (67%, 12/18), malaise (56%, 10/18), abdominal pain (44%, 8/18), dyspnea (33%, 6/18), headache (22%, 4/18), and palpitation (11%, 2/18). Dieting and physical exercise to lose weight were reported in 76% (14/18). The treatments included IV dextrose, sodium bicarbonate, insulin, rehydration, monitoring and replacement of electrolytes, and resumption of a balanced diet. The prognoses were good, with no mortalities. Conclusions: lactation ketoacidosis should be suspected in unwell breastfeeding women with high anion gap metabolic acidosis, after excluding other causes.

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Clinical Manifestations and Characterization of COVID-19 in Liver Transplant Recipients: A Systematic Review of Case Reports and Case Series

Ethiopian Journal of Health Sciences ◽

10.4314/ejhs.v31i2.26 ◽

2021 ◽

Vol 31 (2) ◽

Author(s):

Pirouz Samidoust ◽

Hamed Nikoupour ◽

Hossein Hemmati ◽

Aryan Samidoust

Keyword(s):

Systematic Review ◽

Liver Transplantation ◽

Liver Transplant ◽

Case Reports ◽

Laboratory Finding ◽

Clinical Manifestations ◽

Case Series ◽

Presenting Symptoms ◽

Severity Of The Disease ◽

High Level

BACKGROUND፡ This systematic review is conducted to explore available information on clinical presentations, laboratory finding and outcomes of SARS-COV-2 in liver transplant patients.METHODS: We searched four databases for relevant terms related to COVID-19 and liver transplantation and collected both case reports and case series on liver transplantation published up to the end of September 2020.RESULTS: After initial screening of irrelevant articles, 25 studies were included and analyzed in this review. Among the 59 patients included,78.3% were over 50 years old, and 71.6% were males. The majority of patients (93.3%) were hospitalized. The most common presenting symptoms were fever (72.9%) followed by dyspnea and cough (54.2%). The majority of patients revealed a high level of CRP (64.3%). Moreover, high level ALT, AST and ALP were reported in 64.3, 37.5, 30.5 and 22.2% of patients. A total, 9(15.3%), of cases died as a result of complications of COVID-19. Chest radiographs were reported in 72.9%(43/59) of cases that 94% demonstrated radiologic evidence of abnormality.CONCLUSION: The results demonstrated that the most prevalent symptoms and signs were fever, dyspnea and cough. Moreover, most patients were males and hospitalized. The rate of mortality and high level of CRP, ALT/AST and ALP is similar within the non-immune suppressed and general population. However, early detection of high level of serum CRP, ALT/AST and ALP combined with a clinical COVID-19 symptom and finding of CT scan may be used as an index for the presence and severity of the disease.

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Comparison of the cardiovascular presentations, complications and outcomes following different coronaviruses’ infection: A systematic review

Journal of Cardiovascular and Thoracic Research ◽

10.34172/jcvtr.2021.29 ◽

2021 ◽

Vol 13 (2) ◽

pp. 92-101

Author(s):

Mohammad Mostafa Ansari Ramandi ◽

Hossein Yarmohammadi ◽

Somayeh Beikmohammadi ◽

Behzad Hassan Hosseiny Fahimi ◽

Farbod Hatami ◽

...

Keyword(s):

Systematic Review ◽

Case Studies ◽

Systematic Reviews ◽

Case Reports ◽

Cardiac Injury ◽

Laboratory Data ◽

Case Series ◽

Signs And Symptoms ◽

Mesh Terms ◽

Thrombotic Complications

Manifestations caused by coronavirus family have presented it in many ways during the previous years. The aim of this systematic review was to gather all possible cardiovascular manifestations of the coronavirus family in the literature. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched PubMed, Scopus, Web of Science, Cochrane and ProQuest which were updated on May 1, 2020 for the last time. Regarding to the novelty and speed of publications on COVID-19, we searched Google Scholar and also references of included studies and review articles in the systematic search results were searched manually. The searched keywords were the combination of the following MeSH terms: "COVID-19", "SARS", "MERS" and "cardiovascular presentation". The systematic review was registered with ID CRD42020180736 in International Prospective Register of Systematic Reviews (PROSPERO). After screening, 28 original articles and ten case studies (five case reports and five case series) were included. Most of the studies were focused on COVID-19 (20 original articles and four case studies) while the only studies about Middle East Respiratory Syndrome (MERS) were a case report and a case series. Almost all the cardiovascular presentations and complications including acute cardiac injury, arrhythmias and the thrombotic complications were more prevalent in COVID-19 than severe acute respiratory syndrome (SARS) and MERS. The cardiac injury was the most common cardiovascular presentation and complication in COVID-19 whereas thrombotic complications were commonly reported in SARS. The cardiac injury was the predictor of disease severity and mortality in both COVID-19 and SARS.Coronavirus 2019 may present with cardiovascular manifestations and complications in signs and symptoms, laboratory data and other paraclinical findings. Also, cardiovascular complications in the course of COVID-19 may result in worse outcomes.

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Cannabis-associated arteritis

VASA ◽

10.1024/0301-1526/a000004 ◽

2010 ◽

Vol 39 (1) ◽

pp. 43-53 ◽

Cited By ~ 17

Author(s):

Grotenhermen

Keyword(s):

Systematic Review ◽

Case Reports ◽

Case Series ◽

Cardiovascular Effects ◽

Causative Factor ◽

Cannabis Use ◽

Thromboangiitis Obliterans ◽

Pathological Features ◽

Scientific Support ◽

Clinical And Pathological Features

Background: To investigate the hypothesis that cases of arteritis similar to thromboangiitis obliterans (TAO) and associated with the use of cannabis were caused by cannabis or THC (dronabinol), or that cannabis use is a co-factor of TAO. Patients and methods: A systematic review on case reports and the literature on so-called cannabis arteritis, TAO, and cardiovascular effects of cannabinoids was conducted. Results: Fifteen reports with 57 cases of an arteritis associated with the use of cannabis and two additional case series of TAO, in which some patients also used cannabis, were identified. Clinical and pathological features of cannabis-associated arteritis do not differ from TAO and the major risk factor of TAO, tobacco use, was present in most, if not in all of these cases. The proposed pathophysiological mechanisms for the development of an arteritis by cannabis use are not substantiated. Conclusions: The hypothesis of cannabis being a causative factor or co-factor of TAO or an arteritis similar to TAO is not supported by the available evidence. The use of the term cannabis arteritis should be avoided until or unless more convincing scientific support is forthcoming.

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Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.5.peds19126 ◽

2019 ◽

Vol 24 (5) ◽

pp. 558-571 ◽

Cited By ~ 3

Author(s):

Kartik Bhatia ◽

Hans Kortman ◽

Christopher Blair ◽

Geoffrey Parker ◽

David Brunacci ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Case Reports ◽

Meta Analysis ◽

Case Series ◽

Neurological Outcomes

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

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Risk of colectomy after conservative treatment of diverticulitis of the left hemicolon complicated by abdominal or pelvic abscess: protocol of a systematic review and meta-analysis

BMJ Open ◽

10.1136/bmjopen-2020-042350 ◽

2020 ◽

Vol 10 (12) ◽

pp. e042350

Author(s):

Maximilian Sohn ◽

Ayman Agha ◽

Igors Iesalnieks ◽

Anna Tiefes ◽

Alfred Hochrein ◽

...

Keyword(s):

Systematic Review ◽

Emergency Surgery ◽

Case Reports ◽

Acute Diverticulitis ◽

Meta Analysis ◽

Case Series ◽

Pelvic Abscess ◽

Risk Of Bias ◽

Cochrane Central Register ◽

Review Manager

IntroductionAcute diverticulitis of the sigmoid colon is increasingly treated by a non-operative approach. The need for colectomy after recovery from a flare of acute diverticulitis of the left colon, complicated diverticular abscess is still controversial. The primary aim of this study is to assess the risk of interval emergency surgery by systematic review and meta-analysis.Methods and analysisThe systematic review and meta-analysis will be conducted in accordance to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE will be screened for the predefined searching term: (Diverticulitis OR Diverticulum) AND (Abscess OR pelvic abscess OR pericolic abscess OR intraabdominal abscess) AND (surgery OR operation OR sigmoidectomy OR drainage OR percutaneous drainage OR conservative therapy OR watchful waiting). All studies published in an English or German-speaking peer-reviewed journal will be suitable for this analysis. Case reports, case series of less than five patients, studies without follow-up information, systematic and non-systematic reviews and meta-analyses will be excluded. Primary endpoint is the rate of interval emergency surgery. Using the Review Manager Software (Review Manager/RevMan, V.5.3, Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration, 2012) meta-analysis will be pooled using the Mantel-Haenszel method for random effects. The Risk of Bias in Non-randomized Studies of Interventions tool will be used to assess methodological quality of non-randomised studies. Risk of bias in randomised studies will be assessed using the Cochrane developed RoB 2-tool.Ethics and disseminationAs no new data are being collected, ethical approval is exempt for this study. This systematic review is to provide a new insight on the need for surgical treatment after a first attack of acute diverticulitis, complicated by intra-abdominal or pelvic abscesses. The results of this study will be presented at national and international meetings and published in a peer-reviewed journal.PROSPERO registration numberCRD42020164813.

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Villoglandular adenocarcinoma of the uterine cervix: a systematic review and meta-analysis

Archives of Gynecology and Obstetrics ◽

10.1007/s00404-021-06077-9 ◽

2021 ◽

Author(s):

Anna K. Dietl ◽

Matthias W. Beckmann ◽

Konrad Aumann

Keyword(s):

Systematic Review ◽

Uterine Cervix ◽

Case Reports ◽

Case Series ◽

Disease Free Survival ◽

Conservative Group ◽

Pubmed Database ◽

Significant Difference ◽

Stage Ia ◽

Invasive Management

Abstract Purpose Villoglandular adenocarcinoma (VGA) of the uterine cervix has been classified as a rare subtype of cervical adenocarcinoma with good prognosis. A conservative surgical approach is considered feasible. The main risk factor is the presence of other histologic types of cancer. In this largest systematic review to date, we assess oncological outcomes associated with conservative therapy compared to those associated with invasive management in the treatment of stage Ia and Ib1 VGA. Methods Case series and case reports identified by searching the PubMed database were eligible for inclusion in this review (stage Ia–Ib1). Results A total of 271 patients were included in our literature review. 54 (20%) patients were treated by “conservative management” (conization, simple hysterectomy, and trachelectomy) and 217 (80%) by “invasive management” (radical hysterectomy ± radiation, hysterectomy, and radiation). Recurrences of disease (RODs) were found in the conservative group in two (4%) cases and in the invasive group in nine (4%) cases. There was no significant difference in disease-free survival (DFS) according to conservative or invasive treatment (p = 0.75). The histology of VGA may be complex with underlying usual adenocarcinoma (UAC) combined with VGA. Conclusion The excellent prognosis of pure VGA and the young age of the patients may justify the management of this tumor using a less radical procedure. The histological diagnosis of VGA is a challenge, and pretreatment should not be based solely on a simple punch biopsy but rather a conization with wide tumor-free margins.

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