Tuberculous sacroiliitis: a case report

<p class="abstract">In 1-5% of cases of the infections of the musculoskeletal system are tuberculous. The sacroiliac joint (SI) shows involvement in 3-9.7%. Here, we describe the unique case of a 19-year-old female who presented with pain in the left buttock and low backache. Three months prior, the patient was diagnosed with pulmonary tuberculosis. The patient was started on anti-tuberculosis drugs (ATT) for three months. The pain increased on weight-bearing and on squatting, and it decreased with rest. X-ray and MRI were suggestive of Sacroiliitis secondary to tuberculosis. Now, after conservative management, the patient is symptom-free with no functional limitation. This case report focuses on the importance of continued awareness for early detection and treatment of a tuberculous sacroiliac joint infection.</p>

A Transposition Flap Reconstruction after Resection of a Soft-Tissue Sarcoma in the Buttock

Introduction:Large defects following resection in the gluteal region are challenging. Of note, there are a limited number of fairly morbid options for reconstruction. Case Report:A 65-year-old female presented with complaints of an enlarging mass in the left buttock over the past several months. A high-grade sarcoma was diagnosed based on a biopsy. The final diagnosis was an undifferentiated pleomorphic sarcoma based on the resected tumor. An 11-cm tumor with surrounding tissues, including the great gluteal muscle, was resected, which resulted in a 17-cm full thickness defect. The defect was reconstructed with a transposition flap elevated from the lateral thorax. A transposition flap can cover large buttock defects without sacrificing other muscles. Conclusion:Moreover, a transposition flap is esthetically acceptable because most of the operative scar is within the buttock area. A transposition flap reconstruction is one of the several options for large defects after soft-tissue sarcoma resection in the buttock. Keywords:Buttock, resection, reconstruction, musculocutaneous flap, soft-tissue sarcoma.

Pain Changes Induced by Acupuncture in Single Body Areas in Fibromyalgia Syndrome: Results from an Open-Label Pragmatic Study

To date, there is considerable evidence of the effectiveness of acupuncture in fibromyalgia syndrome (FM). However, it is not known in which body areas acupuncture is more effective. The objective of this study was to assess the improvements of pain induced by acupuncture in single body areas in patients with FM. In this open-label pragmatic study, FM patients in a state of high disease severity were consecutively enrolled and treated with a course of 8 weekly sessions of manual acupuncture. Patients were assessed with the Self-Administered Pain Scale (SAPS) of the Fibromyalgia Assessment Status at baseline and at the end of eight acupuncture sessions. Acupuncture sessions were all conducted with the same acupuncture formula (LV3, SP6, ST36, LI4, CV6, CV12, Ex-HN-3, and GV20) in each session and in each patient. Ninety-six FM patients completed the course of treatment. All the 16 body areas assessed by SAPS showed improvement in pain. A statistically significant improvement was achieved in 12 of the 16 body areas investigated, with the best results in abdomen and forearms ( p = 0.001 ), while the worst results were registered for neck ( p = 0.058 ), chest ( p = 0.059 ), left buttock ( p = 0.065 ), and right thigh ( p = 0.052 ). The treatment has also shown significant effectiveness in improving fatigue and sleep quality ( p < 0.0001 ). Acupuncture has a beneficial effect on pain in all body areas in FM patients with high disease severity, with the greatest effects in the abdominal region and in the forearms, allowing a personalization of the treatment.

Delayed diagnosis of a piriformis abscess due to hyposkillia and communication error

A 69-year-old man with dementia presented to our hospital with fever and left back pain. He was diagnosed with acute pyelonephritis based on microscopy and CT findings indicating bacteriuria and elevated fat density around the right kidney, respectively. Three days post admission, the diagnosis of a urinary tract infection was queried and the patient was re-examined. Marked tenderness was observed in the left buttock; contrast CT scan was subsequently performed and a left piriformis abscess was diagnosed. This diagnostic delay occurred due to a communication error—the referral letter to the radiologist stated ‘fever and back pain’—and the physician’s hyposkillia; hence, differential diagnoses were not considered. Physicians can reduce the frequency of related errors by conducting proper physical examinations and not relying on imaging findings alone. Furthermore, to ensure accurate diagnoses, the comments to the radiologist should be clear and detailed when requesting diagnostic imaging.

GFAP-Negative Subcutaneous Sacrococcygeal Extraspinal Ependymoma

Ependymomas are slowly growing glial tumors derived from the ependymal cells and usually occur in the central nervous system (CNS). Ependymomas rarely occur outside of the CNS and they are called extraspinal ependymomas. In spite of their metastatic potential, extraspinal ependymomas can be misdiagnosed for other benign mass like pilonidal cysts. The diagnosis is confirmed by histopathology and most of the cases are known to show glial fibrillary acidic protein (GFAP), S-100 protein, and keratin (AE1AE3) immunoreactivity. Herein, we present a case of GFAP-negative ependymoma, which presented as asymptomatic subcutaneous tumor of the left buttock and was clinically misdiagnosed as epidermal cyst. Our case indicates that ependymomas cannot be ruled out by lack of GFAP immunoreactivity and an asymptomatic subcutaneous mass could be a malignant tumor like ependymomas, which requires careful examinations.

Aggressive angiomyxoma of left buttock

Aggressive angiomyxoma (AA) is a rare mesenchymal tumour that is characterised by increased incidence in women compared with men, local invasion to the surrounding tissue and high recurrence rate. A premenopausal woman presented to clinic with pelvic pressure, intermittent tingling in the thigh and pressure emptying the bladder. CT scan, vaginal and gluteal biopsies, and MRI scan were performed to conclude a final diagnosis of AA. The patient underwent complete resection of the mass. The mass tested positive for oestrogen receptor and progesterone receptor. The patient received leuprolide postoperatively to prevent recurrence. AA should be considered as a differential diagnosis for a pelvic and perineal mass. Patients should be warned of high recurrence rate, necessity of surgical removal and long-term hormonal treatment.

Germinal GLT8D1, GATAD2A and SLC25A39 mutations in a patient with a glomangiopericytal tumor and five different sarcomas over a 10-year period

Soft tissue sarcoma represents about 1% of all adult cancers. Occurrence of multiple sarcomas in a same individual cannot be fortuitous. A 72-year-old patient had between 2007 and 2016 a glomangiopericytal tumor of the right forearm and a succession of sarcomas of the extremities: a leiomyosarcoma of the left buttock, a myxofibrosarcoma (MFS) of the right forearm, a MFS of the left scapula, a left latero-thoracic MFS and two undifferentiated sarcomas on the left forearm. Pathological examination of the six locations was not in favor of disease with local/distant recurrences but could not confirm different diseases. An extensive molecular analysis including DNA-array, RNA-sequencing and DNA-Sanger-sequencing, was thus performed to determine the link between them. The genomic profile of the glomangiopericytal tumor and the six sarcomas revealed that five sarcomas were different diseases and one was the local recurrence of the glomangiopericytal tumor. While the chromosomal alterations in the six tumors were different, a common somatic CDKN2A/CDKN2B deletion was identified. RNA-sequencing of five tumors identified mutations in GLT8D1, GATAD2A and SLC25A39 in all samples. The germline origin of these mutations was confirmed by Sanger-sequencing. Innovative molecular analysis methods have made possible a better understanding of the complex tumorigenesis of multiple sarcomas.

Germinal GLT8D1, GATAD2A and SLC25A39 mutations in a patient with a glomangiopericytal tumor and five different sarcomas over a 10-year period

Soft tissue sarcoma represents about 1% of all adult cancers. Occurrence of multiple sarcomas in a same individual cannot be fortuitous. A 72-year-old patient had between 2007 and 2016 a glomangiopericytal tumor of the right forearm and a succession of sarcomas of the extremities: a leiomyosarcoma of the left buttock, a myxofibrosarcoma (MFS) of the right forearm, an MFS of the left scapula, a left latero-thoracic MFS and two undifferentiated sarcomas on the left forearm. Pathological examination of the six locations was not in favor of disease with local/distant recurrences but could not confirm different diseases. An extensive molecular analysis including DNA-array, RNA-sequencing and DNA-Sanger-sequencing, was thus performed to determine the link between them. The genomic profile of the glomangiopericytal tumor and the six sarcomas revealed that five sarcomas were different diseases and one was the local recurrence of the glomangiopericytal tumor. While the chromosomal alterations in the six tumors were different, a common somatic CDKN2A/CDKN2B deletion was identified. RNA-sequencing of five tumors identified mutations in GLT8D1, GATAD2A and SLC25A39 in all samples. The germline origin of these mutations was confirmed by Sanger-sequencing. Innovative molecular analysis methods have made possible a better understanding of the complex tumorigenesis of multiple sarcomas.

Posture, movement, and aircraft passengers: An investigation into factors influencing in-flight discomfort

BACKGROUND: Aircraft passengers’ physical activity levels are often limited during flight for extended periods of time, which can have serious impact on health, comfort, and passenger experience. However, several factors, such as limited personal space and social factors, can make movement difficult. OBJECTIVE: The study aimed to identify participant behaviour and postures during medium to long-haul flights and their effect on location and severity of physical discomfort. This work investigated how aircraft passengers’ comfort ratings changed over time and explored the association between postures and comfort ratings during flight. The study also explored the association between performing in-flight exercises and factors limiting participants’ abilities to complete these exercises. METHOD: Twenty-nine participants sat in an aircraft simulated cabin for 180 minutes and periodically performed in-seat exercises. They also completed a questionnaire providing data on demographic information, self-reported discomfort scores for multiple areas of the body, which types of exercises participants performed, and qualitative comments about discomfort. Self-reported comfort ratings were measured at 20 min intervals and posture identification was conducted by analysing the video recordings. RESULTS: Six postures were identified, and it was observed that individual participants changed posture at least once and up to nine times during the three-hour period. Body part areas with the highest reported scores of discomfort ratings were: back of the neck, back-left shoulder, back-right shoulder, back-left buttock, and lower back. Participants reported that they had difficulty in performing recommended in-flight exercises due to limited space. CONCLUSIONS: Limited space in aircraft seating restricts passenger movement. Some body areas are more prone to discomfort.

Giant idiopathic pyoderma gangrenosum at an unusual site with highly elevated c-ANCA levels: A rare association

Pyoderma gangrenosum (PG) is a rare neutrophilic disorder with an incidence rate of 3–10 cases per million per year, characterized by classically painful and aseptic ulcers, which may be associated with underlying systemic diseases. The pathergy reaction is seen in one-fourth of patients with PG. Accurate and timely diagnosis is crucial, as PG is known for its rapid progression. The management of PG is challenging and depends on its severity and rate of progression. An underlying systemic involvement should be sought even in spite of no symptoms. Herein, we report a case of giant pyoderma gangrenosum involving almost the entire left buttock with exceptionally raised c-ANCA levels, but no underlying systemic abnormality. The patient reported intense pain, rapid progression of the ulcers, an inability to perform daily activities, was significantly morbid and pathergy-positive. Aggressive and early management is required in cases such as this. A dramatic response was achieved with a combination of cyclosporine, dapsone, and methylprednisolone pulses.