CASE 614: ELASTOGRAPHY ULTRASOUND for a Case of CKD, Dr PHAN THANH HẢI, Dr NGUYỄN NGHIỆP VĂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male patient 38 yo, follow-up for CKD for years and now preparing hemodialysis by via kidney machine.

Ultrasound B-mode shows hyperechoic pattern of parenchymal and pyelonephritic structure both 2 kidneys but dimensions and vascular Doppler remain in normal ranges.

Elastography ultrasound for kidney was performed on ARFI SIEMENS S 2000, VTQ= 1.4-2.22m/sec

and SWE Supersonics machine= 22-24kPa.

As the results, values of renal parenchymal stiffness increase slightly in 2 machines with 2 different technics of elastography ultrasound.

DISCUSSIONS:

1/ Shear wave elastography and ARFI technic may be a low-cost way to provide additional diagnostic information in CKD.

2/ Our case with increased  values of both  ARFI for CKD from 1.4--2.22m/s and SWE measurements = 22-24kPa that proves a heterogeneicity of kidney, and the  complex parenchymal stiffness which may lead to fibrosing of kidney  in progress.

REFERENCES:

•Acoustic Radiation Force  Impulse Imaging for Evaluation of Renal Parenchyma Elasticity in Diabetic Nephropathy, Cemil Goya et al. AJR 2015; 204:324–329

•Applications of acoustic radiation force impulse quantification in chronic kidney disease: a review, Liang Wang, Ultrasonography 2016;35:302-308

•Shear wave elastography in chronic kidney disease: a pilot experience in native kidneys , Samir et al. BMC Nephrology (2015) 16:119

CASE 613 : BILATERAL BREAST CANCER, Dr PHAN THANH HAI, Dr NGUYEN HUU QUOC, Dr TRAN LAM

Female patient 82 yo, herself detected a right breast mass that had been in traditional management, but it was getting slowly bigger. Now the right breast is swollen and hemorrhage.

Ultrasound detected tumors at right and left breast. Noted BI-RADS 5 with metastase lymph nodes of right breast tumor, and BI-RADS 4A for the left one.

Ultrasound findings:

Right breast = Lesion with mass effect is at 1/2 lateral breast, heterogenous, multiloculated, solid inside with multicalcified foci and neoplastic vessels. Limits of right pectoralis muscle and the lesion is not clear. This lesion invades subcutaneous fatty tissue and right breast skin . Because of big size tumor it can not examined posteriorly the breast tumor. 

Left breast= Many cystic structures with calcified foci, the biggest one is at 3 o'clock and far from center about 3 cm.

Many lymph nodes loss hilus with microcalcification exist in axillary areas both 2 sides and in right supraclavicular fossa.

Comet tail artifacts at the lung base both 2 sides.

MSCT with CE  also detected right  breast tumor and lymph nodes.

CT= Right breast lesion is heterogenous tissue condensation, multiloculated invades breast skin and deformes right breast, highly captured CE, # 61.3 x 80.2mm. Some right axillary lymph nodes # 11mm. There is pulmonary fibrosis  and pleural thickening at the right lung base.

Wait for surgery.

CASE 612: POUTEAU-COLLES FRACTURE, Dr LÊ THANH LIÊM, Dr PHAN THANH HẢI

Female patient 72 yo with vertigo and sudden fall in Medic Clinic. She had been noticed  osteopenia for time that exists threefold bone fracture risk.

At first PoCUS detected right radial bone fracture at 1/3  inferior part with subcutaneous hematoma around.

X-Ray of upper limb later confirmed fracture of right radial bone.

Patient was transmitted to Trauma and Orthopedic Hospital for a 5 week plaster cast of her right arm.

Reference:

Colles fracture or Pouteau Colles fracture.

https://en.wikipedia.org/wiki/Colles%27_fracture

From Dr Nguyen Duc Long, slideshare.

CASE 611: STEVENS - JOHNSON SYNDROME, Dr LÊ ĐÌNH VĨNH PHÚC, Dr PHAN THANH HẢI.

Female patient 46 yo with pruritus and taking unknown medicine for time from Dong nai province. She came to Medic for a check-up and being managed by a kind of antiallergic drug (Rupatadin, Tesafu).

Blood tests=

After 2 hours swallowing drug and days later allergic reaction appeares on face, corpse and limbs as blistering eruptions.

Medic doctor advices her to come Dermatology Hospital but thought about parasite infection, she and family decided going to Hospital of Tropical Diseases. With prescription of parasiticid (ivermectin), but nothing change then, later, she went to Dermatology Hospital.

At Dermatology Hospital, many skin lesions with cleared fluid-filled bullous appeared, vital signs P=112bpm, TA=110/70mmHg, Temp=38.5 degree of Celsius. Then,  bullous exudates and skin detaches (exfoliative dermatitis)  for 3 days after on full body with multiform erythema.

A diagnostic of Stevens-Johnson was notes with proved histopathologc result. At that time she has been managed as corticosteroid  [Medrol] and antibiotics [Vancomycin and Rocephin].

Although there is no evidence of allergic status due to Medic prescription, doctor from Medic came to Dermatology Hospital to keep patient solving her worry about hypersensitive illness. That comprehension of medical staff may cordially support better doctor-patient relationship and help patient bounce back soon.

Based on EuroScar study and performed ALDEN algorithm we determined THIABENDAZOL which was used for about 10 days (before April 3rd) earlier being a suspected cause that induced SJS/TEN for patient.

After 12 days in hospital patient status has got better.

And  later discharged hospital  in her recovery.

References:

1/

2/ 

https://dalieu.vn/di-ung-thuoc-nang-hoi-chung-lyell-va-hoi-chung-steven-johnson/

CASE 610: Multiple Brown Tumour. Dr Phan Thanh Hai Phuong, Dr Ly Van Phai, Dr Hoang Thi Thanh Phuong (Oncology hospital)

Patient came to clinic with history of 3 years worsen polyarthralgia. He has been diagnosed and managed as degenerative arthritis in BacLieu Province Hospital for a year. The pain localized in left shoulder, right knee, hips and left ankle. Patient also experienced general fatigue and weight loss (5kg a year). MSK Ultrasound is indicated as first tool, goes along with blood tests.

Ultrasound of right knee: shows patient area of pain doesn’t come from joint but the bone. It exists erosion of periosteal of proximal tibia and  hypervascularity in surrounding soft tissue. By switching to more penetrative linear probe, a hyperechoic bone mass is seen beneath periosteal erosion. Mass is homoechogeneity and has anechoic cysts inside.

Image 1: Erosion of periosteal of proximal tibia and hypervascularity in surrounding soft tissue

 

 

 

Image 2: A hyperechoic bone mass is seen beneath  periosteal erosion. Mass is homoechogeneity with  anechoic cysts inside. Second images shows normal articular cartilage and not fit for degenerative arthritis.

Ultrasound of left ankle:

Same condition as proximal tibia as in the distal end. Mass is better demonstrated with infiltrative border. During examination, patient feels imminent pain at place that probe compresses. Ankle joint is normal.

Image 3:  Mass is better demonstrated with infiltrative border in distal end of tibia

Ultrasound of shoulder:

Shoulder rotator cuff are normal. Area of pain is at left A-C joint. In comparison to normal right side, same apperance of bone mass revealed at clavicular end.

Image 4: Shoulder rotator cuff are normal. Area of pain is left A-C joint. In comparison to normal right side, same bone mass at clavicular end revealed.

Conclusion : Multiple distal bone masses suggest few differential diagnosis: Metastasis, Multiple myeloma metastasis.

Those could be pseudo-mass  coming from bone erosion in osteclastic hyperactivity  in hyperparathyroidism. Althought the lesions are common in middle diaphysis but not in the distal/proximal end. Radiologist did a quick check on the neck to rule out tumor of parathyroid gland.

Ultrasound of the neck: detected at right lower lobe of thyroid a parathyroid tumor, 3.7x1.4mm, enlarged with capsule and hypervascular on colour Doppler mode.

 

Image 5: Right parathyroid tumor, 3.7x1.4mm, enlarged with capsule and hypervascular signals on colour Doppler mode.

Image 6: Pelvis X-Ray: shows multiple scattered oval-shaped bone radiolucent, losing bone general density.

Image 7 : Right ankle XRay:  radiolucent oval-shaped lesion at distal tibia end in comparison to ultrasound.

 

Image 8:  Right ankle XRay:  radiolucent erosion lesion at distal clavicular end as compared to ultrasound.

Patient is preferred to endocrinologist and  full body scan to perform looking for bone fracture as common complication because patient suffering illness for a long time.

 

Patient blood tests confirmed diagnosis: hypercalcemia and normal RF quantitative. Serum PTH value elevated >1200

 

Patient underwent surgery to remove the tumor. Pathological result : Parathyroid adenoma.

After the surgery, PTH value drops to normal value, serum calcium also drops below normal line and had been got oral calcium supply as he discharged from hospital. 

Follow up on 3 months later, patient recovered and experienced no pain. He has already can go back to work.

Discussion and conclusion:

Primary hyperpaprathyroidism is caused by parathyroid tumor excretes PTH. That activates re-absortion calcium in kidneys, increase absorption in colons and bone loss. Osteoclastic hyperactivity produces subperiosteal erosions, endosteal cavitation and replacement of marrow spaces by vascular granulations and fibrous tissue. Brown tumor is known as Osteoitis fibrosa cystica. Pseudo-tumour, fluid-filled cysts contents hemorrhage and giant cell wrap within fibrous stroma. Giving rise to brownish, tumour-like masses. The lesion can be single or multiple. Well-defined and commonly affecting the facial bone, pelvis, ribs and femoral bone. The classical which should always be sought is sub-periosteal cortical resorption of middle phalanges.

But bone lesions in tibia end and clavicle ends of this case seem not to be so classical findings (in diaphysis instead).