Ecthyma gangrenosum in a patient with febrile pancytopenia

Ecthyma gangrenosum (EG) is a cutaneous infection most commonly associated with Pseudomonas bacteremia and usually occurring in immunocompromised patients [1]. The infection progresses sequentially from a maculopapular rash to hemorrhagic bullae, then to necrotic ulcerations with surrounding erythema [2]. Herein, we report a case of ecthyma gangrenosum in an immunologically compromised patient. A 65-year-old female was admitted to the oncohematology department for febrile pancytopenia. Blood work revealed severe thrombocytopenia at 15,000/mm³), an absolute neutrophil count of 180 cells/mm³, and anemia. A sternal bone marrow puncture found 15% of plasma cells. Four days after the admission, the patient had a painful, quickly extending lesion on the abdomen. She described erythema that progressed to pustules, then ulcerations. On general clinical evaluation, the patient was feverish at 40°C. A dermatological examination revealed the presence of a 6 cm purpuric patch on the left flank with a central necrotic eschar (Fig. 1). The diagnosis of ecthyma gangrenosum was reached and the patient was treated with ceftazidime and vancomycin. Unfortunately, having gone into septic shock, the patient died one week later.

Impacted vesicouretric stone a quagmire settled with holmium laser

A 38 years female presented with left flank pain, nausea, and vomiting. Ultrasound and Noncontrast CT scan were suggestive of left hydronephrosis with left Vesicoureteral stone (Figure 1). Conservative medical treatment previously was not successful. Blood investigations were Hb 11.5 gm%, TLC 11500/mm3 , urea 22, creatinine 0.6, urine was full of RBCs. She was taken to the operation theatre for emergency double j stenting. Cystoscopy showed impacted left vesicoureteral stone (Figure 2,3).

Radiological spectrum of invasive mucormycosis in COVID-19

Mucormycosis, commonly known as the “black fungus” is recently emerging as a deadly complication in COVID patients in the Indian subcontinent. A growing number of cases are being reported from all over the country, with a majority of the patients either undergoing treatment or having recovered from COVID. Here, we report three cases of multisystem mucormycosis in COVID positive patients showing, rhino-orbital, cerebral, pulmonary, and genitourinary involvement. The first is a case of a 41-year-old male patient who during his treatment developed left periorbital swelling with ecchymosis and headache. CT and CE-MRI of the paranasal sinuses and brain revealed features of pan fungal sinusitis and subsequent invasion into the left orbit. The second case is of a 52-year-old male patient who after complaining of a severe left-sided hemicranial headache was diagnosed with cavernous sinus thrombosis. The third is of a 57-year-old male patient who presented with left flank pain and dysuria. HRCT (High-resolution CT) chest revealed a thick-walled cavitary lesion, and NCCT KUB (Non-contrast CT of Kidneys, ureters, and bladder) revealed left-sided pyelonephritis. A cystoscopic and microbiological evaluation revealed fungal growth. In all three patients, a biopsy from the involved area revealed broad aseptate filamentous fungal hyphae suggestive of mucormycosis, which was confirmed on culture. These are all unusual cases and physicians should be aware of the possibility of secondary invasive fungal infections in patients with COVID-19 infection.

Xanthogranulomatous pyelonephritis due to Aspergillus in a non-diabetic older patient

Xanthogranulomatous pyelonephritis is a rare condition characterised by destructive granulomatous inflammation of renal parenchyma. Primary renal Aspergillosis has been reported in patients with immunocompromised states such as diabetes, retroviral disease, organ transplant recipients, etc. We present a unique case of an older adult in his early 60s, presenting with fever and left flank pain with renal angle tenderness, diagnosed with primary renal aspergillosis with xanthogranulomatous pyelonephritis. These symptoms resolved with a long duration of antifungal (itraconazole) therapy and nephrectomy. The unique features are the development of fungal pyelonephritis in the absence of any immunocompromising conditions and the development of xanthogranulomatous changes with no risk factors.

Rare Encounter of Renal Hydatid Cyst: A Case Report

Cystic Echinococcosis (CE) or Hydatid disease is caused by the infection with the larval stage of long tapeworm, Echinococcus granulosus. This condition often remains asymptomatic for years before the cyst grows large enough to cause symptoms in affected organs. The most common organs involved are liver and lungs although the heart, brain, bone, central nervous system, and kidney may also be involved. This case is about a young woman who presented with left flank pain and urinary tract infection who was later diagnosed as having left renal hydatid cyst. The cyst was approximately 7.8×6.6×8cm with internal multiple septations at the lower pole cortex of the left kidney. Laparoscopic pericystectomy was performed and with no postoperative complications, she was discharged on albendazole and other supportive medication. With timely management using combination therapy, this condition is curable and the patient can live a healthy life with normal kidney function.

Extremely high alpha-fetoprotein-producing adrenal hepatoid adenocarcinoma

Hepatoid adenocarcinoma (HAC) is a rare tumour that produces an alpha-fetoprotein (AFP) mimicking hepatocellular carcinoma (HCC). Adrenal HAC is exceedingly rare. Here we report extremely high AFP-producing adrenal HAC, the first case in Thailand. A 47-year-old man presented with left flank pain and weight loss for 2 months. A palpably huge left flank mass was observed on physical examination. CT revealed a 7 cm enhanced mass involving the left adrenal gland and multiple contrast-enhanced hypodense masses in both liver lobes. The largest was a 3.7 cm at liver segment-VII without cirrhotic background, with an AFP level of 321 495 ng/mL. Both adrenal and liver biopsies were performed. This patient received a diagnosis of advanced adrenal HAC. Unfortunately, the tumour progressed, causing massive upper gastrointestinal bleeding and death. Adrenal HAC is challenging to diagnose, which multifocal HCC, pheochromocytoma and adrenocortical carcinoma should be excluded. Surgical resection is preferred among resectable patients. However, no systemic therapy has been standardised.