Intravascular Lymphoma: an Unusual Diagnostic Outcome of an Incidentally Detected Adrenal Mass

ObjectiveTo describe a rare diagnosis of intravascular lymphoma in a patient presenting with an incidentally discovered adrenal mass.MethodsWe describe the patient’s clinical history and the findings from biochemical evaluation, radiologic studies, and surgical pathology and review the relevant literature.ResultsA 43-year-old woman developed sudden onset of flank pain associated with a flushing sensation and presented to the emergency department where computed tomography showed a 5-cm left adrenal mass. She had normal electrolytes, and serum and urinary test results were negative for pheochromocytoma. A 24-hour urinary cortisol level was minimally elevated, and the midnight salivary cortisol value was within the reference range. Magnetic resonance imaging revealed a 6.5 × 5.8-cm left adrenal lesion that demonstrated moderate T2-weighted signal and gradual delayed enhancement with no drop in signal on out-of-phase images. Since the lesion lacked high intensity and the biochemical testing results did not suggest a pheochromocytoma, it was deemed likely that the mass was a malignant lesion of the left adrenal gland. A laparoscopic left adrenalectomy was performed. Morphologic and immunohistochemical findings were consistent with a large B-cell lymphoma, which by virtue of its near exclusive distribution in vascular spaces, was consistent with the diagnosis of intravascular large B-cell lymphoma.ConclusionIntravascular large B-cell lymphoma should be included in the differential diagnosis of an incidentally detected adrenal mass even though the diagnosis is rare. (Endocr Pract. 2008;14:884-888)     

Giant aneurysm of basilar artery

In the article we showed the patient, a woman with unruptured giant aneurysm of basilar artery, we showed the done examinations, and therapy dilemmas about what to do in the given case. We found in literature a number of examples which suggest operation treatment, but of embolisation too, some suggest conservative treatment.     

Assessing Stressors in Coastal Ecosystems: An Approach to the Patient

Medicine employs an approach to diagnose, give a prognosis, and develop a treatment for human patients. Specific signs and symptoms determined from medical examinations, laboratory tests, and patient history are utilized to predict the outcome of a potential pathological disorder. Utilizing a strategy similar to the medical examination, the status of ecosystems can be examined. To demonstrate this concept a “patient” case study of the Gulf of Mexico is described. The diagnosis of potential abnormalities within the Gulf of Mexico was conducted by examining field indicators including sediment chemistry and tissue chemistry (field examinations), sediment toxicity (laboratory testing), and a benthic index (patient history and existing symptoms). Based on the diagnosis (ecological assessment), a prognosis for the Gulf of Mexico was determined and specific areas that are impacted by stressors were identified for more detailed assessments. Pensacola Bay was identified as such an area impacted by stressors. The case study example demonstrates that a medical approach of “diagnosis and prognosis” can be utilized as a strategy to help identify stressors, develop a successful treatment plan, and prevent future ecosystem degradation.     

Patient dose levels for seven different radiographic examination types

This study was carried out as a part of a comprehensive project to establish a national diagnostic reference level (NDRL), for the first time, in Saudi Arabia. Seven of the most common X-ray examinations (10 projections) were included. This study consisted of 200 patients who were referred for X-ray examinations at King Khalid University Hospital (KKUH). The selected X-ray examinations were skull (PA), kub (AP and LAT), ankle (AP and LAT), foot (AP/OBL and LAT/OBL), hib (AP and LAT) and sinuses paranasal (AP). Mean patient information and exposure parameters for these seven radiographic examinations were recorded at KKUH. Some of these radiographic examinations were compared with their corresponding values at other national places [Security Forces Hospital (SFH); King Abdulaziz City for Science and Technology (KACST)] in Saudi Arabia. We found that the patient mean dose values recorded at KKUH were varied from those recorded at other national places. Wide variations in patient dose arising from a specific type of X-ray examination at different national places suggests that significant reductions in patient dose would be possible without affecting image quality. Furthermore, variations in patient dose may emerge from the examination technique, clinical condition, radiologist skill, tube current, tube potential and focus to film distance. The data of this study will be useful for the formulation of NDRLs, and it is also provides local diagnostic reference levels for some diagnostic X-ray examinations at KKUH and other national places in Saudi Arabia.     

Hearing loss in suppurative meningitis and encephalitis in our cases

Seventeen cases of the suppurative meningitis complicated by hearing loss have been analysed clinically. Emphasis is on the possibility of such a complication in any case of the suppurative infection of CNS. The authors have shown the necessity of otolaryngological examinations in each patient, basing on their own experience and available literature. An early diagnosis and appropriate treatment produces complete recover or decreases the degree of hearing loss being a complication of the suppurative neuroinfections.     

Amiodarone pulmonary toxicity. Clinical, cytologic and ultrastructural findings

Amiodarone, a new antiarrhythmic drug, may produce severe and potentially lethal pulmonary toxicity. A case is presented of a patient on amiodarone therapy who presented with recurrent pleural effusions and subsequently developed pulmonary infiltrates. The diagnosis of lung toxicity was documented by the cytologic examination of the pleural effusions and the bronchial washings. It was further supported by the ultrastructural demonstration of the characteristic cytoplasmic osmiophilic lamellar inclusions in the foamy macrophages. We conclude that cytologic and ultrastructural examinations of bronchial lavage cells are extremely helpful in the diagnosis of amiodarone-induced pulmonary toxicity.     

An Imported Case of Echinococcosis of the Liver in a Korean Who Traveled to Western and Central Europe

Echinococcus granulosus, an intestinal tapeworm of dogs and other canids, infects humans in its larval stage and causes human echinococcosis or hydatid disease. In the Republic of Korea, 31 parasite-proven human echinococcosis cases have been reported, most of which were imported from the Middle East. We recently examined a 61-year-old Korean man who had a large cystic mass in his liver. ELISA was negative for tissue parasitic infections, including echinococcosis, cysticercosis, paragonimiasis, and sparganosis. The patient underwent surgery to remove the cyst, and the resected cyst was processed histopathologically for microscopic examinations. In sectioned cyst tissue, necrotizing protoscolices with disintegrated hooklets of E. granulosus were found. In some areas, only freed, fragmented hooklets were detected. The patient had traveled to western and central Europe in 1996, and had no other history of overseas travel. We report our patient as a hepatic echinococcosis case which was probably imported from Europe.     

Partial trisomy 3q in a child with sacrococcygeal teratoma and Cornelia de Lange syndrome phenotype

Partial duplication of 3q is a rare chromosomal disorder that leads to multiple congenital abnormalities such as growth retardation, microcephaly and characteristic facial features. Although the phenotype of the patient has similarities with Cornelia de Lange Syndrome they are etiologically different. We report here a 9 months old baby boy with partial duplication of 3q and features similar with Cornelia De Lange syndrome. Conventional cytogenetic analysis revealed a derivative chromosome 21. In order to determine the origin of this chromosome region we used subtelomeric FISH technique. Based on the results of all these cytogenetic studies and the physical examinations, the diagnosis is partial 3q duplication.     

Evaluation of patient organ doses from kilovoltage cone-beam CT imaging in radiation therapy

BackgroundCurrently, CBCT system is an indispensable component of radiation therapy units. Because of that, it is important in treatment planning and diagnosis. CBCT is also an crucial tool for patient positioning and verification in image-guided radiation therapy (IGRT). Therefore, it is critical to investigate the patient organ doses arising from CBCT imaging. The purpose of this study is to evaluate patient organ doses and effective dose to patients from three different protocols of Elekta Synergy XVI system for kV CBCT imaging examinations in image guided radiation therapy.Materials and methodsOrgan dose measurements were done with thermoluminescent dosimeters in Alderson RA NDO male phantom for head & neck (H&N), chest and pelvis protocols of the Elekta Synergy XVI kV CBCT system. From the measured organ dose, effective dose to patients were calculated according to the International Commission on Radiological Protection 103 report recommendations.ResultsFor H&N, chest and pelvis scans, the organ doses were in the range of 0.03–3.43 mGy, 6.04–22.94 mGy and 2.5–25.28 mGy, respectively. The calculated effective doses were 0.25 mSv, 5.56 mSv and 4.72 mSv, respectively.ConclusionThe obtained results were consistent with the most published studies in the literature. Although the doses to patient organs from the kV CBCT system were relatively low when compared with the prescribed treatment dose, the amount of delivered dose should be monitored and recorded carefully in order to avoid secondary cancer risk, especially in pediatric examinations.     

Pituitary Macroadenoma in a Patient with Poems Syndrome in Conjunction with Castleman Disease: First Report of a Case and Review of Related Literature

ObjectiveTo describe the first reported case of a patient with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) in conjunction with the endocrinologic manifestation of panhypopituitarism due to a large clinically nonfunctioning pituitary adenoma.MethodsWe present the clinical, laboratory, and radiologic details of the case and review the relevant updated literature.ResultsA 48-year-old man with hypopituitarism and progressive polyneuropathy presented to an outside hospital with confusion and diaphoresis. He also had diffuse lymphadenopathy, monoclonal gammopathy, and skin lesions consistent with a diagnosis of POEMS syndrome. Cytopathologic study of a lymph node showed findings consistent with Castleman disease. A large suprasellar mass was found to be the cause of the hypopituitarism.ConclusionPOEMS syndrome is a rare paraneoplastic condition, commonly associated with Castleman disease, that manifests with progressive distal polyneuropathy and a monoclonal plasma cell disorder, often accompanied by endocrinopathy, organomegaly, skin changes, sclerotic bone lesions, ascites, erythrocytosis, and thrombocytosis. Our current patient had all 5 classic features of POEMS syndrome along with some diagnostic elements of Castleman disease, sclerotic bone lesions, and thrombocytosis. To our knowledge, this is the first known reported case of a patient whose endocrinologic manifestation of POEMS syndrome was panhypopituitarism attributable to a large clinically nonfunctioning pituitary adenoma. (Endocr Pract. 2010;16:97-101)     

Heavy Hymenolepis nana Infection Possibly Through Organic Foods: Report of a Case

We encountered a patient with heavy Hymenolepis nana infection. The patient was a 44-year-old Korean man who had suffered from chronic hepatitis (type B) for 15 years. A large number of H. nana adult worms were found during colonoscopy that was performed as a part of routine health screening. The parasites were scattered throughout the colon, as well as in the terminal ileum, although the patient was immunocompetent. Based on this study, colonoscopy may be helpful for diagnosis of asymptomatic H. nana infections.     

Blunt Traumatic Aortic Injury of Right Aortic Arch in a Patient with an Aberrant Left Subclavian Artery

Right-sided aortic arch (RAA) is a rare congenital developmental variant present in about 0.1 percent of the population. This anatomical anomaly is commonly associated with congenital heart disease and complications from compression of mediastinal structures. However, it is unknown if patients are at a higher risk of blunt thoracic aortic injury (BTAI). We report a case of a 20-year-old man admitted to the hospital after being hit by an automobile. Computed tomographic scan revealed an RAA with an aberrant left subclavian artery originating from a Kommerell’s diverticulum. A pseudo-aneurysm was also seen along the aortic arch. A diagnosis of blunt traumatic aortic injury was made. The patient was successfully treated with a 26mm Vascutek hybrid stentgraft using the frozen elephant trunk technique.A literature review of the pathophysiology of BTAI was performed to investigate if patients with right-sided aortic arch are at a higher risk of suffering from BTAI. Results from the review suggest that although theoretically there may be a higher risk of BTAI in RAA patients, the rarity of this condition has prevented large studies to be conducted. Previously reported cases of BTAI in RAA have highlighted the possibility that the aortic isthmus may be anatomically weak and therefore prone to injury. We have explored this possibility by reviewing current literature of the embryological origins of the aortic arch and descending aorta.     

Diagnostic monitoring of urine by means of synchronous fluorescence spectrum

A novel approach to clinical-biochemical analysis of urine is presented in this work. Urine composition is defined graphically as a record of synchronous fluorescence spectra (SFS). The graphical standard has been made from SFS of urine samples from healthy children. Simple comparison of a standard record with that of an analyzed urine sample will immediately reveal changes in its composition. Reproducibility of the graphical definition is very high and it maintains its characteristic shape during repeated measurements over a span of 2 years. It is possible to elaborate patients' own standard for those with chronic illness. It differs from a normal course but it is characteristic for a given patient and it enables the clinician to monitor changes or the outcome of therapy at regular medical examinations. Application of this method for monitoring of urine composition for selected cases is a new alternative with several advantages. Analysis without any added reagents very quickly detects some illnesses near onset when they may be clinically asymptomatic and classical screening methods show negative results. Computerization of spectral measuring and filing the results enables to give a likely diagnosis or a deviation from standard. This method can also serve a doctor-clinician either to confirm or to exclude a concrete diagnosis.     

Use of repetitive DNA for diagnosis of chromosomal rearrangements

Summary We have used two repeated DNA fragments (3.4 and 2.1 kb) released from Y chromosome DNA by digestion with the restriction endonuclease Hae III to analyze potential Y chromosome/autosome translocations. Two female patients were studied who each had an abnormal chromosome 22 with extra quinacrine fluorescent material on the short arm. The origin of the 22p+ chromosomes was uncertain after standard cytologic examinations. Analysis of one patient's DNA with the Y-specific repeated DNA probes revealed the presence of both the 3.4 and 2.1 kb Y-specific fragments. Thus, in this patient, the additional material was from the Y chromosome. Analysis of the second patient's DNA for Y-specific repeated DNA was negative, indicating that the extra chromosomal segment was not from the long arm of the Y chromosome. These two cases demonstrate that repeated DNA can distinguish between similar appearing aberrant chromosomes and may be useful in karyotypic and prenatal diagnosis.     

首例圈养大熊猫难产的治疗与原因分析

2004年8月,成都大熊猫繁育研究基地1只雌性大熊猫发生难产,临床表现以阵缩及努责匮乏为主要特征,经过B超检查、药物辅助治疗等一系列保守措施后,胎儿于4天后排出。鉴于大熊猫难产病例在国内外至今未见报道,现将该病的临床特点、诊断和处治情况介绍如下。     

Chylothorax as a possible diagnostic pitfall: a report of 2 cases with cytologic findings

BACKGROUND: Chyothorax is an uncommon medical condition. To the best of our knowledge, there have been no detailed English-language report dealing with its cytopathologic findings and diagnostic pitfalls CASES: A 12-year-old boy, hemodialysis dependent, with congenital nephrotic syndrome due to focal segmental glomerular sclerosis and a failed renal transplant, developed shortness of breath. Physical and radiologic examinations revealed a left pleural effusion. A 7-year-old boy developed shortness of breath, with a subsequent finding of a left pleural effusion. Multiple osteolytic skeletal lesions were found in this patient. Both patients underwent thoracocentesis. Cytologically, both fluids contained many relatively uniform, large lymphoid cells with high nuclear/cytoplasmic (N/C) ratio, condensed chromatin and occasional nucleoli, resembling blasts. Some nuclei were convoluted. Mitotic figures were present. Foamy macrophages were present in both cases. The differential diagnosis of these populations of cells included a lymphoproliferative disorder. However, the mature T-lymphocytic nature of the cells was confirmed by immunohistochemistry performed on cell block preparations, confirming the clinical impression of chylothorax in both cases. The first patient had chylothorax as a result of trauma due to therapeutic interventions (subclavian vein cannulation), in the second patient the chylothorax was a part of Gorham-Stout syndrome. CONCLUSION: The large T-lymphocytes that are the major cellular component of chylothorax may arouse suspicion of a lymphoproliferative disorder. Attention to the clinical history and immunophenotyping confirm the benign nature of the pleural space fluid. Also, abundant foamy macrophages can be considered a low-power clue to this diagnosis.     

Homogeneous triploidy in 2 premature infants (69 XXY)

Two new cases of 69 XXY triploidy in live-born neonates are reported. As in 40 others cases of literature observed after 24 weeks of gestation, this chromosome abnormality was lethal. The clinical features are: a large posterior fontanelle, low set ears, syndactylies of hands and feet, and genital abnormalities in the presence of a 69 XXY karyotype. The first patient present a macrocytosis of red blood cells. Macrocytosis, large polymorphonuclear leukocytes and platelets can evoke the diagnosis of triploidy in a malformed newborn.     

Angiosarcomas of the chest wall and breast after radiotherapy: The questions of radiogenic origin,diagnosis and treatment

PURPOSE: To present medical history of secondary chest wall and breast angiosarcomas (AS) developed after radiotherapy, and to discuss the questions of radiogenic origin, diagnosis and treatment by the review of the literature. METHODS: Report of two cases and MEDLINE search for relevant publications. RESULTS: Secondary AS occured in a previously irradiated field after a long (6 and 8 years) latency period in both cases. Detailed histopathological and immunohistochemical examinations from the biopsy and/or surgical specimens confirmed the diagnosis as AS. The first patient with moderately differentiated AS was treated successfully with radical surgery. The second patient with irresecable AS died of rapid local progression within 4 months. The incidence of chest wall and breast AS is increased after irradiation, however, controversial data exist in the literature. The incidence of chest wall and breast AS after radiotherapy was found to be 0.39% in our patient population, which means an estimated odds ratio of 2.4 for secondary AS. Stewart-Treves syndrome is not of radiogenic origin, since postoperative lymphoedema has been considered as primary etiological factor. CONCLUSIONS: Patients treated with surgery and/or radiotherapy for primary breast cancer are at higher risk for developing secondary AS, compared to the healthy population. An etiological relationship between radiotherapy and subsequent AS of chest wall and breast is likely, but still controversial. Initial radical surgery is the only effective treatment for achieving long term survival. Further adjuvant radiotherapy is no longer feasible, due to the previous irradiation. Chemotherapy has only palliative effect. These very rare cases deserve special attention due to the atypical clinical appearance, difficulties of differential diagnosis and poor prognosis.     

ELISA detection of vivax malaria with recombinant multiple stage-specific antigens and its application to survey of residents in endemic areas

An ELISA was developed for the diagnosis of vivax malaria using multiple stage-specific recombinant antigens of Plasmodium vivax. The DNA from the whole blood of a malaria patient was used as template to amplify the coding regions for the antigenic domains of circumsporozoite protein (CSP-1), merozoite surface protein (MSP-1), apical merozoite antigen (AMA-1), serine repeat antigen (SERA), and exported antigen (EXP-1). Each amplified DNA fragment was inserted into pQE30 plasmid to induce the expression of His-tagged protein in Escherichia coli (M15 strain) by IPTG. His-tagged proteins were purified by Ni-NTA metal-affinity chromatography and used as antigens for ELISA with patient sera that were confirmed previously by blood smear examinations. When applied to patient sera, 122 (80.3%) out of 152 vivax malaria cases reacted to at least one antigen, while no reactions were observed with 128 uninfected serum samples. We applied this ELISA to the screening of 3,262 civilian residents in endemic regions near the DMZ, which resulted in 236 positively detected (7.2%) cases. This method can be applied to serological diagnosis and mass screening in endemic regions, or can be used as a safety test for transfusion blood in endemic areas.     

A case of granulomatous skin lesions caused by Mycobacterium marinum in the Campania region

The diagnosis of cutaneous Mycobacterium marinum infection is frequently presumptive, as detection by conventional methods is difficult. We describe a patient with granulomatous skin lesions on the right dorsal hand and forearm. Histological examinations were presumptive for mycobacterium lesions. We identified Mycobacterium marinum directly in the patient's lesional skin biopsy combining polymerase chain reaction (PCR) amplification using Mycobacterium genus-specific primers, and subsequent restriction enzyme analysis enabling identification to the species level. The symptoms were no longer present after specific therapy, thereby confirming the initial diagnosis.