CASE 705: PRIMARY HYPERPARATHYROIDISM with normal CALCEMIA (nHPT), Dr PHAN THANH HẢI, Dr HUỲNH TRÁC LUÂN , Dr JASMINE THANH XUÂN, Prof NGUYỄN THY KHUÊ, Dr PHẠM HUỲNH BẢO TRÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 A 64 year-old woman with fatigability in general check-up.

Neck ultrasound incidentally detects a right 16×11mm parathyroid tumor in right posteroinferior face of thyroid.

Laboratory findings note PTH value highly raised but not raised calcemia value. Osteogram notes her osteoporosis status with the bone fracture risk 6 times more.

Parathyroid Scan BIMI-99 Tc confirms a right parathyroid tumor.

Surgery removes  the right parathyroid tumor and PTH post-op value comes back to normal value. Histopathological result is a benign parathyroid tumor.

Summary

Normocalcemic hyperparathyroidism is a newly described variant of hyperparathyroidism. 

It is defined as persistently low or normal corrected or ionized serum calcium levels taken at least six months apart in the presence of elevated parathyroid hormone levels.

It may be primary or secondary. Normocalcemic secondary hyperparathyroidism is treated medically, while primary may need surgery.

….

The initial diagnostic approach for the patient is to rule out all secondary causes of hyperparathyroidism.

Normocalcemic primary hyperparathyroidism may be present in up to 17% of all cases of elevated PTH.

While usually asymptomatic, over one-third of nPHPT will progress to symptomatic bone disease or nephrolithiasis.

Familial hypocalciuric hypercalcemia needs to be ruled out. This can generally be done via a low calcium/creatinine clearance ratio. 

CASE 703-704: STROKE due to CEREBRAL ISCHEMIA, Dr PHAN THANH HẢI, Dr NGUYỄN THỊ ÁNH HỒNG, Dr TRẦN THỊ THANH NGA, Dr PHAN THANH HẢI PHƯỢNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Cerebral ischemic diagnosing bases on spontaneity of  decreasing and loss memory and vision. And Face  Arm Speech Time [FAST] scale. Roles of diagnostic imaging in cerebral ischemia are exactly detecting and rapidly in time (less than one hour).

CASE 01:

A male patient 55 year-old with left eye blurred vision and left dull headache for 2 days. 8 months ago his right arm was in weakness in 2 hours. History notes no FAST, without HTA, DM, except smoking for 30 years.

Brain MRI notes left brain ischemia at occipital region in small area and leukoaraiosis.

Vascular ultrasound notes plaque of the left ICA from its origin to occlude all its length and cause no ICA flow;  and the left central retinal artery flow decreases.

Because of the ipsilateral ICA occlusion,  the left ECA flow becomes internalization.

CTA notes the left ICA occlusion and the left middle cerebral artery is enhanced from the left anterior cerebral artery.

CASE 2:

A HTA male patient 63 year-old with spontaneous loss memory after a critical headache for 6 days. His history is smoking and alcohol beverage for 40 years. No FAST. No loss vision.

Vascular ultrasound notes plaque at the right ICA origin which narrows up 90% lumen and total left ICA occlusion (NASCET), ICA/CCA ratio> 2.

Brain MRI shows large cerebral ischemia,  occlusion of the left middle cerebral artery and the left ICA.

FAST scale and types of diagnostic neuroimaging (vascular ultrasound, CTA and MRI) take  theirs roles in cerebral ischemia and stroke.

REFERENCES: [for vascular ultrasound]

CASE 702: SMALL INTESTINE GIST INCIDENTALOMA, Dr PHAN THANH HẢI, Dr PHAN THANH HẢI PHƯỢNG , MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 A HTA 65 year-old female with chest pain, mild apsnea and without gastroenterological symptom.

Ultrasound incidentally detects a 37x29 mm hypervascular hypoechoic mass which seems to be from the small bowel at her left abdomen.

Because of the rare incidence of small intestine (SI) tumor and in SI GIST, sonologists choose a SI polyp in differentiaziting a SI GIST.

MSCT confirms a 30x40 mm non invasive bowel wall tumor of GIST, strongly captures CE.

Endoscopic examination notes an exophytic jejunum tumor and open surgery removes  a small intestine loop which is an adequate clearance of 5 cm upper and lower of the tumor, and performs an end-to-end anastomosis. 

Gross specimen is a 5cm bowel intestine that exists at submucosa layer. The tumor section surface is solid, whitish with hemorrhagic ulceronecrosis.

Microscopic studies reveales spindle cells type of GIST with low mitose index.

CASE 701: BREAST TUMOR CASE, Dr PHAN THANH HẢI, Dr JASMINE THANH XUÂN, Dr NGUYỄN KIM HIẾU, Dr VÕ KIM LOAN, Dr NẠI THỊ HƯƠNG NG THOANG, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

A 30 year-old female patient with a 13x17 mm right breast tumor goes through breast ultrasound 3 times.

In the first time, results are tumor BI-RADS 4A, FNAC : Fibrocystic changes.

Second time breast examnination, 14x19 mm tumor

BI-RADS 4A, FNAC , Fibroadenoma.

The third exam results are 12×20 mm,BI-RADS 4C, inhomogeneous hypoechoic with microcalcification, malignant doutfully elastography.

Core biopsy result is invasive breast carcinoma of no special type, grade 2.

Mammography BI-RADS 4 with multiformal collective microcalcification at 11o'clock 3 cm far from nipple.

Lame consultation is Atypical ductal hyperplasia with chemohistoimmunological staining results are P63+, ER + 50%, CK5/6 +.

But Breast MRI thinks about breast tumor BI-RADS 5.

In cancer hospital, guided ultrasound biopsy by VABB removes the 20×24 mm hole tumor.

The last result is Intraductal Papilloma.

The patient remains well after 2 months reexamination.

Conclusion: 

A right breast tumor of the 30 year-old patient raises gradually its size which ultrasound scoring from BI-RADS 4A to 4C. 

MRI BI-RADS 5. Mammography BI-RADS 4. 

FNAC, Core biopsy results are different.

And the last result due to VABB and Chemohistoimmunological staining is Intraductal Papilloma.

CASE 700: RIGHT THORACIC WALL TB ABSCESS, Dr PHAN THANH HẢI, Dr JASMINE THANH XUÂN, Dr HỒ CHÍ TRUNG, Dr LÊ THÔNG LƯU, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

 A 45 year-old  female patient with right thoracic painful swollen area for 5 months.

Ultrasound detects right pleural effusion, thoracic wall mass which contains rib cartilage destruction, close by pleural wall thickening at 4 th intercostal space, and local lymph nodes.

Chest X-RAY  shows right pleural effusion and nothing about thoracic wall. 

MSCT  confirms a right thoracic wall lesion and right lung NAD.

FNAC and core biopsy of right thoracic wall results  think  about TB inflammed lesion with ADA raises slightly in right pleural fluid.

So it exists a painful right thoracic wall for 5 months and evidents belongs to a TB infection without primary lung lesion.

Histoimmumologic staining results are TB inflammed cartilage and soft tissue which exists granular cells and lymphocytes.

It will be planned for a TB regimen in TB and Lung hospital.

CASE 699: DIFFUSE LARGE B CELL LYMPHOMA and WALDEYER'S RING, Dr PHAN THANH HẢI, Dr DƯƠNG XUÂN TÙNG , MEDIC MEDICAL CENTER, HCMC, VIETNAM

A male patient 41 year-old with multiple cervical nodes and sore throat as tonsillitis.

Chest X-RAY notes left lung lesion.

Ultrasound detects many lymph nodes  # 17-15-13 mm without nodal hilus, solid, hypoechoic on his neck and in the abdomen : at liver hilus :27mm, mesenteric,  pelvic: 17-21 mm and a splenomegaly :141mm. Results of ultrasound notes a multiple lymph nodes in cervical, supraclavicular and abdominal region that leads to a diffuse lymphoma. 

Biopsies of tonsils and pharyngeal cavum results are lymphoma infiltration without immunohistochemical staining.

ENT examinations results are many lesions of tonsils and oral cavity and Waldayer's ring.

Biopsy of right tonsil ulcer for ruling out cancer and immuohistochemical staining result is diffuse lymphoma type large B cell.

Patient goes through a chemotherapy planning for lymphoma. Cervical nodes reduce their sizes with effective management. 

REFERENCES: