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Sivanandam LK, Gupta P, Rahim M, Sanker V, Pandita A, Gupta U. Stars from the bones-An uncommon presentation of fat embolism syndrome. Clin Case Rep 2023; 11:e7496. [PMID: 37305886 PMCID: PMC10248480 DOI: 10.1002/ccr3.7496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 06/13/2023] Open
Abstract
Trauma or surgery to the lower limbs can cause fat from the marrow within the leg bones to enter the bloodstream and form an embolus. However, if there is cerebral involvement without any pulmonary or dermatological manifestations at diagnosis, it could delay identifying cerebral fat embolism (CFE).
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Affiliation(s)
| | - Prakash Gupta
- Team ErevnitesTrivandrumIndia
- Computational Cardiovascular Simulations CenterUniversity of MiamiCoral GablesFloridaUSA
| | - Maliha Rahim
- Team ErevnitesTrivandrumIndia
- Jinnah Sindh Medical UniversityKarachiPakistan
| | - Vivek Sanker
- Team ErevnitesTrivandrumIndia
- Noorul Islam Institute of Medical SciencesTrivandrumIndia
| | - Ashna Pandita
- Team ErevnitesTrivandrumIndia
- University of NisNisSerbia
| | - Umang Gupta
- Team ErevnitesTrivandrumIndia
- Nepalgunj Medical CollegeNepalgunj BankeNepal
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Multisystemic involvement of post-traumatic fat embolism at a Pediatric Trauma Center: a clinical series and literature review. Eur J Pediatr 2023; 182:1811-1821. [PMID: 36790485 DOI: 10.1007/s00431-023-04869-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
UNLABELLED Post-traumatic fat embolism syndrome (FES) is a severe complication consequent to bone fractures. The authors describe its clinical features and management in a population of teenagers by detailing demographics, organ involvement, laboratory, and imaging findings, as well as outcome. Moreover, a systematic review of pediatric published case reports of post-traumatic FES is provided. First, a series of eight episodes of post-traumatic FES that occurred in seven patients (median age 16.0 years, IQR 16.0-17.5) admitted to a pediatric intensive care unit (PICU) in an 8-year period was analyzed through a retrospective chart review. Secondly, a systematic research was performed on PUBMED database. Trauma patients ≤ 18 years without comorbidities in a 20-year period (2002-2022) were included in the review. Neurological impairment was present in five out of seven patients, and a patent foramen ovale was found in four cases. Hemodynamic instability requiring vasoactive drugs was recorded in four patients. A severe form of acute respiratory distress syndrome (ARDS) occurred in five cases, with the evidence of hemorrhagic alveolitis in three of them. In the literature review, eighteen cases were examined. Most cases refer to adolescents (median age 17.0 years). More than half of patients experienced two or more long bone fractures (median: 2 fractures). Both respiratory and neurological impairment were common (77.8% and 83.3%, respectively). 88.9% of patients underwent invasive mechanical ventilation and 33.3% of them required vasoactive drugs support. Neurological sequelae were reported in 22.2% of patients. CONCLUSION Post-traumatic FES is an uncommon multi-faceted condition even in pediatric trauma patients, requiring a high level of suspicion. Prognosis of patients who receive prompt support in an intensive care setting is generally favorable. WHAT IS KNOWN •Post-traumatic fat embolism syndrome is a severe condition complicating long bone or pelvic fractures. •Little is known about clinical features and management in pediatric age. WHAT IS NEW •Post-traumatic fat embolism syndrome can cause multiple organ failure, often requiring an intensive care management. •Prompt supportive care contributes to a favorable prognosis.
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Jain V, Remley W, Bunag C, Rodriguez E, Albayram MS, Wilson C, Patterson A, Bonnell G, Okun MS, Patel B. Clinical Reasoning: A Case of Acute Akinetic Mutism and Encephalopathy. Neurology 2022; 99:761-766. [PMID: 36008149 PMCID: PMC9620815 DOI: 10.1212/wnl.0000000000201207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/21/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Varun Jain
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville.
| | - William Remley
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Cyra Bunag
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Elsa Rodriguez
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Mehmet S Albayram
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Christina Wilson
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Addie Patterson
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Gabriel Bonnell
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Michael S Okun
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
| | - Bhavana Patel
- From the Department of Neurology (V.J., C.B., E.R., C.W., A.P., G.B., M.S.O., B.P.), University of Florida, Gainesville; Lake Erie College of Osteopathic Medicine (W.R.), Bradenton, FL; and Department of Radiology (M.S.A.), University of Florida, Gainesville
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Zhang X, Zheng L, Duan J, Zhang S, Zhou Y, Tang Y. Susceptibility-weighted imaging of cerebral fat embolism: A case report. Medicine (Baltimore) 2022; 101:e29462. [PMID: 35960082 PMCID: PMC9371500 DOI: 10.1097/md.0000000000029462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Cerebral fat embolism (CFE) is a rare but critical disease in a clinical setting. Considering that manifestations and CT findings of CFE tend to be atypical, this condition is very difficult to diagnose. The purpose of this article was to assess the value of susceptibility-weighted imaging (SWI) in the diagnosis of CFE. PATIENT CONCERNS Our patient was an 80-year-old woman who developed hypoxemia, quadriplegia, and progressive confusion after fracture of the right femoral neck and right superior ramus of pubis within 24 hours. DIAGNOSIS T2-weighted magnetic resonance imaging (T2 W MRI), fluid-attenuated inversion recovery sequences, and diffusion-weighted imaging showed numerous hyperintense foci in the subcortex and white matter of both cerebral hemispheres, some of which were confluent and SWI showed multiple symmetrical punctate microhemorrhages in both hemispheres. Base on the history and MRI findings, the patient was diagnosed with CFE. INTERVENTIONS The patient received anticoagulation and lipid-lowering therapy. OUTCOMES The patient regained consciousness, and her muscle strength in the limbs gradually recovered. One year after discharge, the patient could independently walk on her own. LESSION This case report shows the characteristics of CFE on SWI, which can help clinicians in diagnosing which can help clinicians in diagnosing CFE.
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Affiliation(s)
- Xianwen Zhang
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Liaoyuan Zheng
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Jinfeng Duan
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Shunyuan Zhang
- Department of Radiology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Ying Zhou
- Department of Radiology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Yufeng Tang
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
- *Correspondence: Yufeng Tang, Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China No.12, Changjia Lane, Fucheng District, Mianyang, 621000, Sichuan, China (e-mail: )
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Li YS, Liu YH, Chou HD, Tseng HJ, Fu YC, Liu WC. Concomitant post-traumatic ocular and cerebral fat embolism syndrome and thrombotic pulmonary embolism: A case report. Medicine (Baltimore) 2022; 101:e29331. [PMID: 35713435 PMCID: PMC9276092 DOI: 10.1097/md.0000000000029331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/01/2022] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Fat embolism syndrome (FES) is composed of a triad of symptoms, including respiratory distress, neurologic deficit, and petechiae. Respiratory distress usually presents first before the other symptoms. Thrombotic pulmonary embolism (TPE) is a differential diagnosis of FES. Trauma is a risk factor for both diseases; however, co-occurrence is rare. PATIENT CONCERNS A 35-year-old male patient presented with altered consciousness, focal neurologic deficit, and respiratory distress after a left femoral subtrochanteric fracture and subsequent open reduction and internal fixation with an intramedullary nail. DIAGNOSIS Computed tomography pulmonary angiography (CTPA) revealed lower pulmonary artery filling defects and ground-glass opacities in bilateral lung, indicating TPE and FES, respectively. INTERVENTIONS Heparin was initially added and subsequently switched to apixaban. The symptoms improved quickly without major bleeding complications. LESSION SUBSECTIONS Concomitant TPE and FES after trauma are rare and require different treatment approaches. Due to clinical similarities, prompt chest CTPA was advised to detect TPE that was treated with anticoagulant therapy instead of supportive care for FES.
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Affiliation(s)
- Ying-Sheng Li
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical
| | | | - Hung-Da Chou
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiang-Jui Tseng
- Department of Orthopedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yin-Chih Fu
- Department of Orthopedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Orthopedic Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
- Ph.D Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chih Liu
- Department of Orthopedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Ph.D Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Filippatou AG, Naveed M, Barry DP, Deboer SR, Haas CJ. Sickle cell disease and fat embolism: a rare complication of vaso-occlusive crisis. Pract Neurol 2022; 22:410-412. [PMID: 35450964 DOI: 10.1136/practneurol-2021-003166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/04/2022]
Abstract
A 61-year-old woman was admitted to the hospital for management of a painful vaso-occlusive crisis. She had a history of sickle cell beta-thalassaemia and end-stage renal disease managed with intermittent haemodialysis. While hospitalised, she became lethargic and unresponsive and developed acute chest syndrome. Initial MR scan of brain, cerebrospinal fluid examination and continuous electroencephalogram were unremarkable, but subsequent MR scan of brain identified a right transverse venous sinus thrombosis and extensive supratentorial and infratentorial microhaemorrhages consistent with fat emboli. We; therefore, discuss a case of non-traumatic fat embolism syndrome, a rare complication of sickle cell disease.
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Affiliation(s)
| | - Muhammad Naveed
- Department of Internal Medicine, MedStar Health, Baltimore, Maryland, USA
| | - Daniel P Barry
- Department of Internal Medicine, MedStar Health, Baltimore, Maryland, USA
| | - Scott R Deboer
- Department of Neurology, MedStar Health, Baltimore, Maryland, USA
| | - Christopher J Haas
- Department of Internal Medicine, MedStar Health, Baltimore, Maryland, USA
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Salimi Z, Ami Ali M, Tazi R, Mimouni Y, Hazim A, Aasfara J. A Rare Case of Cerebral Fat Embolism With No Respiratory or Dermatologic Involvement. Cureus 2022; 14:e22192. [PMID: 35308671 PMCID: PMC8926028 DOI: 10.7759/cureus.22192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 11/25/2022] Open
Abstract
Fat embolism syndrome is potentially lethal. It is frequently a complication of long bone fractures and/or orthopedic surgery. Cerebral fat embolism is an unusual condition characterized by purely cerebral involvement. Neurological signs can be variable and brain MRI has a pivotal role in the diagnosis. We report the case of a 69-year-old male who presented motor impairment and a disorder of consciousness in the early postoperative course of total hip arthroplasty for a left femoral neck fracture, which occurred 24 hours before surgery. He had no dermatologic or respiratory signs. No respiratory or dermatologic signs were found. Blood samples showed moderate thrombopenia and hemolytic anemia. Multiple lesions were found on brain MRI. Diagnosis of cerebral fat embolism was established after ruling out differentials.
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Abstract
Surgery and anesthesia carry risks of ischemic, hemorrhagic, hypoxic, and metabolic complications, all of which can result in neurologic symptoms and deficits. Patients with underlying cardiovascular and cerebrovascular risk factors are particularly vulnerable. In this article the authors review the neurologic complications of surgery and anesthesia, with a focus on the role of the neurologic consultant in preoperative evaluation and risk stratification and diagnosis and management of postoperative complications.
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Affiliation(s)
- Daniel Talmasov
- Department of Neurology, New York University School of Medicine, 222 East 41st Street, 14th Floor, New York, NY 10017, USA
| | - Joshua P Klein
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Room 4018, 60 Fenwood Road, Boston 02115, MA, USA.
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Wang W, Chen W, Zhang Y, Su Y, Wang Y. Post-traumatic cerebral fat embolism syndrome with a favourable outcome: a case report. BMC Neurol 2021; 21:82. [PMID: 33602171 PMCID: PMC7890386 DOI: 10.1186/s12883-021-02076-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 01/25/2021] [Indexed: 11/20/2022] Open
Abstract
Background Fat embolism syndrome (FES) is a change in physiology resulting from mechanical causes, trauma, or sepsis. Neurological manifestations of FES can vary from mild cognitive changes to coma and even cerebral oedema and brain death. Here, we present an unusual case of cerebral fat emboli that occurred in the absence of acute chest syndrome or right-to-left shunt. Case presentation A previously healthy 57-year-old right-handed male was admitted to our department because of unconsciousness after a car accident for 3 days. He suffered from multiple fractures of the bilateral lower extremities and pelvis. This patient had severe anaemia and thrombocytopenia. Head MRI showed multiple small lesions in the whole brain consistent with a “star field” pattern, including high signals on T2-weighted (T2w) and fluid-attenuated inversion recovery (FLAIR) images in the bilateral centrum semiovale; both frontal, parietal and occipital lobes; and brainstem, cerebellar hemisphere, and deep and subcortical white matter. Intravenous methylprednisolone, heparin, mannitol, antibiotics and nutritional support were used. Although this patient had severe symptoms at first, the outcome was favourable. Conclusions When patients have long bone and pelvic fractures, multiple bone fractures and deteriorated neurological status, cerebral fat embolism (CFE) should be considered. Additionally, CFE may occur without an intracardiac shunt. The early diagnosis and appropriate management of FES are important, and prior to and following surgery, patients should be monitored comprehensively in the intensive care unit. With appropriate treatment, CFE patients may achieve good results.
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Affiliation(s)
- Wei Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, 45th Changchun Street, 100053, Beijing, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, 45th Changchun Street, 100053, Beijing, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, 45th Changchun Street, 100053, Beijing, China.
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, 45th Changchun Street, 100053, Beijing, China
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, 45th Changchun Street, 100053, Beijing, China
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Shao J, Kong DC, Zheng XH, Chen TN, Yang TY. Postoperative complications of concomitant fat embolism syndrome, pulmonary embolism and tympanic membrane perforation after tibiofibular fracture: A case report. World J Clin Cases 2021; 9:476-481. [PMID: 33521118 PMCID: PMC7812904 DOI: 10.12998/wjcc.v9.i2.476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/09/2020] [Accepted: 11/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fat embolism syndrome (FES) is a rare disease characterized by pulmonary distress, neurologic symptoms, and petechial rash and seriously threatens human life and health. It is still neglected clinically because of the lack of verifiable diagnostic criteria and atypical clinical symptoms. No studies on FES with pulmonary embolism (PE) and tympanic membrane perforation have been reported to date. Here, we report a rare case of concomitant FES, PE and tympanic membrane perforation after surgery in a patient with a tibiofibular fracture.
CASE SUMMARY A 39-year-old man presented with right lower extremity pain due to a car accident while driving a motorbike on the road. X-ray and computed tomography scans revealed a fracture of the right mid-shaft tibia and proximal fibula categorized as a type A2 fracture according to the AO classification. A successful minimally invasive operation was performed 3 d after the injury. Postoperatively, the patient developed sudden symptoms of respiratory distress and hearing loss. Early diagnosis was made, and supportive treatments were used at the early stage of FES. Seven days after surgery, he presented a clear recovery from respiratory symptoms. The outcome of fracture healing was excellent, and his hearing of the left ear was mildly impaired at the last follow-up of 4 mo.
CONCLUSION Concomitant FES, PE and tympanic membrane perforation are very rare but represent potentially fatal complications of trauma or orthopedic surgery and present with predominantly pulmonary symptoms. Early diagnosis and treatment can reduce the mortality of FES, and prevention is better than a cure.
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Affiliation(s)
- Jin Shao
- Department of Orthopedics, Pudong New Area Gongli Hospital, School of Clinical Medicine, Shanghai University, Shanghai 200135, China
| | - De-Ce Kong
- Department of Orthopedics, Pudong New Area Gongli Hospital, School of Clinical Medicine, Shanghai University, Shanghai 200135, China
| | - Xin-Hui Zheng
- Graduate School, Ningxia Medical University, Yinchuan 750004, Ningxia Hui Autonomous Region, China
| | - Tian-Ning Chen
- Graduate School, Ningxia Medical University, Yinchuan 750004, Ningxia Hui Autonomous Region, China
| | - Tie-Yi Yang
- Department of Orthopedics, Pudong New Area Gongli Hospital, School of Clinical Medicine, Shanghai University, Shanghai 200135, China
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Timing of Extremity Fracture Fixation in Patients with Traumatic Brain Injury: A Meta-Analysis of Prognosis. World Neurosurg 2020; 133:227-236. [DOI: 10.1016/j.wneu.2019.09.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 01/23/2023]
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Abstract
Neuroimaging is an invaluable diagnostic tool for sorting through the vast array of etiologies that underlie altered mental status (AMS). Head computed tomography (CT) without contrast is the primary modality for evaluation of AMS and should be complemented by MR imaging in cases of negative CT but high clinical concern. Studies to maximize brain imaging efficiency and improve the yield of positive scans through the utilization of clinical and laboratory pre-scan diagnostics are ongoing. However, imaging remains the gold standard due to its rapidity with which certain diagnoses can be made or excluded.
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Affiliation(s)
- Alina Uzelac
- Neuroradiology, Department of Radiology, Zuckerberg San Francisco General Hospital, University of California, 1001 Potrero Avenue, Room 1X56, San Francisco, CA 94110, USA.
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