Thoracic Splenosis - A necessary differential diagnosis for pleural based nodules with history of thoracoabdominal trauma

Thoracic Splenosis (TS) is a rare medical condition, where there is auto-transplantation of the splenic tissue in the thoracic cavity, often leading to pleural based nodules. Our patient is the first ever case of this condition in Pakistan, and underwent extensive diagnostic procedures as well as medical treatments, before receiving the diagnosis of TS. He underwent HRCT for chronic cough that revealed pleural and mediastinal nodules. This coupled with a vague mass in the testes led to the provisional diagnosis of metastasized testicular tumour, and later a diagnosis of pulmonary tuberculosis was made. However, eventually a 99mTc denatured red blood cell scan confirmed the diagnosis of TS. TS is a benign condition, whereas other causes of pleural nodules are relatively malignant, hence its diagnosis is essential in ruling out malignancies. Among the multiple invasive and non-invasive diagnostic modalities, the gold standard remains 99mTc denatured red blood cell scan, which is a sensitive test that provides an accurate diagnosis and bars the need of multiple invasive procedures. doi: https://doi.org/10.12669/pjms.38.3.4563 How to cite this:Mehmood F, Murtaza MM, Ali S, Ashraf A. Thoracic Splenosis - A necessary differential diagnosis for pleural based nodules with history of thoracoabdominal trauma. Pak J Med Sci. 2022;38(3):---------. doi: https://doi.org/10.12669/pjms.38.3.4563 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The role of central autonomic nervous system dysfunction in Takotsubo syndrome: a systematic review

Introduction Takotsubo syndrome (TTS), also known as stress cardiomyopathy or “broken heart” syndrome, is a mysterious condition that often mimics an acute myocardial infarction. Both are characterized by left ventricular systolic dysfunction. However, this dysfunction is reversible in the majority of TTS patients. Purpose Recent studies surprisingly demonstrated that TTS, initially perceived as a benign condition, has a long-term prognosis akin to myocardial infarction. Therefore, the health consequences and societal impact of TTS are not trivial. The pathophysiological mechanisms of TTS are not yet completely understood. In the last decade, attention has been increasingly focused on the putative role of the central nervous system in the pathogenesis of TTS. Conclusion In this review, we aim to summarize the state of the art in the field of the brain–heart axis, regional structural and functional brain abnormalities, and connectivity aberrancies in TTS.

Purposeful use of multimodality imaging in the diagnosis of caseous mitral annular calcification: a case series report

Background Caseous mitral annular calcification (CMAC) is a rare liquefactive variant of mitral annular calcification (MAC) and superficially mimics a cardiac vegetation or abscess. CMAC is viewed as a benign condition of MAC, while MAC has clinical implications for patients’ lives. Correctly diagnosing CMAC is essential in order to avoid unnecessary interventions, cardiac surgery or even psychological suffering for the patient. Case presentation We report on 6 patients with suspected intra-cardiac masses of the mitral annulus that were referred to our institution for further clarification. A definitive diagnosis of CMAC was achieved by combining echocardiography (Echo), cardiac magnetic resonance imaging (MRI) and cardiac computed tomography (CT) for these patients. Echo assessed the mass itself and possible interactions with the mitral valve. MRI was useful in differentiating the tissue from other benign or malign neoplasms. CT revealed the typical structure of CMAC with a “soft” liquefied centre and an outer capsule with calcification. Conclusion CMAC is a rare condition, and most clinicians and even radiologists are not familiar with it. CMAC can be mistaken for an intra-cardiac tumour, thombus, vegetation, or abscess. Non-invasive multimodality imaging (i.e. Echo, MRI, and CT) helps to establish a definitive diagnosis of CMAC and avoid unnecessary interventions especially in uncertain cases.

Metabolic Profiling Of Obesity With And Without The Metabolic Syndrome – A Multi-Sample Evaluation

Context There is a dispute whether obesity without major metabolic derangements may represent a benign condition or not. Objective We aimed to compare the plasma metabolome in obese subjects without the metabolic syndrome (MetS) to normal-weight subjects without MetS, as well as to obese subjects with MetS. Design Cross-sectional. Setting Two academic centers in Sweden. Participants Three population-based samples (EpiHealth, n=2342, SCAPIS-Uppsala, n=4985 and SCAPIS-Malmö, n=3978) in which individuals were divided into groups according to their BMI and presence/absence of MetS (NCEP/consensus criteria). Intervention None Main Outcome Measure 791 annotated endogenous metabolites measured by ultra-performance liquid chromatography tandem mass spectrometry Results We observed major differences in metabolite profiles (427 metabolites) between obese (BMI ≥ 30 kg/m 2) and normal-weight (BMI < 25 kg/m 2) subjects without MetS after adjustment for major life-style factors. Pathway enrichment analysis highlighted branch-chained and aromatic amino acid synthesis/metabolism, aminoacyl-tRNA biosynthesis and sphingolipid metabolism. The same pathways, and similar metabolites, were also highlighted when obese subjects with and without MetS were compared despite adjustment for BMI and waist circumference, or when the metabolites were related to BMI and number of MetS components in a continuous fashion. Similar metabolites and pathways were also related to insulin sensitivity (Matsuda index) in a separate study (POEM, n=501). Conclusion Our data suggest a graded derangement of the circulating metabolite profile from lean to obese to the metabolic syndrome, in particular for metabolites involved in amino acid synthesis/metabolism and sphingolipid metabolism. Insulin resistance is a plausible mediator of this gradual metabolic deterioration.

How to Prevent, Reduce, and Treat Severe Post Sympathetic Chain Compensatory Hyperhidrosis: 2021 State of the Art

The role of thoracic surgery in the management of hyperhidrosis is well-known and thoracoscopic sympathetic interruption is commonly accepted as being the most effective treatment. However, some concerns still remain regarding the potential to develop compensatory hyperidrosis (CH), the most troublesome and frequent side effect after surgery and its management. Compensatory hyperidrosis prevention may be achieved by identifying subjects at higher risk and/or targeting nerve interruption level on the base of single patient characteristics gathered during the preoperative survey. Furthermore, the surgical treatment may consist of different techniques aimed at reversing the effects of previous sympathetic interruption. To predict CH after sympathectomy, the most interesting proposals in recent literature are a temporary thoracoscopic sympathetic block and the introduction of new and targeted preoperative surveys. If the role of nerve clipping technique vs. the definitive cutting is still intensely under debated, new approaches have been recently proposed to reduce the incidence of CH. In particular, extended sympathicotomy has been described as an alternative to overcome severe forms. Last, among the techniques developed to reverse sympathetic interruption effect, diffuse sympathicotomy (DS) and microsurgical sympathetic trunk reconstruction represent advances in this field. An all-round review of these topics is strongly needed. Our aim is to cover all the above issues point by point. Although sympathectomy represents a small part of thoracic surgery, we believe that it is worthy of interest because of the profound effect that complications for a benign condition can have on patients.

Association of meningitis and clival canal defect: case illustration, management, and systematic review of the literature

OBJECTIVE Improper embryological development of the clivus, a bony structure that comprises part of the skull base, can lead to a clival canal defect. Previously thought to be a benign condition, clival canals have been reported to be associated with meningitis and meningoceles. In this review, the authors sought to present an unpublished case of a patient with a clival canal defect associated with meningitis and to evaluate all other reported cases. METHODS In October 2020, a search of PubMed, Web of Science, and Scopus was conducted to identify all cases of clival canals reported from January 1, 1980, through October 31, 2020. RESULTS Including the case presented herein, 13 cases of clival canals, 11 in children (84.6%) and 2 in adults (15.4%), have been identified. Of the pediatric patients, 5 (45.5%) had an associated meningocele, and 8 (72.7%) had meningitis. Nine of the 13 patients (69.2%) had defects that were treated surgically, 5 (38.5%) by a transnasal approach and 4 (30.8%) by a transoral approach. Two patients (15.4%) were treated with drainage and antibiotics, 1 patient (7.7%) was treated solely with antibiotics, and 1 patient (7.7%) was not treated. In the literature review, 8 reports of clival canals were found to be associated with meningitis, further contributing to the notion that the clival canal may be an overlooked source of recurrent infection. In several of these cases, surgical repair of the lesion was curative, thus preventing continued episodes of meningitis. CONCLUSIONS When a patient has recurrent meningitis with no clear cause, taking a closer look at clival anatomy is recommended. In addition, if a clival canal defect has been identified, surgical repair should be considered a safe and effective primary treatment option.

Acute Benign Hepatitis Due to Glycogen Hepatopathy

Glycogen hepatopathy is a very rare and forgotten complication of poorly controlled type 1 diabetes mellitus. Glycogen hepatopathy may also present in type II diabetes mellitus, especially when managed with high doses of insulin. Although it is a benign condition, it is rarely diagnosed in a timely manner. It is characterised by hepatomegaly causing abdominal pain due to stretch on the liver capsule causing capsulitis, and derangement of liver enzymes. In this article we report a patient who presented with severe abdominal pain, hepatomegaly and transaminitis, the symptoms persisted for one year before the diagnosis of glycogen hepatopathy was made.

Spontaneous pneumomediastinum – a rare cause of chest pain and dyspnoe in children

Introduction. Spontaneous pneumomediastinum is a very rare condition in children. Nevertheless it should be considered in the differential diagnosis in patients who present with chest pain and dyspnoe.Aim. The aim of our study was to describe clinical presentation, management and outcomes of the paediatric patients with spontaneous pneumomediastinumMaterial and Methods. This was a retrospective analysis of the charts of all the patients who were admitted to the Department of Pneumonology, Paediatric Allergy and Clinical Immunology in a ten year period from 01.01.2011 till 31.12.2020 in whom spontaneous pneumomediastinum was diagnosed.Results. There were 11 children (7 females) with spontaneous pneumomediastinum. The median age of the children was 11 years (range 3 to 17.5 years). Most of the children presented to the hospital with chest pain, three children complained of the neck swelling and four children developed dyspnoe. Three children with the primary spontaneous pneumomediastinum had a history of physical exercise prior to the onset of symptoms. The secondary spontaneous pneumomediastinum occurred in two children with asthma and 4 children with pneumonia. Genetic material of human Bocavirus was identified in 3 cases. In 81.8% of children pneumomediastinum was accompanied by subcutaneous emphysema and in one case, in a child with severe pneumonia and respiratory insufficiency caused by Bocavirus with pneumorrhachis. In 10 children computed tomography was performed, bronchoscopy in 4 and esophagoscopy in two children. There was no evidence of esophageal rupture or bronchial tree rupture in any of our patients. Three children with pneumonia and pneumomediastinum developed respiratory insufficiency, two of these were treated with mechanical ventilation and one with High Flow Nasal Cannula oxygen therapy. All the children received oxygen. In one child surgical procedure was performed and the drain was inserted into mediastinal space in order to decompress it. Outcome was favourable in all children. Mean time to recovery was 10.6 ± 1.2 days. There was no recurrence of symptoms in any of our patients.Conclusions. Spontaneous pneumomediastinum in most cases is a benign condition, sporadically however it may progress rapidly, leading to respiratory insufficiency and warrant invasive management.

Robotic Assisted Flexible Ureteroscopy in Covid-19 Positive Patient Using Thulium Fiber Laser: Case Report and Literature Review

Flexible Ureteroscopy (FURS) has become an integral aspect of the surgical armamentarium to treat intra-renal stones that are less than 2 cm in diameter. Despite the progress made with regards to the design of the flexible ureteroscopes, surgeons still need to work with suboptimal ergonomics, which may result in orthopedic complaints, which as a result lead to imperfect performance. Robotic- Assisted FURS with Avicenna Roboflex has provided significant improvement of ergonomics. The Super Pulse Thulium Fiber Laser (SPTFL) may be considered as a viable alternative to holmium laser in stone management. Coronavirus Disease- 19 (Covid-19) has been declared as a pandemic by the World Health Organization (WHO) on March 11, 2020. As a result, many hospitals have been converted to dedicated facilities to manage the Covid-19 patients. Urinary stone disease represents a benign condition, but in non-negligible number of cases, it can lead to potential severe septic complications that could increase the burden on emergency services. Many surgical specialties including urology has made short pathways for patient flow to decrease the contact with the patients which in turn will decrease the possibility of transmission of Covid-19. The use of new technologies such as Avicenna Roboflex and thulium fiber laser in Covid-19 positive patients when performing flexible ureteroscopy can minimize direct contact with the patient, expedite the procedure, while protecting the staff from getting Covid-19 infection.

Arthroscopic Management of Synovial Chondromatosis of the Knee Joint

Synovial Chondromatosis is a rare and it is a benign condition characterized by multiple cartilaginous nodules in synovial facet spaces. Synovial Chondromatosis affects most commonly the knee joint. This is a case report of a 30-year-old male patient presented with pain and swelling over the left knee joint. On evaluation MRI shows loose bodies, for which he underwent, arthroscopic exploration. Viscous fluid and loose bodies were identified and showed synovial hyperemia. Synovial debridement was done and loose bodies were removed and sent to histopathological examination. The result signify that arthroscopy is efficient method both in diagnostic as well as therapeutic management of synovial chondromatosis.