CASE 448 : FEVER and ASCITES, Dr PHAN THANH HẢI, Dr NGUYỄN PHÚ HỮU, MEDIC MEDICAL CENTER, HCMC,VIETNAM

Woman 40 yo with one week  fever,  abdomen pain  and distention..

Clinical examination ruled out  surgical needs , chest  X-ray is normal.

• Ultrasound of abdomen = liver, biliary system,  kidney are normal, huge amount of  ascites volume with cloudy fluid  (us1 , us2, us3 pelvis  us4 ovary).

CT scan of abdomen  =  No tumor detection [ ct1,frontal view, ct2, ct3  cross section].

Blood tests =  WBC  15k with 13,3 k neutro, CRP= 25.9,  amylase, CEA , CA 125  are  normal level.  But Widal test is  positive th;1/320

Ascites punction= yellow  clear,   analysis =  ADA= 19.5 ng/mL,  CA125 :396 UI/mL, CEA: 0,8UI,  albumine =3.9 mg/mL

After 2 weeks treated with antibiotics;   response is good,   no fever  but ascites  is  distention after  aspiration  many times.

Summary=   Fever with typhoid  but ascites  still  persistent after one month.

Discussion :   Fever and   Widal test positive  is  Typhoid fever, treated response with antibiotics, but ascites  is still  progressing, so that  is not feature of Typhoid fever (one  expert of infectious disease says). Ascites analysis  can rule out  pancreatitis,  tuberculosis and  cirrhosis.  With CT , ultrasound  don't  detect any tumor intra abdomen. Then the short  way for diagnosis is  laparoendoscopy  for biopsy.

Laparoendoscopy  detected  multiple white spots intra parietal peritoneum,  most common in diaphragma area  (see foto)  suspected peritoneal carcinomatosis.

Microscopic result is malignant mesothelioma.

Reference:

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CASE 447: RETROPERITONEUM CYST, Dr PHAN THANH HẢI, Dr PHẠM THỊ THANH XUÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 20 yo with abdomen distention at  right subcostal region,  no pain  no fever.

Ultrasound of abdomen detected  one big mass in retroperitoneum, multiseptation and  multiloculated in connection with troubled fluid inside.

US 1=  longitudinal scan  over right kidney.

US 2 = crossed sectionnal scan over aorta.

US 3 = longitudinal  scan over spine.

US 4 = longitudinal  scan at  pelvis.

MSCT of  abdomen with CE:

CT 1 = sagital scan of  cystic mass  retroperitoneum.

CT 2 = frontal scan  of this mass  is cystic homogeneous.

CT 3 = frontal view of  this mass  and  gastrointestinal mass arround.

CT 4 =  aorta  no deplacement.       

Normal blood test and  all biocancer markers.

Open operation laparotomy  surgeon detected this cystic tumor in retroperitoneum , thin wall and  old blood  inside.

 Removed  this mass.

Microscopic result is benign 
 cavernous hemangioma.

CASE 446: KILT SYNDROME, Dr PHAN THANH HẢI, Dr LÊ TỰ PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 35 yo,  hematuria repeated  many times with  many  dilated subcutaneous veins on the abdomen wall [photo].

US of  kidneys   showed  righ and left kidney looked like hydronephrosis. But cannot detected the cause ( US 1, US 2)   US 3  =  CDI of  renal artery;  US 4 = spectral Doppler of pyramid arteries; US 5 = varicosis in urinary bladder wall.

CT of kidney without CE ( CT 1)=   HU of pelvis kidney  = 8 UI

CT 2  with CE ,  CT 3: secretion phase; CT 4= small ureter on R and L sides.

 MRI 1, MRI 2= kidney non CE   showed pelvis kidneys dilated and fluid collection around  2 kidneys.

Ultrasound of the leg = dilated chronic  deep vein thrombosis.

Conclusion= absence of IVC  suprarenal with DVT of  the legs, it is  K I L T syndrome.

Reference:

CASE 445: LIVER PEDUNCULATED, Dr PHAN THANH HẢI, Dr NGUYỄN PHÚ HỮU, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 33 yo  with epigastric pain  has been treated as  gastritis.

Ultrasound of  abdomen detected  one mass near  the liver border having hypoechoic peduncule from liver,  and changing position with  respiration movement (US1). There is vessel from the liver for peduncule of tumor (US ). In  cross-sectionnal scanning,  this tumor represented its well bordered, solid, hypervascular structure (US 3)

MSCT with CE detected this tumor in  connecting with  the liver by a long peduncule ( CT 1,sagital view) and in  frontal view, this mass is  nearby the  ligamentum falciformis (CT2).

CT 3: cross sectionnal scan of  tumor = well contrasted enhancement.

CT 4: vascular supplying for this tumor is a branch from  left gastric artery and  another one from liver.

Laparoscopic operation  detected  tumor  from  liver  at the border of falciform ligament,  and its structure  like liver tissue.

   Microscopic report  is  liver tissue.

Conclusion: it is a case of liver pedunculated .

Reference:

CASE 444: FEVER in PREGNANCY, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 23 yo, 28 weeks primigravida with 5 days fever and abdominal pain in  periodic crisis.

WBC=  27 k  with neutro 97% ;  CRP= 342 mg/L,  normal urine test . And clinical suspected  appendicitis.

Ultrasound of  abdomen reported 29w pregnancy and  normal status of fetus. One cystic mass retro-uterus  near left pelvis  iliac artery, was suspected  left kidney  ectopic pelvis with hydro-pyonephrosis while  right kidney is normal ( US 1, US 2, US 3, US 4).

MRI  reported  left kidney hydronephrosis due to ureter obstruction.

Emergency cystoendoscopy was done for putting  stent  to release pus out from left kidney.

Conclusion=Pregnancy with  fever due to left pyohydronephrotic kidney as obstruction of ureter.

Reference :

http://www.bjuinternational.com/case-studies/hydronephrosis-pregnancy-ectopic-pelvic-kidney/