Case of leprosy mimicking preseptal cellulitis: a diagnostic dilemma

A 36-year-old Asian man presented with swelling over the left frontal region involving the upper eyelids, with associated erythema and tenderness for 1 month duration. Clinically he was diagnosed as a case of preseptal cellulitis, however, the lesion did not improve on broad-spectrum systemic antibiotics. CT showed superficial soft tissue swelling in the forehead extending till the superior part of orbit. Histopathological assessment of the lesion revealed clusters of epithelioid cells with multinucleate giant cells in the dermis along with perivascular and periadnexal lymphocytic infiltrates, suggestive of leprosy. The patient was started on oral steroids with multidrug therapy, following which the patient showed early resolution of the lesion within 10 days of treatment. Leprosy is endemic in India, leprosy with reactional episodes mimics other inflammatory and infective etiologies making diagnosis difficult. Leprosy should be present in an ophthalmologist’s diagnostic repertoire while dealing with periorbital swellings for early clinical diagnosis and favourable outcomes.

Carpometacarpal Dislocation with Third Metacarpal Fracture

Case Presentation: A 17-year-old male presented to the emergency department (ED) due to trauma to the right hand and wrist after punching a locker at school. He had significant soft tissue swelling. Radiographs demonstrated intra-articular metacarpal fractures with associated carpometacarpal dislocations. The dislocation was reduced bedside in the ED and ultimately underwent closed reduction surgical management with orthopedic surgery. Discussion: Metacarpal fractures result from high-force impact injuries and account for 30-40% of all hand injuries. The most common sites of second through fifth metacarpal fractures are at the neck and the shaft, with the majority involving the fifth metacarpal neck (commonly coined “boxer’s fractures”). Carpometacarpal (CMC) dislocations are a rare injury associated with high-force impact trauma to the wrist. These injuries account for as little as 1% of all acute hand and wrist injuries. Carpometacarpal dislocations are often difficult to diagnose on physical examination due to significant soft tissue swelling, and they can easily be missed on anterior-posterior views of the hand. Lateral and oblique plain radiograph views are essential in the diagnosis as they are more likely to show dislocations. Despite appropriate plain radiographic views, subtle CMC dislocations may be difficult to discern dependent on the level of dislocation or subluxation and overlapping of joints. These injuries are rare due to otherwise highly stable ligamentous and muscular attachments within the wrist. Because of these attachments, dislocations are often associated with concomitant metacarpal fractures.

Invasive Tendon Sheath Fibrosarcoma Causing Radial Osteolysis in a Golden Retriever

ABSTRACT This case report details a previously undescribed malignancy of the tendon sheath in a golden retriever. This dog originally presented with lameness of the left forelimb, at which point radiographs revealed a monostotic, lytic lesion of the distal radius with overlying soft-tissue swelling. A fine-needle aspirate was performed, and cytology was compatible with a sarcoma, with the primary differential being an osteosarcoma. After amputation, the leg was submitted for histopathology, which revealed inconsistencies with a typical osteosarcoma lesion, including lack of osteoid deposition. Second opinion histopathology showed a fibrosarcoma that appeared to have originated in the tendon sheath of an extensor tendon and then secondarily invaded the radius. At the time of publication, ~17 mo after amputation, the dog continues to do well without any evidence of recurrent or metastatic disease.

592 A Large Lipoma: An Unusual Presentation of the Tongue

Background Lipomas are commonly identified tumours of the body however they are rarely found in the oral cavity. Rarer still is it to report a case of a lipoma in the tongue as they are more commonly located in the buccal mucosa. Objectives To diagnose and explore the pathogenesis of a soft-tissue swelling of unknown origin Method A thorough patient history and clinical examination was undertaken followed by magnetic resonance imaging (MRI) which revealed an alarming report at first glance. An incisional biopsy of the lesion was then carried out to aid in diagnosing the lesion. Results The swelling caused the patient no pain however the mere size of the lesion affected the patient’s tongue movement and function which therefore affected the patient’s quality of life. The imaging and the biopsy of the lesion led to a diagnosis of a large lipoma on the lateral border of the tongue. Conclusions To the authors’ best knowledge, we present a rare case of a patient whom we diagnosed with a large lipoma on the lateral border of the tongue. This case report discusses the stages of patient management from initial presenting complaint, up to the maintenance of the patient following the diagnosis of this lesion.

An Unusual Clinical Appearance of Lymphangioma in the Cheek of a 52-Year-Old Female - A Rare Case Report

Lymphangioma is a rare developmental hamartomatous malformation of the lymphatic vessels. It usually occurs in the dorsum of the tongue resulting in macroglossia that can interfere with speech and mastication. About 10 % of lymphangiomas can occur in the buccal mucosa resulting in multiple discrete vesicle like structures resembling frogs-egg or pebbly surface or Tapioca pudding like appearance containing clear proteinaceous rich fluid. They also can appear reddish or reddish - purple coloured pebbly surface and are completely asymptomatic. In due course can result in painless, asymptomatic soft tissue swelling on the face resulting in facial disfigurement. Such a rare occurrence of lymphangioma reported in the cheek of a 52-year-old female and treated by ultrasonographic guided Bleomycin sclerotherapy is discussed here. A lymphangioma is a misnomer as it is not a tumour of lymphatic vessels. It is a developmental hamartomatous malformation of the lymphatic vessels that usually clinically becomes more apparent only after second year of age. Clinically they appear as painless soft swellings of the face resulting in facial asymmetry. Patients affected by lymphangioma usually report to the physician or a dentist and complain only of cosmetic defect.1

Delayed Peroneal Neuropathy After Bosworth Fracture Dislocation of the Ankle

The Bosworth ankle fracture-dislocation is a rare injury and is often irreducible because of an entrapped proximal fragment of the fibula behind the posterior tibial tubercle. Repeated closed reduction or delayed open reduction may result in several complications. Thus, early open reduction and internal fixation enable a better outcome by minimizing soft-tissue damage. We report on a 27-year-old man who underwent open reduction and internal fixation after multiple attempts at failed closed reduction, complicated by severe soft-tissue swelling, rhabdomyolysis, and delayed peroneal nerve palsy around the ankle.

Tabetic Arthropathy

Tabetic Arthropathy (TA) defines bone- and joint-destructive processes associated with neurosensory deficits due to syphilis infection. It occurs at the late stages of the disease, and affects 10% of patients with Tabes Dorsalis. The mean age at diagnosis is 60 years with a predilection for male patients. TA became less common thanks to the early diagnosis of syphilis infection, but its management remains complicated given the severity of injuries and the lack of specific treatment. TA can affect every joint, mainly the knees. Patients usually present with a single painless and swollen joint. Deformities are seen in advanced stages. Plain radiographs and CT findings include subchondral sclerosis, osteophytosis, subluxation, and soft tissue swelling. MRI shows articular destruction with irregularities of articular surfaces, deformation, and intraarticular effusion. It also helps differentiate neuropathic osteoarthropathy from other articular diseases as infection, osteonecrosis, and psoriatic arthritis (Figure 1 and 2).

POS0126 EARLY STAGE HAND OSTEOARTHRITIS IN PATIENTS WITH THE EHLERS-DANLOS SYNDROME: AN EXPLORATIVE STUDY

Background:The Ehlers-Danlos Syndromes (EDS) are a group of rare heritable connective tissue disorders caused by various defects in the biosynthesis or secretion of fibrillar collagens. The three main clinical features of EDS are joint hypermobility, skin fragility and general soft tissue fragility. 13 clinical subtypes of EDS are recognized, of which the hypermobile type (hEDS) and classical type (cEDS) are the most prevalent. It has been hypothesized that the (micro-)trauma in the joint due to typical subluxations and dislocations, make EDS patients prone to developing osteoarthritis (OA) in early stage. Conversely, it has been mentioned that joint hypermobility provides a larger joint surface area and prevents OA. Abnormal biomechanical loading has been identified as a risk factor for the development of OA in the wrist and hand. However, no studies have yet been performed in EDS patients.Objectives:The primary aim was to investigate the presence of any degenerative features for hand OA, and if this differs between cEDS and hEDS patients. The second aim was to evaluate hand function and pain related to OA signs in EDS patients.Methods:cEDS and hEDS patients between 35 and 50 years old were invited to participate. cEDS diagnosis was genetically confirmed and hEDS diagnosis was performed according the clinical 2017 hEDS criteria. Exclusion criteria were a body mass index ≥35, not being able to stand straight up for five minutes, suffering from an auto-immune disease or rheumatological condition, or pregnancy. Conventional X-rays of both hands were performed and scored independently by three assessors according to Kallman1. Presence of osteophytes (0-3), joint space narrowing (0-3), malalignment (>15°)(0/1), erosions (0/1), subchondral sclerosis (0/1), and subchondral cysts (0/1) were scored in all interphalangeal (distal and proximal), metacarpophalangeal and thumb base joints of both hands1. We defined early hand OA as minimally three features (≥1) were present. Several clinical assessments were made, e.g. tenderness, bony swelling and soft tissue swelling. The Michigan Hand Outcomes Questionnaire (MHOQ) and Australian/Canadian Osteoarthritis Hand Index (AUSCAN) questionnaires were completed.Results:In total, 31 patients (mean age 41 ± 5.6 years, 13 men and 18 women) diagnosed with EDS participated, of whom 19 with cEDS and with 12 hEDS. In total, 927 joints were assessed. Level of agreement of radiographic assessments was very high (>98%). Early hand OA was found in more than 40% of the EDS patients, with a significant higher frequency in cEDS patients compared to hEDS patients (58% vs. 17%) (p=0.032). Joint space narrowing was most frequently present and significantly more in the cEDS patients compared to hEDS patients (79% vs. 21%) (p=0.003). However, radiographic changes were found in only 10% of all finger joints. Of all fingers, thumb joints were most affected. Regarding the clinical features of hand OA, all patients showed deformity in one or more finger joints, most frequently at the thumb, especially the IP joint (both hyperflexion and hyperextension). Tenderness and bony swelling was present in 36% and 45% of all patients, respectively, whereas soft tissue swelling was less frequently observed (10% of all patients). Here, no significant differences were found between cEDS and hEDS patients. Moderate disability was present (mean (SD) AUSCAN= 45.47 (27.10) and MHQ = 65.97 (14.21). cEDS showed significant less hand pain (p=0.03), a better hand function (p=0.03) and less disability (p=0.026) than hEDS.Conclusion:This explorative study demonstrates that a high number of EDS patients present with minimal degenerative features of hand OA, but in a minority of joints. Patients with cEDS were significantly more affected, but showed a better function compared to hEDS. Possibly, cEDS patients are more susceptible to develop hand OA.References:[1]Altman R, Gold G. Atlas of individual radiographic features in osteoarthritis, revised. OARSI. 2007;15:A1-A56.Disclosure of Interests:None declared