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Saturday, 10 April 2021
CASE 611: STEVENS - JOHNSON SYNDROME, Dr LÊ ĐÌNH VĨNH PHÚC, Dr PHAN THANH HẢI.
Monday, 5 April 2021
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).
Wednesday, 17 March 2021
CASE 609: INTERESTING GASTRIC TUMOR, Dr LÊ THANH LIÊM, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM
Male patient 54 yo, with hemorrhagia due to gastric ulcer for 2 years. From late 2 months patient got pain from neck to epigastric area, loss of appetite and weight. (Weight=58 kg, height=160 mm).
Ultrasound detected some nodes in both 2 lobes=10-38mm with halo sign and without Doppler signal. No thrombus in portal vein, IVC and hepatic veins. None lymph node. Small amount fluid in pelvic area.
Stomach= Irregular thickening wall, d#27-69 mm of nearly total gastric wall of corpus and fundus that formed hypoechoic mass d# 161x166x163mm, hypervascular which takes wide place of lumen and compressed cardia. Though about Gastric GIST with hepatic metastases.
MSCT with contrast confirmed gastric GIST # 16 cm, adhesing around and liver metastases. Some low signal liver lesions 10-35 mm were in lower density than liver parenchyma. Corpus of stomach has lesion d= 16 cm with soft tissue density and has big ulcer at center. Lesion was adhesive and compressed around. Pelvic area has a little of fluid.
Blood tests= Severe anemia Hb 6.0 g/dl; Hct 25%; MCV 57.6 fL; MCH 13.9 pg; WBC slight raised=11.90 x 10^9/L; PLT high raised 794x10^9/L. HP Test-IgG (Elisa) POS 69.88 U/mL; HP Test-IgM (Elisa) POS 68.48 U/mL.
In Binh dan hospital, gastroendoscopy shows big gastric tumor in fundus with deep ulcer having hard border and compresses lower 1/3 part of esophagus.
Histopathologic results= Infiltrating of lymphocytes and plasmocytes gastric mucosa proliferates fiber tissue and fibrosis. Masses of cells line in band with fusiform nucleii on base of fiber tissue. Follow up GI GIST.
Waiting for histoimmunostaining.
CONCLUSION= Interesting diffuse appearance of entire gastric wall tumor helps diagnosing gastric GIST based on ultrasound and MSCT findings.
Saturday, 6 March 2021
CASE 608: APPENDICOLITH, Dr NGUYỄN NGHIỆP VĂN, Dr VÕ NGUYỄN THÀNH NHÂN, Dr NGUYỄN PHÚ HỮU, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM
Male patient 17yo, RLQ pain at 01:00 a.m. March 6, 2021.
Ultrasound at Medic Center at 10:00 a.m. detected an 33x10 mm swollen appendix at RLQ with fecolith =11 mm inside which has echo rich pattern and posterior shadowing. No free fluid around. A diagnosis of acute appendicitis with fecolith was made.
Lab results= WBC with neutrophil raised and CRP raised.
Later MSCT of abdomen confirmed an acute appendicitis with fecolith.
Patient was hospitalized at 12:00 p.m. in Binh dan hospital. Endoscopic operation performed at 12:30 p.m..
And surgical macroscopic specimen (received via email at 03:00 p.m.).
Reference:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072212/