CASE 663: ENDOMETRIOSIS and DIENOGEST, Dr PHAN THANH HAI, Dr NGUYEN THI XUAN HOA, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 38 year-old female patient, TPAL 1-0-0-1, with sideropenia, dysmenorrhea and menorrhagia that has been diagnosed endometriosis in uterus and right ovary by transvaginal ultrasound  (TVUS) and pelvic MRI.

On MRI, size of endometriosis in uterus # 5×7 centimeter and, in ovary # 1.5 centimeter.

She is managed for iron deficiency, and her endometriosis with Dienogest 2mg one tablet per day. For 5 months, focal lesions in her uterus and right ovary are getting smaller sizes. Dysmenorrhea appears slightly and she is with the new generation of progestin acceptable menorrhagia.

NOTA:

CASE 662: MYOCARDIAL INFARCTUS with ST non Elevated, Dr PHAN THANH HAI, Dr BUI BINH HUAN, Dr VU BICH DOAN TRANG , MEDIC MEDICAL CENTER, HCMC, VIETNAM

 A 68 year-old HTA male patient with right chest pain for 8 hours while holding some water buckets.

Troponin I: 648.6 ng/L, CPK MP: 13.32 ng/mL are elevated, but EKG and cardiosonography have no clue of an acute myocardial infarctus.

About 50% patients of unstable angina  [UA] and NSTE MI have no change of EKG in early time while troponin-I elevated during the first 24 hours.

Based on elevated troponin-I and CPK, the patient is transferred to an emergency hospital after a diagnosis of myocardial infarctus is made.

CASE 661: RCC DETECTED in Check-up ULTRASOUND, Dr PHAN THANH HAI, Dr NGUYEN PHUOC TOAN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 45 year-old male employee is detected occasionally a # 25 mm left renal tumor in a check-up by ultrasound in his company. He has not signs of lumbago and hematuria.

MSCT later confirms the 30 mm left kidney tumor at lower pole and anterior face which is thought maybe a RCC.

Endoscopic surgery removes the tumor in its capsule by pure enucleation technique.

Result of histopathogy is a clear cell renal carcinoma, grade 2.

Portable ultrasound in control check-up for worker and employee in the companies may detect some cases with subclinical symptom. If it exists any abnormal evident, they will be called going to our center for more informations by other modalities of diagnostic imaging and added lab data. With a final clear diagnosis he/she will be help by an available management.

CASE 660: PHEOCHROMOCYTOMA, Dr PHAN THANH HAI, Dr PHAM THE ANH, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 43 year-old male patient with gastritis and hypertensive crisis, TA=140/100mmHg, P=88b/min.

Ultrasound detects a right adrenal tumor # 41x47milimiter, solid echo poor, less vascularized.

MSCT confirms the right adrenal tumor, with HU density =25 and in late phase of contrast, HU=43.

Surgery removes the tumor carefully in touch due to heart rate and arterial tension going down.

Report of histopathology is a pheocromocytoma of the right adrenal gland.

CASE 659: FIBROSARCOMA of Left SCAPULAR REGION, Dr PHAN THANH HAI, Dr LE VAN THO, Dr HO CHI TRUNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 19 year-old female patient with a huge mass on her left shoulder for 2 years.

Shouder X-ray represents a # 15 centimeter soft tissue mass of left shoulder with invasion left scapulum.                                                  

On ultrasound this is a huge solid mass, echo poor, well limited border, poor vascularized from left axilla to posterior shoulder. Thermography notes high temperature in tumoral region.

MSCT shows a soft tissue sarcoma of left shoulder that invades left scapulum. There is an arterial branch from left subclavian artery going to nourrish the tumor.

MRI confirms the soft tissue sarcoma of left shoulder invasive the left scapulum but glenohumeral joint intact.

Surgery removes the tumor and a lower part of left scapulum  keeping of superior part with glenoid fossa of scapulum.

Histopathologic report is fibrosarcoma low malignancy.

Due to COVID19 pandemic, so late the patient goes to hospital in case of tumor with bone metastasis.

Although the surgical management is successful, the patient will still face in high risk of recurrent of  fibrosarcoma and its metastases.

CASE 658: CYST of PROSTATE or FISTULA of INTERNAL ILIAC VESSLES, Dr PHAN THANH HAI, Dr LY VAN PHAI, Dr LE THANH LIEM, Dr HO KHANH DUC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 67 year-old male patient is detected a small cyst of prostate on the right side by via abdominal ultrasound without any symptom. But on Doppler techniques the real one is a fistula of right internal iliac vessels.

The lesson is a cyst on B-mode may being a dilated vessel on Doppler investigation if sonographer does not apply the Doppler technique to watch a cystic structure.

MSCT and vascular surgery  [vessel collage] proved the  fistula of right internal iliac vessel.

On reexamination, next to the prostate on right side, Doppler ultrasound reveales a # 20x20x24 milimeter aneurysm with arterial low spectral waveform and venous waveform which means a fistula of internal iliac vessels.

MSCT confirms a fistula of the right internal iliac vessels.

An on-line investigation performs with an expert of Binh dan hospital, and this vascular surgeon makes his decision to solve the fistula by collage technique for it, via DSA in his hospital.

The aneurysm of right internal vessel is disappeared on screen while performing of vessel collage technique.

And it exists not any recurrent of right internal iliac fistula on the next 15 days.

CASE 657: MEDIASTINAL ABSCESS, Dr PHAN THANH HAI, Dr PHAN NGUYEN THIEN CHAU, Dr LE HUU LINH, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 69 year-old male patient enters Medic Center with ten days of fever,  thoracic pain and trouble ingestion. He was managed as gastritis but nothing change.

Blood tests show an infectious syndrome, while EKG, cardiac ultrasound results are in normal limits.

MSCT represents  a # 3 centimeter mass containing air  which is an upper mediastinal abscess with  some calcified foci inside due to a fistula of 1/3 middle part of esophagus.

Surgeon advises immediatly transferring the patient to a surgery hospital.

Gastroendoscopy shows a thickening lesion of middle esophagus and a normal chest X-Ray.

A MSCT is performed to prove the mediastinal abscess, and a bronchoscopy is done to rule out lesion from lung and airways. 

A decision of conservative treatment with antibiotics and a gastrostomy are noted to keep nourrishing the patient which is lasting from now to a half and one month later.

Mediastinal abscess is in recovery phase, reduces its size with calcifications, in two times of re-examination.

This is a mediastinal abscess case due to middle esophagus fistula which is unveiled the cause. 

Clinical clues are fever and thoracic pain and trouble ingestion. The role of MSCT and endogastroscopy are more clearer than chest X-Ray and cardiac ultrasound. Gastrostomy and medical treatment are well enough to help the patient avoiding an unnecessary operation with risks.

And patient remains well and can eating normally by mouth in happiness. 

May the abscess come back?

CASE 656: BOWEL VOLVULUS due to MESENTERIC CYST, Dr PHAN THANH HẢI, Dr TRẦN NGÂN CHÂU, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 

A 23 year-old male patient with periumbilical pain and left flank pain for 5 days and vomiting. 

Ultrasound detects a cystic mass # 17.9x11.2 centimeter from his navel to pubis, and jejunum dilatation with obstruction sign (washing machine sign). The cystic mass contents fluid and septation with vascular sign on its walls. The cause of bowel obstruction was noted by a non-dilated bowel loop at the mesenteric root with whirpool sign.

There is not  bowel malrotation nor duplication cyst, so the ultrasound findings is bowel volvulus due to a mesenteric cyst.

MSCT confirms bowel volvulus due to a mesenteric cyst later.

Open surgery is done after endoscopic investigation. The cystic mass with yellowish fluid and a part of bowel are removed. Patient remains well post-op.

The histopathological report is a benign cyst with inflammation of the mesentery.

 

Bowel volvulus is still a rare entity especially in young adult.  Mesenteric cyst causes bowel volvulus may happen in emergency room in case of ruling out bowel malrotation, urachal cyst, Meckel diverticulum.