CASE 137: APPENDIX TUMOR, Dr PHAN THANH HẢI , Dr LÝ VĂN PHÁI, Dr NGUYỄN THIỆN HÙNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Man 25 year-old was in pain at RLQ for 3 days. In abdominal ultrasound scans with curve probe 3.5 MHz (image 1), a cross-sectional view disclosed a big appendix in black border and its central part in white spot like bull-eye.

Image 2 in longitudinal section, the appendix was like a finger, noncompressible with white line in its center looks like an ascaris inside appendix.

Ultrasound with linear probe 12 MHz, (image 3: cross-sectional scanning) showed many rings in the center as intussusception.

Image 4, longitudinal section: the appendix with black content like mucocele.

But there was no raising of WBC in blood test. For verifying the appendiceal mucocele, a colonoscopy was done and detected this mass was like a finger covering by mucosa and protruding from appendiceal aperture (see photo).

It was hard, not content the mucus after many punctures, so it was thought to be a solid tumor according the report of endoscopist.

MDCT without CE also susgested a tumor of appendix (see CT image).

Via endoscopic laparoscopy, operation was done but surgeon could not detect any tumor of appendix. Open surgery detected the appendiceal tumor being an intracecal intussusception of appendix. And the surgeon removed the tumor after opening of cecum (see photo).

Microscopic histology and histoimmunostaining report is chronic inflammation and fibrosis of appendix.

 

Appendiceal intussusception into cecum is a rare condition so it could be detected in open surgery.

CASE 136: COLD ABSCESS, Dr PHAN THANH HẢI, Dr LÊ ĐÌNH VĨNH PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

WOMAN 31 YO COMPLAINED OF PAIN AT LEFT LOWER LUMBAR REGION, DIFFICULT WALKING, FOR ONE MONTH BUT NO  FEVER.

ULTRASOUND  EXAMINATION DETECTED A BIG MASS IN THE LOWER POLE OF LEFT KIDNEY, COVERED PSOAS MUSCLE AND  STORED AT LATERAL WALL OF ILIAC CREST. ITS CONTENT WAS VISCOUS FLUID WITH  DEBRIS. 

BLOOD TEST WITH RAISING OF WBC OF 11K WITH 65 % NEUTROPHIL.

MDCT  WAS  DONE IN DISCLOSING OF MANY LESIONS OF SPINAL BONES AND ILIAC  BONE.

We think it an abscess around the destruction bone (spinal and iliac ). Puncture for aspiration is done, the withdrawed pus was in brownish color, smelless.

During aspiration, the tip of needle is made doppler color due to the flow out of the pus (see video). At the iliac crest erosive the bone made doppler artefact like twinkling.
The pus is analysis: no bacteria, no BK present in direct microscope view. But ADA test is strong positive: 126 UI/L. It make a diagnosis of COLD ABSCESS due to BONE TUBERCULOSIS. (ADA: 100% sensitive, 98% specific).

Ref on ADA: ijcri-00203201122-dikensoy.pdf

CASE 135: HUGE CYSTIC LYMPHANGIOMA of PANCREAS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

MALE 26YO  PAIN AT RIGHT LUMBAR AREA  AND POLYURIA.
XRAY KUB FILM SHOWED A RIGHT URETERAL STONE AND ONE MASS ON THE LEFT  SITE OF HIS ABDOMEN.

ULTRASOUND  DISCLOSED RIGHT HYDRONEPHROSIS AND A BIG CYSTIC TUMOR AT THE LEFT RETROPERITONEAL AREA EXTENDING  FROM THE LEFT KIDNEY TO THE PELVIS.

AT FIRST, ONE SONOLOGIST'S SUGGESTION WAS PSEUDOCYST OF PANCREAS.
MDCT abdomen with CE showed this tumor being in retroperitoneum without contrast enhancement, and right hydronephrosis due to ureteral stone.

Blood test Amylasemia of 70.3 (normal= 35-115UI/mL).
Percutanous puncture withdrawed 3 liters of brown clear fluid. Analysis no abnormal cell, no inflamation cell, with biochemistry results.

Ultrasound guided puncture images and then 3 liters of fluid removed...

DISCUSSION: IT WAS A BIG CYST OF RETROPERITONEUM. BASED ON THE WALL, NO SEPTATION, AND ANALYSIS OF THE FLUID, WE CAN RULE OUT URINOMA, OR PSEUDOCYST OF PANCREAS. IT IS LYMPHANGIOMA OF THE TAIL OF PANCREAS.

(REF. Abdominal Lymphangiomas: Imaging Findings with Pathologic Correlation.)