Fat necrosis as a differential diagnosis for recurrence in a treated case of breast cancer: A case report

Fat necrosis is a benign inflammatory process that can involve adipose tissue that most frequently affects peri-menopausal women. It can mimic breast cancer clinically or radiologically. The incidence of breast fat necrosis overall is roughly 0.6%, representing 2.75% of all benign lesions. Fat necrosis presents in 0.8% of breast tumors and 1–9% of breast reduction surgery cases. Most at risk are middle-aged women, with an average age of 50 years, and women with pendulous breasts. Traumatic Fat Necrosis is an important differential diagnosis to be kept in mind in Carcinoma Breast patients who are treated with surgery and adjuvant radiation therapy. We present a case where radiation is followed by a large non-healing ulcer in a known case of breast carcinoma patient.

Recurrent Anti-AMPA Receptor Limbic Encephalitis: A Case Report and Literature Review

Alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor encephalitis is a relatively rare anti-neuronal surface antigen autoimmune encephalitis (LE). We described a case of a 47-year-old Chinese man having anti-AMPA receptor limbic encephalitis initially presented with cognitive decline, undetectable antibodies, and normal imaging findings in magnetic resonance image (MRI) and then developed into typical autoimmune limbic encephalitis a few months later with a course of multiple relapses. In addition, we found progressive brain atrophy in our case, which was a rare presentation of LE. This report also summarized the characteristics of nine reported cases of anti-AMPA receptor limbic encephalitis with relapse up to date. This case highlighted that autoimmune limbic encephalitis is an important differential diagnosis for patients with typical symptoms even when the MRI and antibodies are normal, and more attention should be paid to the relapse of anti-AMPA receptor encephalitis.

P-O13 Spontaneous Splenic Rupture as first presentation of Chronic Myeloid Leukaemia

Background Although rare, spontaneous splenic rupture (SSR) is a potentially life threatening condition and most commonly associated with infection and malignancy. Haematological malignancies are an important differential diagnosis and among these chronic myeloid leukaemia (CML) has one of the highest associations with SSR. Methods This case report follows a previously fit and healthy thirty-three year old gentleman who presented to accident and emergency with one day history of sudden onset, severe, left upper quadrant pain. CT of the abdomen and pelvis including an arterial phase, confirmed splenic rupture with moderate volume haemo-peritoneum, but no active bleeding. White cell count (WCC) was 225.8 x10^9/l and blood film confirmed suspicion of haematological malignancy. The patient was haemodynamically stable and therefore transferred to the surgical high dependency unit for observation and conservative management. He was commenced on hydroxycarbamide on the advice of haematology. Results Genetic screening detected BCR-ABL1 and Philadelphia chromosome; this along with bone marrow aspirate confirmed diagnosis of CML. His WCC decreased with hydroxycarbamide therapy. He made good clinical progress and was discharged home with haematology follow up. Hydroxycarbamide has since been stopped and he has been initiated on Imatinib therapy. His WCC has returned to normal and he has remained well with no further complications. Conclusions SSR is an extremely rare first presentation of CML. Given its associated morbidity and mortality, it should remain an important differential diagnosis in patients presenting acutely to the General Surgeon with abdominal pain and shock, especially in those with a known underlying haematological malignancy.

First diagnosis of thrombotic thrombocytopenic purpura after SARS-CoV-2 vaccine – case report

Background We report a case of a 25-year-old male patient, who developed acquired thrombotic thrombocytopenic purpura (aTTP) after receiving a first dose of mRNA-based SARS-CoV-2 vaccine Spikevax (mRNA-1273, Moderna Biotech, USA). While this is the first case in literature describing a case of aTTP after receiving the Spikevax vaccine, there are two other cases after mRNA-based Covid-19 vaccine and two after adenoviral SARS-CoV-2 vaccine. Case presentation The patient presented with persisting malaise, fever, headache, word-finding difficulties, nausea, vomiting, petechial bleeding, and hematuria 13 days after receiving a first dose of vaccination. Laboratory testing showed low platelet count, Coombs-negative hemolytic anemia, and mild acute kidney injury. We excluded vaccine induced immune thrombotic thrombocytopenia (VITT) as another important differential diagnosis and the final diagnosis was established after ADAMTS-13 (A Disintegrin And Metalloproteinase with a ThromboSpondin type 1 motif, member 13) activity was found to be < 1% (reference range > 40%) and ADAMTS-13 antibodies being 72.2 IU/L (reference range < 12 IU/L). We initiated empiric therapy of plasmapheresis and corticosteroids on admission and started caplacizumab the day after. The patient’s thrombocyte count normalized 3 days after admission, hemolysis and acute kidney injury resolved after 2 weeks. The patient received 2 doses of rituximab (1 g each) after the diagnosis of immune TTP was established. One month after the initial presentation, the patient is in good overall condition, but still receives daily caplacizumab due to ADAMTS-13 activity of < 1%. Conclusions Low platelet count after vaccination against SARS-CoV-2 has gained attraction after vaccine-induced immune thrombotic thrombocytopenia (VITT) has been described as a rare but severe complication of adenoviral-based vaccines. Thrombotic thrombocytopenic purpura (TTP) is an important differential diagnosis, but there are only few reports of TTP following SARS-CoV-2 vaccination. Despite pathophysiological and clinical differences of both entities, diagnostic uncertainty can result in the acute setting, since they share main symptoms such as headache and neurological alterations in addition to thrombocytopenia. In difference to other cases reported, this patient developed first symptoms of TTP as early as 4 days after vaccination, which suggests that vaccination merely acted as trigger for occult TTP, instead of truly inducing an autoimmunological process.

PATH-43. RAMAN SPECTROSCOPY AS A TOOL IN NEUROSURGERY

BACKGROUND Raman Spectra have been shown to be sufficiently characteristic to their samples of origin that they can be used in a wide range of applications including distinction of intracranial tumors. While not replacing pathological analysis, the advantage of non-destructive sample analysis and extremely fast feedback make this technique an interesting tool for surgical use. METHODS We sampled intractanial tumors from more than 300 patients at the Centre Hospitalier Luxembourg over a period of three years and compared the spectra of different tumor entities, different tumor subregions and healthy surrounding tissue. We created machine-learning based classifiers that include tissue identification as well as diagnostics. RESULTS To this end, we solved several classes in the intracranial tumor classification, and developed classifiers to distinguish primary central nervous system lymphoma from glioblastoma, which is an important differential diagnosis, as well as meningioma from the surrounding healthy dura mater for identification of tumor tissue. Within glioblastoma, we resolve necrotic, vital tumor tissue and peritumoral infiltration zone.We are currently developing a multi-class classifier incorporating all tissue types measured. CONCLUSIONS Raman Spectroscopy has the potential to aid the surgeon in the surgery theater by providing a quick assessment of the tissue analyzed with regards to both tumor identity and tumor margin identification. Once a reliable classifier based on sufficient patient samples is developed, this may even be integrated into a surgical microscope or a neuronavigation system.

Painless spontaneous haemoperitoneum secondary to a uterine leiomyoma/fibroid: unusual presentation of a life-threatening differential

This is a case of a 47-year-old woman with a spontaneous haemoperitoneum secondary to uterine leiomyomas (fibroids), an important differential diagnosis in patients with uterine fibroids and hypovolaemic shock. Uterine fibroids are very common in women of reproductive age, yet little is taught about their potential to cause hypovolaemic shock. Although it is a rare complication, given the prevalence of fibroids, it is important to bear this life-threatening differential in mind to optimise the care for these women. Presentation typically involves abdominal pain, syncope, haemodynamic instability and an intra-abdominal mass. CT of the abdomen and pelvis can be helpful in identifying the source of the haemoperitoneum, but should not delay surgery, which is the definitive management.

Eumycetoma Osteomyelitis Calcaneus in Adolescent; report of case and literature review

Background Mycetoma is the most common neglected disease in humans. It is a chronic, progressive, and destructive disease primarily caused by fungi or bacteria characterized by formation of dark pale grains commonly involve skin, soft tissue and rarely bone. Case presentation A 19 year old male patient with chronic right ankle pain, swelling and abscess formation for more than 1 year, patient was treated repeatedly with incision and drainage without any success. No X-ray, biopsy or swab for culture and sensitivity had been considered through the course of presentation. Patient was referred to Omdurman hospital where osteomyelitis secondary euomycetoma infection has been confirmed based on radiological and pathological assessment. Patient was treated surgically with aggressive debridement and bone curettage plus postoperative Itraconazole for 1 year. Conclusion Clinicians must consider osteomyelitis as important differential diagnosis during initial assessment Eumycetoma infection in adults. Aggressive bone curettage followed by regular X-ray follow up can be limb saving procedure in such cases.