CASE 194: ASCARIS in CBD and ULTRASOUND and ERCP, Dr LÊ THỐNG NHẤT, Dr TRẦN NGÂN CHÂU, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER. HCMC, VIETNAM

A 33 yo  female patient from Phu quoc province came to Medic Center for  painful cramp episodes 2 days before as failed in treatment of gastritis.
Ultrasound at Medic revealed an ascaris that was moving inside  common bile duct while unfortunatly CT cannot see it.

ERCP was performed to make clear diagnosis of ascaris in CBD and removing ascaris out.

The worm was still alive outside patient body being a male ascaris with hook and genital specula.

In ten years, there were 42 worms of CBD ascaris from 54 cases detected by ultrasound which were removed out by ERCP.

CASE 193: MEDIC RADIOLOGY CASE 07: ACQUIRED TRACHEOBRONCHOMALACIA, Dr LÊ HỮU LINH, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 31 yo female patient came to Medic Center for loss of her voice and dyspnea. For 2 years she had got suddenly deafness after giving birth. During 6 months, she coughs slightly and complaints dyspnea, getting worse when  making every effort.  There are slight whistles of her chest in 2 phases of breathing which are more clear in fast breathing.

Laryngoscopy showed normal appearance and normal motion of vocal cords, but no sound in speaking.

Bronchial endoscopy was done easily, lumen were smooth and soft, no obstacle, but getting stenosis in first part of  trachea and  bronchii which were thought to be a tracheobronchomalacia.

Chest CT confirmed  the result of bronchial endoscopy that an unknown stenosis of  1/3 upper part of trachea, stenosis of right and left main bronchii, and right intermediate bronchiole. And an old scar of right lung apex.

Because of dyspnea getting worse so she underwent a tracheostomy. After tracheostomy, chest CT proved total stenosis of trachea, and stenosis of right and left main bronchii, and  right intermediate bronchiole.

Surgery was performed to repair the trachea. And the final diagnosis is an acquired tracheobronchomalacia which causes stenosis of trachea and main bronchii. For the cause of this case is still unknown and with the deafness we may think about the immunologic reaction of a polychondritis.

CASE 192: AVM IN THE KIDNEY. Dr Nguyen Nghiep Van , Dr Nguyen Hoai Thu, Medic Medical Center, HCMC.

A 51 yo female patient suffered from hematuria for a few weeks. She went to Medic Center for abdominal ultrasound. Color Doppler of the abdomen detected an AVM at the upper pole of the right kidney, d= 4.6cm in diameter, which has aliasing inside and spectral waveform of AVM (see 2 images).

MSCT with CE detected A-V shunt at the upper pole of right kidney (see 3 images).

The patient underwent DSA to make sure AVM diagnosis. The right renal artery divides into 2 branches: the upper branch feeding for lower pole of the kidney, and the lower branch, for  the A-V shunt. This is not detected on the Angio MSCT ( see 3 images ).

Noted the IVC dilated and early filling contrast, therefore we decided not to treat by coiling, because the coil may move to right atrium. And the patient transmitted to Binh Dan hospital for nephrectomy.

CASE 191: MEDIC RADIOLOGY CASE 06:TWO CASES of CERVICAL MYELOPATHY and SPINAL SCHWANNOMA, Dr NGÔ TẤN HÙNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM

                      

CASE 1: 47yo M patient, Vinh long province. 6 months with:  Lower extremities weakness and numbness. Neck pain, muscles atrophy. No disturbance in sphincter tone as it related to his bowel or bladder function.Tender reflex (++), Babinski’s sign (++), Hoffmann’s sign (++).

MRI= Intra-and extradural and paravertebral mass of C3.

Microscopic result: Schwannoma of nerve sheath.

CASE 2 : 53yo F patient, Binh thuan province. 4 months with: Right leg weakness. No neck pain. No disturbance in sphincter tone as it related to his bowel or bladder function. Tender reflex (++), Babinski’ s sign (++), Hoffmann’ s sign (++).

MRI= Intra-and extradural mass of C6-7

Microscopic result: Schwannoma of nerve sheath.

DISCUSSIONS:

LOW EXTREMITIS WEAKNESS :  BE CAREFUL WITH CERVICAL SPINAL CORD LESIONS.

CERVICAL MYELOPATHY: A routine neurological examination is important. Complaints involving gait, equilibrium, and /or paresthesias, extremities weakness or numbness. Cervical spine pain is rarely among these complaints. [Bucy PC, Heimburger RF, Oberhill HR. Compression of the cervical spinal cord by herniated intervertebral discs. J Neurosurg.2009].

CASE 190:LARGE TRAUMATIC PSEUDOCYST OF PANCREAS IN ADULT: Nguyen Duc Duy Linh, MD - Nguyen Ngoc Xuan Giang, MD – Dr Phan Thanh Hai, Binh An Hospital, Kien Giang, Viet Nam.

 A 29 year-old male patient complains:  for six months bloating of the abdomen, non deep ache, difficulty in eating and digesting food and having a mass of 150x200mm in his epigastric region. He had a trauma of epigastric region by traffic accident seven months ago and had been operated for it.

Ultrasound  examination : Cross-sectional images of the mass in epigastric region. It was a large anechoic mass with posterior acoustic enhancement, smooth contour, unilocular, no Doppler signal, size of 145x134mm, was thought to be a pseudocyst which had pressed on nearby organs (liver, stomach). It was a pancreatic pseudocyst but having a differential diagnosis of liver cyst.

MSCT examination:

 MSCT showed a well-defined unilocular pseudocyst in the pancreatic head and body, thin wall, size of 85x138mm.

Operation:

It was pancreatic pseudocyst, wall thickness of 7mm, filled  yellowish fluid. Surgical drainage of the pseudocyst, which involves making a connection between the cyst and the jejunum (Roux-en-Y anastomosis).

Microscopic report:

 Pancreatic pseudocyst.

Discussion:

Pancreatic pseudocyst caused rarely by trauma and frequently happens in children. This case was a  large pancreatic pseudocyst in adult due to trauma. Ultrasound was confused with a liver cyst and priority of was MSCT higher than. In this case, surgery asked for fluid analysis but forgetting of counting amylase enzyme in withdrawn fluid, but we had microscopic report of specimen to confirm a pancreatic pseudocyst.

References

Dapo Popoola, Mary Ann Lou, and Edward H. Sims. Traumatic Pancreatic Pseudocysts .J Natl Med Assoc. 1983 May; 75(5): 515–517.

Griffith, Antonio, Wong, Lee Chu, Levine, Ho, Paunipagar. Expertddx ultrasound. Amirsys. 2010. Section 5:2-3.

Hassan A El Musharaf, Mohamed A Al Auriefi. Traumatic pancreatic pseudocyst. The Saudi Lewis G, Krige JE, Bornman PC, Terblanche J. Traumatic pancreatic pseudocysts. Br J Surg. 1993 Jan; 80(1):89-93.

Louis R Lambiase, MD, MHA; Chief Editor: Julian Katz, MD. Pancreatic Pseudocysts . http://emedicine.medscape.com.

Michael AJ Sawyer, MD; Chief Editor: Eugene C Lin, MD. Pancreatic Pseudocyst Imaging. http://emedicine.medscape.com.

CASE 189: NUTCRACKER‘S SYNDROME, Dr PHAN THANH HAI, Dr NGUYEN DUC TRI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male boy 12 yo had been in operation of cystostomy for removing blood clot 3 months before, but unkwon cause , and now hematuria is recurring.

Ultrasound of abdomen detected left renal vein dilated, big and big in comparison to one on right site, color Doppler shows very low flow in left dilated renal vein. (see 3 pictures).

 

 

 2 kidneys are normal.

MSCT CE UROLOGY detected left renal vein dilated and pressed between aorta and SMA,  and early filling contrast,  suspected one A-V SHUNT at upper pole of left kidney.(See 3 images of CT with CE).
 

 

 

 

 

 

 

Planning to do DSA for make sure diagnosis of hematuria and site of bleeding.

CASE 188: MEDIC RADIOLOGY CASE 5: THYMOMA and THYMOCARCINOMA, Dr Nguyễn văn Công-Dr Hồ Chí Trung, Medic Medical Center, HCMC, Vietnam.

Mr A. and Mr B. are two 64 yo male patients, have a heath check at Medic Center some days apart.

      

      

On the PA and lateral CXR a round shadow about 3-6 cm of diameter seen on anterior mediastinum R side.

 

On thoracic US examination, 2 encapsulated, with septations mixed structrure of solid and liquid contents on R lower anterior mediastinum of 3-5 cm diameter look alike on both patients.

          

CT scan of both chests show almost the same findings as a mixed components with solid and fluid, septated, encapsulated, contrast enhanced on R lower anterior mediastinum.

Imaging diagnosis: Right Anteroinferior Mediastinal Tumor can be thymic origin.

Both men go for surgery to remove the anterior mediastinum tumor.

 But the resullts from pathology are different:

The pathology report of Mr A.: THYMOMA TYPE A  WITH CYSTIC CHANGE. 

The pathology report of Mr B.:Undifferentiated Adenocarcinoma, invading lung tissue, EGFR (+)

Outcome of the patients:

Mr A. after the surgery is still living and working till now.

Mr B. still alive some months after radiation and chemotherapy.

A coincidence : 2 cases of incidentaloma with different outcomes. From this lesson we can learn that:

1/ Imaging diagnosis is only the shadow of the truth.

2/ Pathology give us one part of the truth.

3/ Clinical findings, imaging and pathology can give us almost the truth.

4/ But the truth itself  is the outcomes of the patients .