CASE 617: PROSTATE on SWE TRUS with BIPLAN PROBE, Dr NGUYEN MINH THIEN, Dr PHAN THANH HAI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male patient 64yo with fever and voiding discomfort for month.

Digital rectal examination detected a big prostate with a hard nodule on right side.

On MRI there were a 22x15mm hard node of right lobe and another one, 12x16mm, on the left of prostate which concern neoplastic foci , but  PSA=1.75 ng/mL;  F/T=20%

At Medic, an SWE elastography TRUS with biplane probe was done

On TRUS B-mode,  peripheral area of right lobe exists a 16x18 mm hypoechoic nodule, not well-limited,  hypervascular and irregular capsule of right lobe.

On strain elastography, nodule is harder than transitional area while surrounded area of right lobe is softer than the nodule.

On 2D SWE, stiffness of nodule on right side has got a value of 50 kPa [mild hard] while lesion of transitional area of left lobe of 47 kPa.

By via  transperineal a biopsy of prostate was perfomed and histopathological result is TB of prostate and subacute prostatitis.

Conclusion: 

SWE TRUS with biplan probe helps imaging lesions of prostate with more  information to plan for treatment better.

CASE 616: INFECTED SCROTAL SKIN, Dr LE TU PHUC, Dr LE VAN TAI, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 74-year-old male patient presented to our clinic because of pain and swelling in the right scrotum for 10 days. The scrotum became larger, harder and pus drained out of the scrotum about 3 days before the ultrasound examination.

About 3 months ago, he underwent transurethral resection of the prostate (TURP) and was infected with COVID-19 in the postoperative period. After the COVID isolation, the patient did not show any symptoms of infection.

On ultrasound of the scrotum, we found scrotal edema, thickening, interstitial fluid and gas between the scrotal skin layers. Gas spreads anteriorly to the right pubic tubercle and posteriorly to the base of the penis near the anus.

Gas was not seen in the left scrotum, in the spermatic cord, in the skin of the abdomen and on the buttocks and thighs. No fistula from the rectum was found.

Due to the patient's recent urinary tract surgery, urinary catheterization, history of diabetes, gas and fluid in the right scrotal skin. We therefore assumed diagnosis of Fournier's gangrene.

The paitent was transferred to surgery department after and treated with debridement surgery in combination with antibacterial and detoxification therapy. He improve well till now.

Getting well at hospital discharge.

SPECIAL NEWS: SPLEEN PERIPHERAL FOCUSED ULTRASOUND [pFUS] at MEDIC MEDICAL CENTER

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/