A RARE CASE OF COLON CANCER IN A YOUNG PATIENT: A CASE REPORT AND LITERATURE REVIEW

Malignant neoplasms of the colon and rectum are often missed in patients younger than 45 years, the uncertainty of the diagnosis by the surgical team due to unavailability of clear screening guidelines in this population may be one of the reasons. The objective of this case report is to highlight the occurrence of colon cancer in a patient younger than 45 years to avoid the delay in management and the need for clear screening guidelines. Our patient, a 30 years old lady with an average risk of colon cancer demonstrated clinical symptoms and signs suggestive of partial bowel obstruction. After full radiological and laboratory investigations, she was initially diagnosed with inflammatory vs infectious cause of this obstruction. Colonoscopy showed a mass in the right hepatic flexure and sessile polyp in the transverse colon, Histopathology result showed moderately differentiated colon cancer. The patient was taken to the operation theater, right extended hemicolectomy was done, final histopathology result showed stage IIIc cancer, the patient was sent for oncology. In a conclusion, Colon cancer in patients younger than 45 years old requires a high index of suspicion by the surgeon and the managing team despite the unavailability of clear guidelines for screening at a young age.

Appendicular Tuberculosis as Manifestation of Gastrointestinal Tuberculosis: A Case Report

Introduction: Gastrointestinal tuberculosis (GI TB) is quite rare with 3% incidence of all extrapulmonary involvement. Appendicular TB may occur in 0.1 - 3% of cases. Diagnosis is often difficult because the patient usually complains about chronic abdominal pain and fever. A definite diagnosis is based on histopathological examination of resected specimens from the appendectomy procedure.Case: We present a 37-year-old male patient admitted to the hospital with chronic abdominal pain, fever, nausea, and loss of body weight. The patient never had a persistent cough, hemoptysis, or night sweating. Physical examination showed pain and muscular rigidity in the right iliac area during palpation with Blumberg's sign and Rovsing's sign positive. Abdomen ultrasound imaging showed an appendicular abscess. The patient underwent appendectomy afterwards with histopathology result showing TB. The patient was treated with first category anti-tuberculosis drugs (ATD).Discussion: Diagnosis of appendicular TB is difficult due to unspecific clinical presentations. Appendicular TB patients often complain of signs and symptoms which are similar to acute appendicitis. These conditions can delay ATD treatment because the definitive diagnosis could be made after histopathological examination.Summary: Appendicular TB is a rare case of extrapulmonary TB. It can present as acute appendicitis. The definitive diagnosis is based on the histopathological examination. It is recommended to check the appendicectomy specimens histopathologically to exclude TB or other diseases.

A Rare Case of Chronic Suppurative Appendicitis in Neonatal Presenting as Intestinal Malrotation

Neonatal appendicitis (NA) is an extremely rare acute abdomen condition, moreover, if it is a chronic suppurative one. The definite risk factor of NA is barely unknown. The signs and symptoms are often nonspecific and appear after perforation occurs. Most of the cases were found unexpectedly during surgery suspected as other diagnoses. A 7-day-old male neonate presenting lethargic and hypoglycemia since 1 st day of life. Patient drunk breast milk right after since he was born. Meconium was produced <24 h. On the 3 rd day of hospitalization, he experienced bilious vomiting and abdominal distension, so nasogastric tube was installed. Physical examination revealed decreased bowel sound. Investigation showed leucocytosis, slightly increased procalcitonin and abdominal X-ray showed that gas distribution lasted until third part of duodenum followed by minimal gas distribution in the distal part of duodenum. The patient was suspected as distal duodenum stenosis or proximal jejunum. Intraoperatively, it was found that there was second part duodenum malrotation and open Ladd’s procedure was done. During Ladd’s procedure, a perforated appendix was also found. The histopathology result revealed that it was a chronic suppurative appendicitis. Patient was discharged in good condition 20 days after surgery. NA is a rare condition with nonspecific signs and symptoms which was usually found accidentally during surgery suspected as other diagnoses.

Catastrophic Presentation of a Ruptured Pheochromocytoma

Background: Pheochromocytoma is a catecholamine-secreting tumor, encountered in less than 0.5% of patients with hypertension and around 4% of patients with adrenal incidentaloma.1 It classically presents with episodic headache, sweating, and hypertension but rarely can present with serious complications such as hypertensive, pheochromocytoma crisis, and hemorrhagic shock. Clinical Case: We report a 49-year-old male patient with a history of hypertension for five years on Amlodipine but not compliant. Presented to the Emergency Department with sudden onset left severe flank pain associated with one episode of vomiting for six hours. Vital signs were stable, and basic labs were within normal. Bedside ultrasound couldn’t appreciate any abnormality due to obesity, urinary tract CT-scan showed a large heterogeneous non-enhancing mass, possibly hematoma arising from left adrenal gland. Afterward, his condition deteriorated rapidly, he became hypotensive, and hemoglobin level dropped from 14 to 8gm/dl within a few hours. He became agitated with a worsening level of consciousness, so he was admitted under the medical intensive care unit (MICU) and required intubation and started on mechanical ventilation. Abdominal CT-angiography was done to look for any active bleeding, showed re-demonstration of the same lesion in the left adrenal without contrast enhancement or extravasation. He underwent urgent explorative laparotomy that showed ruptured large left adrenal hematoma, which was entirely evacuated with the adrenal tissue, his vital signs were maintained stable during the surgery. Postoperative course showed uncontrolled blood pressure requiring three anti-hypertensive medications; otherwise, he had gradual improvement until successful weaning, and returned to his baseline. The histopathology result was suggestive of pheochromocytoma with extensive bleeding. Conclusion: Ruptured pheochromocytoma is an extremely rare presentation of hemorrhagic shock and needs a high index of suspicion. In our patient, the lack of classical presentation and imaging features of pheochromocytoma combined with the condition rarity, made the diagnosis very challenging. Urgent surgical intervention may be warranted, and multidisciplinary perioperative preparation is the key to a favorable outcome. References: 1 Bravo EL. Pheochromocytoma: new concepts and future trends. Kidney Int. 1991 Sep;40(3):544–56. doi: 10.1038/ki.1991.244. PMID: 1787652.

Squamous cell carcinoma (SCC) of the renal pelvis following chronic nephrolithiasis; presented with feature suggesting xanthogranulomatous pyelonephritis

Background: Squamous cell carcinoma (SCC) which originated in the urothelium of the urological system is not uncommon; however, it is rare in the renal pelvis. Additionally, it is hard to be diagnosed without high clinical suspicion.Case summary: A-66-years old female presented with left loin pain for 6 years, hematuria, and fever for months. Examination revealed no abnormality apart from pallor and bimanually palpable left kidney. Her investigations showed normal renal function and anemia, Computer Topography for Kidney, Ureter, and Bladder (CT-KUB) revealed a large left renal pelvic stone with a hugely enlarged kidney with suspicion of xanthogranulomatous pyelonephritis (XGPN), with almost absent function of the left kidney in DTPA. She underwent Left trans-peritoneal radical nephrectomy. Post-operative histopathology result was moderately differentiated squamous cell carcinoma (T3, N0, M0). To our knowledge this was the first reported case in our hospital, we think that the treatment was fair putting in mind the poor prognosis of the condition and the difficulty in diagnosis.Conclusion: This case demonstrates renal pelvis SCC presented with radiological features suggestive of xanthogranulomatous pyelonephritis.

MRI-Guided Breast Biopsy-Histopathological Verification of Suspicious Breast Lesions Visible on MRI Only

Background: Breast cancer is currently the most frequently diagnosed cancer in women. While the range of modalities enabling suspicious lesions detection is wide, MRI remains the most sensitive one. Therefore, the number of methods verifying the lesions seen only on MRI images grows. The aim of this study is to check the usefulness of MRI guided breast biopsy in clinical use. Methods: The study involved 120 patients who underwent diagnostic MRI before the biopsy that revealed suspicious lesions (BI-RADS 4 and 5). Those lesions had not been seen on initial ultrasonography or mammography. In each case, a marker was placed in the biopsy site and histopathological examination of the obtained samples was performed. Results: The study revealed benign lesions in 86 patients (71.7%). The remaining 34 lesions (28.3%) were determined as malignant, including 19 noninfiltrating (15.8%) and 15 infiltrating lesions (12.5%). Study showed correlation between kinetic curve type and lesion malignancy. Breast type, BPE and enhancement type did not have impact on the histopathology result. Conclusion: Breast MRI-guided biopsy is a reliable way to verify lesions not visible on any other diagnostic imaging methods and therefore should be developed.

Biochemical and toxicological effects of methanolic extract of Asparagus africanus Lam in Sprague-Dawley rats

Asparagus africanus Lam. is a plant used traditionally to treat different ailments. Currently, scanty information is available on its safety. The aim of this study is to determine the acute toxicity of the methanolic extract on vital organs and its associated biochemical parameters. Fifteen female Sprague-Dawley rats were divided into five groups. Group I served as normal control, groups II, III, IV, and V were orally administered single dose of crude extract dissolved in distilled water at 5 mg/kg BW, 50 mg/kg BW, 300 mg/kg BW and 2,000 mg/kg BW. Rats were observed for 14 days and body weights were recorded. On day 15, the rats were sacrificed and blood samples were collected for biochemical and haematological analyses, while the liver and kidneys were sampled for histopathological examination. Body weight and haematology parameters results showed significance difference (p < 0.05) among means of HGB, RDW, RBC, and MCHC; likewise, (p < 0.001) for WBC and platelet among treated groups. Histopathology result showed that kidneys appeared normal while livers were congested with mildly swollen hepatocytes and occasional binucleation. Focal lobular hepatitis was observed in all treated animals. However, hepatic enzymes were not significantly affected and no histopathological harmful effects were observed in kidney. In conclusion, methanolic extracts of A. africanus are safe up to 2,000 mg/kg BW. The obtained results could be used as a justification for the traditional application of the plant for treatment of various ailments.

CHEK2 Mutation in Patient with Multiple Endocrine Glands Tumors. Case Report

Background: Many studies show the occurrence of several multiple endocrine neoplasia syndromes caused by different mutations, for example, in MEN1 and RET genes. Nevertheless, there are less common mutations causing multiple endocrine glands tumors. Examples of such mutations are CHEK2 gene mutations, causing breast, kidney, gastric, colorectal, prostate, lung, ovarian, and thyroid cancers. Case description: In 2005, a 30-year-old woman was admitted to the hospital due to uncontrolled hypertension and obesity. Performed tests have shown ACTH (adrenocorticotropic hormone)—independent micronodular adrenal hyperplasia (AIMAH) as a cause. In 2010, the further diagnostic analysis revealed Cushing’s disease caused by ACTH-secreting pituitary microadenoma. Additionally, in 2011, the patient underwent the strumectomy of multinodular struma. Papillary thyroid carcinoma was found in the excised tissue. In 2018, transvaginal ultrasonography revealed a tumor of the right ovary. After a performed hysterectomy with bilateral salpingo-oophorectomy, the histopathology result has shown female adnexal tumors of probable Wolffian origin (FATWO) located in the broad ligament of the uterus. Due to the history of multiglandular diseases, the patient was referred to genetic testing. We found a positive pathogenic mutation in CHEK2-suppressor gene involved in DNA repair, cell cycle arrest, and apoptosis in response to DNA damage. Conclusion: CHEK2 variants may predispose to a range of endocrine glands tumors, including those identified in our patient. Multiple endocrine glands tumors, as in the presented patient, are a serious problem of public health, due to numerous hospitalizations and necessary repeated surgical treatments. Moreover, the association between CHEK2 and ovarian cancer can be a serious problem with reproductive health.

Angiectatic nasal polyp diagnostic quandary of sinonasal malignancy

<p class="abstract">Angiectatic nasal polyp (ANP) is a rare entity of inflammatory nasal polyp accounts for only 4 to 5% of all nasal polyp.It is often misdiagnosed as a malignant neoplasm due to its aggressive clinical presentation and radiological findings mimicking a neoplastic characteristic. achieving the diagnosis of ANP can be a challenge but crucial as management and prognosis of malignant and benign sinonasal tumour differs significantly. We describe a unique case of an ANP in a 33 year old gentleman presented with left sided nasal obstruction associated with blood stained nasal discharge, facial pain and left eye epiphora. There was proptosis of the left eye and his left nasolabial fold was obliterated due to a vague left cheek swelling. Clinical presentation was highly suspicious of malignancy. CT scan finding was also suggestive of malignant tumour with surrounding bony bowing and erosions, while MRI was reported as haemangioma. Post-surgery of left endoscopic medial maxillectomy, histopathology result was negative for malignancy. After revision of specimen done and further discussions, the diagnosis of ANP was made. Patient was postoperatively well with regression of symptoms along 5 months follow-up. ANPs are relatively uncommon pseudoneoplastic lesion that can cause a significant diagnostic dilemma as illustrated in this case. awareness of distinctive radiological and histopathological findings of ANP is important to establish the diagnosis and managed accordingly. However, little is known to guide the approach in such cases, therefore we find the case report to be noteworthy in this field.</p>

EPIDEMIOLOGY STUDY OF NPC PATIENTS IN BANGLI HOSPITAL AT 2015-2017

Introduction: Nasopharyngeal carcinoma (NPC) is a malignancy of the nasopharyngeal epithelium. Nasopharyngeal carcinoma is the five positions among other malignancies. Objective: To determine the distribution of patients with nasopharyngeal cancer (NPC) in department of ENT Bangli hospital, the period during January 2015-December 2017. Material and methods: This descriptive study by collecting data from the medical record of NPC patients who come to the outpatient's clinic ENT Bangli hospital and data from the Department of Pathologic Anatomy at Bangli hospital. Results: The distribution patients with NPC was conducted from January 2015 until December 2017 there were 169 people. This research obtained the highest patients with NPC in 2016 as 67 cases. NPC based on sex in 2015 is males as 27 cases (58.70%), in 2016 is males as 43 cases (64.18%) and 2017 is males as 36 cases (64.29%). NPC based on age group is 41-50 years that in 2015 as 16 cases (34.70%), in 2016 as 27 cases (40.30%) and by age group 51-60 years in 2017 as 23 cases (41.07%). NPC patients based on stage most in stage III in 2015 as 18 cases (39.13%), in 2016 as 24 cases (35.82%) and in 2017 as 16 cases (28.57 %). NPC patients based on sex was found in stage III were males in 2015 as 14 cases, in 2016 as 16 cases and 2017 as 12 cases. NPC patients based on histopathology result at most on the WHO-3 classification, in 2015 as 44 (95.65%), in 2016 as 62 cases (92.54%) and in 2017 as 53 cases (94.64%). Conclusion: Distribution of patients with NPC in Bangli hospital from January 2015 until the highest December 2017 were 169 people. This research obtained the highest population of NPC in 2016 as 67 cases. NPC based on sex in 2016 is male as 64.18%. NPC most found by age group in 41-50 years in 2016 as 40.30%. NPC based on stage most found in stage III, in 2016 as 35.82%. NPC based on sex most found in stage III in 2016 as 16 cases. NPC based on histopathology result is WHO-3 in 2016 as 92.54%.