Diagnostic Difficulty
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2021 ◽  
Vol 16 (1) ◽  
Mi Zou ◽  
Rong Chen ◽  
Yahong Wang ◽  
Yonglan He ◽  
Ying Wang ◽  

Abstract Background A virilizing ovarian tumor (VOT) is a rare cause of hyperandrogenism in pre- and postmenopausal women. Although transvaginal ultrasound is considered as the first-line imaging method for ovarian tumors, it is examiner-dependent. We aimed to summarize the clinical and ultrasound manifestations of VOTs to help establish the diagnosis with emphasis on those causing diagnostic difficulty. Method We retrospectively identified 31 patients with VOTs who underwent surgery at Peking Union Medical College Hospital. Results Patients with VOTs were predominantly premenopausal. All patients showed androgenic manifestations with serum testosterone levels elevated to varying degrees. The tumor size of VOTs was significantly correlated with age (P < 0.001). The VOTs in the postmenopausal group were significantly smaller than those in the premenopausal group (median 1.8 cm [range, 1.3–4.8 cm] vs 4.5 cm [range, 0.7–11.9 cm]; P = 0.018). Twenty-seven out of 31 VOTs were successfully identified by ultrasound. On ultrasound, VOTs are mostly solid and hypoechoic masses with enhanced vascularity. Four VOTs (0.7–1.5 cm) were radiologically negative, and they were the smallest among all patients. Conclusion Patients with VOTs showed androgenic manifestations with varying degrees of hyperandrogenemia. Older patients tend to have smaller VOTs. Ultrasound is an effective method for the detection of VOTs. Some VOTs can be very small and difficult to visualize radiologically, especially in postmenopausal patients. Examiners must remain vigilant about very small VOTs on the basis of endocrine symptoms.

2021 ◽  
Vol 51 (3) ◽  
pp. 303-305
Lionel Bapteste ◽  
Zeinab Kamar ◽  
Anthony Mazaud ◽  
Baptiste Balança ◽  

Only a few clinical cases of cerebral arterial gas embolism during spinal surgery are published. It seems important not to overlook this diagnosis in order to initiate rapid appropriate treatment. This was a suspected case of paradoxical gas embolism revealed postoperatively by neurological deficits and whose recovery was noted during hyperbaric oxygen treatment. Unfortunately, no complementary examination showed gas embolism and only the context, the clinical picture and the case evolution evoke this diagnosis. The diagnostic difficulty in the immediate postoperative period is highlighted.

Khalilah Alhuda Binti Kamilen ◽  
Mohd Yusran Othman

Intussusception is a well-known cause of intestinal obstruction in children. Its occurrence in fetus as an intrauterine incidence is extremely rare and poses a diagnostic difficulty. Intrauterine intussusception may result in intestinal atresia once the gangrenous segment resorbed. However, a very late occurrence of intussusception just prior to delivery may present as meconium peritonitis. We are reporting a case of premature baby who was born at 35 weeks gestation via emergency caesarean for breech in labour. Routine scan 4 days prior to the delivery showed evidence of fetal ascites. She was born with good Apgar Score and weighed 2.5kg. Subsequently she developed respiratory distress syndrome requiring mechanical ventilation. She passed minimal meconium once after birth then developed progressive abdominal distension and vomiting. Abdominal radiograph on day 4 of life revealed gross pneumoperitoneum and bedside percutaneous drain was inserted to ease the ventilation. Upon exploratory laparotomy, a single ileal perforation was seen 20cm from ileocecal junction with an intussusceptum was seen in the distal bowel. Gross meconium contamination and bowel edema did not favour the option of primary anastomosis, thus stoma was created. Reversal of stoma was performed a month later and she recovered well. Fetus with a complicated intrauterine intussusception may present with fetal ascites and their postnatal clinical and radiological findings need to be carefully assessed for evidence of meconium peritonitis; in which a timely surgical intervention is required to prevent the sequelae of prolonged intraabdominal sepsis in this premature baby.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S18

2021 ◽  
Vol 8 (10) ◽  
pp. 1739
Amitkumar Jadhav ◽  
Goutam Chakraborty ◽  
Nidhi Sugandhi ◽  
Sameer Kant Acharya

Spontaneous perforation in Choledochal cyst (CDC) is a very rare initial manifestation and more commonly seen beyond infantile age. The management is challenging due to acute presentation, poor general condition of the patient and inflamed tissue that may jeopardize the appropriateness of any surgical intervention. The aim of the study was to analyse this rarity depending on clinical findings, diagnostic difficulty and optimum management plan in a limited resource set-up. It was a retrospective observational study where five patients presenting to the casualty department with biliary peritonitis between January 2015 and December 2020 were included. They were analysed with respect to symptomatology, laboratory parameters, radiology, emergency intervention with findings and definitive management plan. A female preponderance (60%) was found. Mean age was 5.4 years. One was a known case of CDC. Abdominal pain was the most common symptom. Inflammatory markers like Total leucocyte count (TLC) and Erythrocyte sedimentation rate (ESR) were raised in all (100%). Lipase was raised in 40% (2/5). Anaemia and low serum albumin were non-specific findings. A dilated Common bile duct (CBD) on Ultrasound (US) was seen in 80% (4/5). Magnetic resonance cholangio pancreaticography (MRCP) demonstrated type I CDC in all. All underwent laparotomy with lavage and external drainage followed by interval definitive surgery. Pre-operative diagnosis of a perforated CDC may not be possible. Strong clinical suspicion and bilious peritoneal fluid may point to this rare complication. Minimum exploratory manoeuvre with good lavage and external drainage should be the optimum emergency intervention. Definitive bilio-pancreatic reconstruction should be performed when tissue oedema subsides and general condition is improved. This approach usually achieves a rewarding outcome.

2021 ◽  
Vol 8 (10) ◽  
pp. 1494
Nyamnyei Konyak ◽  
Linda Marangmei ◽  
Medo M. Kuotsu ◽  
Laishram Chittaranjan Singh ◽  
L. Shaini Devi ◽  

Background: The overlap of clinical presentation between sepsis and SIRS has presented diagnostic difficulty in these two close common scenarios. Blood culture remains the gold standard for detection of specific micro-organism, the non-availability of culture report early and difficulty in culture of many organisms is a challenge in differentiation of sepsis from its mimickers. Keeping this background, a simple tool is needed to guide sepsis management while awaiting the culture report. Therefore, the present study is conducted to determine the procalcitonin level in the setting suspicious of sepsis and to differentiate it from SIRS. The objective of the study was to determine Serum procalcitonin level as a biomarker of early diagnosis of sepsis and also to differentiate sepsis from severe inflammatory response syndrome.Methods: Cross sectional study on 79 patients aged above 18 years with suspected sepsis admitted in medicine ward. Serum procalcitonin levels were measured and analysed to look for any association with sepsis.Results: Culture was positive in 41 patients and 38 patients were procalcitonin positive. The sensitivity, specificity, positive predictive value and negative predictive values of serum procalcitonin were found as 96.68%, 94.74%, 95% and 92.30% respectively.Conclusions: There was a significant association between serum procalcitonin and culture positivity. Procalcitonin levels was found to have high sensitivity and high positive predictive value which may aid in the early diagnosis and guide initiation of anti-microbial therapy in sepsis.

2021 ◽  
Vol 51 (3) ◽  
Karina Yonamine ◽  
Cecilia Curvale ◽  
Raul Matanó ◽  
Alejandro Hensel ◽  
María Fernanda Yankowyez

Brunner's gland hamartoma or hyperplasia is a rare benign neoplasm of the small intestine, usually small, that is discovered incidentally on an upper digestive endoscopy or imaging tests. When it reaches a large size, it can cause digestive bleeding or intestinal obstruction. The pathogenesis is unknown. The endoscopic presentation can be nodular, polypoid or a diffuse glandular proliferation with thickening of the duodenal wall, and may be mistaken for a malignant neoplasm. Endoscopic resections of large Brunner's gland hamartomas in the duodenum is little reported in literature, due to its low incidence and diagnostic difficulty. The surgical approach is associated to greater morbidity compared to an endoscopic approach. The case of a 62-year-old patient is reported, who presented melena and symptomatic anemia, secondary to a giant polyp in the duodenal bulb. The polyp was successfully resected endoscopically without complications, which made it possible to avoid a more extensive surgical procedure. Histopathological examination of the whole specimen showed a Brunner's gland hamartoma. Conclusion: Brunner's gland hyperplasia or hamartoma is a benign neoplasm that rarely produces symptoms. Large lesions can become symptomatic and a high clinical-endoscopic suspicion and an evaluation of the extension are necessary before applying any therapeutic procedure, in order to avoid complex surgeries and favor a complete and safe endoscopic resection.

2021 ◽  
pp. 106689692110415
Xunda Luo ◽  
Christopher Preciado ◽  
Anupma Nayak ◽  
Lauren E. Schwartz ◽  
Thomas J. Guzzo ◽  

Here we report a case of renal oncocytoma in a 68 year-old male. The diagnosis was initially made on a needle biopsy 6 years prior to the partial nephrectomy. The case is unique that in addition to the gross and microscopic features commonly seen in renal oncocytomas, both lymphovascular invasion and prominent intracytoplasmic vacuole-like spaces are also present in this tumor. Although vascular invasion is increasingly recognized as compatible with renal oncocytoma, intracytoplasmic vacuoles are a rare and unusual finding that may lead to diagnostic difficulty. The diagnosis of renal oncocytoma was confirmed after immunohistochemistry was performed to argue against succinate dehydrogenase deficient renal cell carcinoma (RCC) and chromophobe RCC. This case highlights the importance for practicing pathologists to recognize the rare co-occurrence of lymphovascular invasion and large intracytoplasmic vacuole-like spaces in renal oncocytoma. Other differential diagnoses may include emerging renal tumor entities, such as the recently-proposed eosinophilic vacuolated tumor.

2021 ◽  
Vol 89 (4) ◽  
pp. 460-461
Ravindra Chari ◽  
Madhusmita Mohapatra ◽  
Ramya Priya ◽  
Vinod Kumar

Panduranga Seetahal-Maraj

Tumours of the foramen magnum are infrequent compared to other locations within the neuraxis. Meningiomas are one of the most frequently encountered tumours of the nervous system, but only 1.8 to 3.2% actually originate within the foramen magnum. However, they account for almost 50% of all tumours in this region. We report a case of a large foramen magnum meningioma in a 16-year-old female, the diagnostic difficulty it presents due to its rarity and indolent course, and the surgical strategies employed to manage this case. This was the first performance of a far-lateral craniotomy in San Fernando General Hospital. The use of a staged procedure to facilitate this skull base tumour resection resulted in an excellent outcome.

2021 ◽  
Vol 15 (7) ◽  
pp. 1672-1675
Muhammad Awais ◽  
Sundas Javeed ◽  
Mahnoor Mohydin ◽  
M. Kamil Zulfiquar ◽  
Usama Rafi ◽  

Fibroid is a benign lump of growth, occurring within or outside the uterus. It is a rarity for such growths to occur intra-abdominally. Such cases are of aggressive fibromatosis which are marked by the presence of desmoid tumours. It is most commonly seen in patients with a history of familial adenomatous polyposis (FAP) or past surgical procedures. As FAP has a wide fibroepithelial growth spectrum, the symptomatology and therefore the prognosis varies. Unpredictable clinical behaviour, varied location and non-specific presentation are the factors accounting to diagnostic difficulty. Therefore, misdiagnosing the disease is not uncommon. Here we report a case ofa26-year-old pregnant female presenting with lower abdominal pain and mass. Preoperative diagnosis was of uterine fibroids as per radiological evidence, but on exploration it turned out to be a large right colonic mass. The patient underwent right hemicolectomy. Histopathological reports confirmed morphological and immuno-histochemical features indicating fibromatosis. This fibromatous mass though intra-abdominal was not growing from the mesentery/mesocolon or the pelvis. It appeared to grow from the wall of the colon. This is a confirmatory presentation of true colonic wall fibromatosis which is deep and isolated form of intra-abdominal desmoid tumours. As this lesion was isolated in nature, the treatment of choice was surgical resection. It is essential to have a multi-disciplinary team approach in the management of such a patient. This improves the treatment and the prognostic outcomes. Keywords: Fibroid, Colon, Fibromatosis, Hemicolectomy, Desmoid Tumour

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