78 A Lockdown Dilemma; Ingestion of Magnetic Beads Presenting as Right Iliac Fossa Pain and Sub-Acute Small Bowel Obstruction

A 13-year-old girl presented with a three-day history of migratory right iliac fossa pain. Observations and inflammatory markers were normal, and an ultrasound scan was inconclusive. A provisional diagnosis of non-specific abdominal pain or early appendicitis was made, and she was discharged with safety netting advice. She represented six days later with ongoing abdominal pain now associated with multiple episodes of vomiting; hence, the decision was made to proceed to diagnostic laparoscopy rather than a magnetic resonance scan for further assessment as recommended by the radiology department. Intra-operative findings revealed 200mls of serous fluid in the pelvis, normal-looking appendix, dilated stomach, and a tangle of small bowel loops. Blunt and careful dissection revealed fistulous tracts that magnetized the laparoscopic instruments. A mini-laparotomy was performed with the extraction of fourteen magnetic beads and the repair of nine enterotomies. Foreign body ingestion is a known cause of abdominal pain, which in some cases might mimic or even be the cause of acute appendicitis. This case highlights the importance of careful history taking in children presenting with acute abdominal pain of doubtful aetiology.

Unilateral leg swelling in a newborn

A female neonate was born with asymmetric lower limbs, the right leg appearing enlarged, with thickened, reddish-purple skin and ectasic superficial reticulum (figure 1A,B). Limb pulses were present and symmetrical. The girl’s family history and prenatal scans were unremarkable. Laboratory findings were within the normal range, except for a mild thrombocytopenia (90 000/μL), which spontaneously resolved during the next few days. A leg X-ray and the Doppler analysis ruled out the presence of calcifications and venous varices, respectively. Ultrasound showed significant skin thickening, with marked dermal hypertrophy and hyperechogenicity. Magnetic resonance showed circumferential thickening of the derma, with mild hypertrophy of some perforating vessels (figure 2). A biopsy of the right thigh showed capillary malformations on histology.Figure 1(A, B) Hypertrophy of the right lower limb, with large capillary malformation extending to the gluteus and the external genitalia.Figure 2Axial THRIVE magnetic resonance scan of the thighs’ proximal third, showing circumferential dermal thickening and inhomogeneity of the right leg’s subcutaneous tissue.QuestionsBased on the clinical picture and investigations results, which is the most likely diagnosis?Beckwith-WiedemannCLOVES syndromeKlippel-Trenaunay syndromeKaposiform hemangioendotheliomaHow can the diagnosis be confirmed?CT with PETLymphoscintigraphyGenetic testingNone of the above, the diagnosis is clinicalWhat is the mainstay of management?Conservative with follow-upPharmacotherapySclerotherapySurgeryWhich of the following complications can occur?ScoliosisGlaucomaUrinary and gastrointestinal bleedingAll of the aboveAnswers can be found on page 02.

Lockdown dilemma: ingestion of magnetic beads presenting as right iliac fossa pain and subacute small bowel obstruction

A 13-year-old girl presented with a 3-day history of migratory right iliac fossa pain. Observations and inflammatory markers were normal, and an ultrasound scan was inconclusive. A provisional diagnosis of non-specific abdominal pain or early appendicitis was made, and she was discharged with safety netting advice. She presented again 6 days later with ongoing abdominal pain now associated with multiple episodes of vomiting; hence, the decision was made to proceed to diagnostic laparoscopy rather than a magnetic resonance scan for further assessment. Intraoperative findings revealed 200 mL of serous fluid in the pelvis, normal-looking appendix, dilated stomach and a tangle of small bowel loops. Blunt and careful dissection revealed fistulous tracts that magnetised the laparoscopic instruments. A minilaparotomy was performed with the extraction of 14 magnetic beads and the repair of nine enterotomies. This case highlights the importance of careful history taking in children presenting with acute abdominal pain of doubtful aetiology.

Diastolic and systolic function of diabetic cardiomyopathy are affected by diffuse myocardial fibrosis: a cardiac MRI study

Background Increased myocardial extracellular volume (ECV) likely is suggested to be of importance for cardiac function in type 2 diabetes (T2DM). Purpose We analysed the effect of increasing ECV on cardiac myocardial structure and function and association to typical complications related to diabetes Methods 296 patients (pt.) with T2DM and 25 controls were recruited. Cardiac magnetic resonance scan with adenosine stress and gadolinium was performed. Left ventricle (LV) diastolic function was evaluated by echo Doppler. Results 246 pt. scan and all control scans were available for analysis. ECV was significantly different between pts. and controls (29.5±3.3 vs 26.1±1.5, P<0.001). Pts. were grouped in ECV percentiles: ≤25, 25–75, and ≥75. Pts. with ECV in the highest percentile had lowered LV ejection fraction (LVEF) and increased LV end-diastolic (EDV) and end-systolic (ESV) volumes, and left atrial (LA) maximal volume. No difference was found on LV mass. With increasing ECV a lowered LV myocardial perfusion index (MPRI) and an increased prevalence of albuminuria, retinopathy, and autonomic neuropathy was found. Of interest, with increasing ECV lateral as well as septal e' were lowered and the E/e' increased. Conclusions In combination with lowered myocardial perfusion but independently of myocardial hypertrophy, myocardial interstitial diffuse fibrosis is related to the diastolic dysfunction of diabetic cardiomyopathy. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): NSR hospital, Denmark and the Danish Heart Foundation

A Rare Case of Heterotopic Ossification of the Patella Tendon in an Adolescent Presenting with Tendon Rupture

Heterotopic ossification is the abnormal formation of mature, lamellar bone in nonosseous tissue such as tendons, ligaments, muscles, and soft tissue. We discuss a rare case of a young adolescent with patellar tendon rupture postheterotopic ossification. A 13-year-old male presented to us with knee pain and inability to extend for 6 weeks following trivial trauma. Preliminary radiological investigations revealed a high riding patella with ossification in the patella tendon. The magnetic resonance scan confirmed the same with patellar tendon disruption and heterogeneous ossification. He underwent surgery with patella tendon repair, augmentation with autograft, and had complete recovery at 6 months' follow-up.

Ventral holocord spinal epidural abscess managed surgically in a critical setting

Background: Extensive epidural abscess is an uncommon entity which is increasing in the aging population. Its prevalence is also greater among those with diabetes mellitus and in those who are immunocompromised. Here, a 59-year-old female presented with a spinal epidural abscess (SEA) warranting operative intervention. Case Description: A 59-year-old female with a history of diabetes and hypertension, presented with the acute onset of a high-grade fever, generalized back pain, and an evolving quadriparesis. Preliminary laboratory studies revealed elevated inflammatory markers. The magnetic resonance scan showed a ventral epidural abscess extending from C1-2 to the L5 level. She underwent urgent surgical decompression using a Nelaton catheter placed through an L4-L5 hemilaminectomy and threaded cephalad (40 cm); this resulted in a complete recovery. Conclusion: This case study underscores a unique way of managing an anterior holospinal SEA extending from the C1-2 through the L5 spinal levels.

Establishment and Imaging Studies of Human Lung Cancer-Associated Brain Metastasis Animal Models

Background: Lung cancer is one of the malignant tumors with fast increase in morbidity and mortality, and great threat to human health and life. Methods: Animal models (n = 5) were performed by injecting 1 × 106 A549 cells in 0.1 mL phosphate buffer saline into nude mice through the left ventricle. Body weight of animals was measured every 3 days, and changes in the appearance and behavior were observed. Brain magnetic resonance imaging of 5 animals were performed using T1, T1 enhancement and T2 scan at the 4th, 6th, and 7th weeks after injected with tumor cells. Animals (n = 5) were sacrificed after the last magnetic resonance scan, and brain slices of the animals were prepared to conduct hematoxylin-eosin staining. Results: At the 4th weeks after inoculation of tumor cells, there was no obvious change in the appearance and behavior of animals and there were no obvious tumor metastases in the brains from brain magnetic resonance scan. At the 6th weeks, body weight of all animals (n = 5), one of which appeared paralysis in hind limb, decreased obviously, and results from MR scans showed there were tumor metastases in the brains of all animals. Results from brain magnetic resonance scan images of one animal at 4th, 6th, and 7th weeks showed tumor metastases appeared in the animal's brain and gradually grew bigger. Result from hematoxylin-eosin staining of brain slices showed multiple tumor metastases, consistent with the results of magnetic resonance imaging. Conclusions: Human lung cancer-associated brain metastasis animal models was successfully established, and micro-magnetic resonance imaging is a sensitive, accurate and non-invasive method for the detection of lung cancer brain metastases in mice through this study.

Placental chorioangioma associated with polyhydramnios and hydrops fetalis

A 27-year-old multigravida woman was noted on routine growth scan at 27 weeks gestation to have a central placental hypoechoic area measuring 6.7×6.0×4.4 cm. A subsequent magnetic resonance scan confirmed a solid mass in the placenta lying anteriorly; therefore, a preliminary diagnosis of giant placental chorioangioma was made. A repeat ultrasound scan at 30 weeks gestation indicated that the mass had increased, with the presence of polyhydramnios. The patient experienced reduced fetal movements at 31 weeks gestation. There was persistent fetal tachycardia at 33 weeks gestation, and consequently the neonate was delivered by emergency caesarean section. The placenta revealed a large chorioangioma. The neonate’s birth weight was 2.85 kg and non-immune hydrops fetalis was diagnosed. The neonate improved significantly in the neonatal intensive care unit and is currently well with no medical problems.

The use of Apixaban for the treatment of an LV thrombus

Summary A 42-year-old male was admitted with shortness of breath secondary to suspected heart failure and chest infection. An echocardiogram revealed a dilated and impaired left ventricle; ejection fraction 29%, with a large, mobile thrombus within the left ventricular apex. Due to the presence of liver dysfunction, vitamin K antagonists were deemed inappropriate; thus, the decision was taken to use the novel anticoagulation agent Apixaban. After 6 days of receiving Apixaban, a cardiac magnetic resonance scan was preformed, which showed complete resolution of the LV apical thrombus. Learning points: Patients with a dilated and impaired LV are at an increased risk of developing LV thrombus. A large and mobile LV thrombus is associated with an increased risk of embolic events. Vitamin K antagonists (VKAs) are often the first-line therapy for LV thrombus; however, these may be inappropriate in some patients. NOACs are advantageous in comparison to VKAs and are used to treat: non-valvular atrial fibrillation, pulmonary embolisms and used in the prevention of recurrent deep vein thrombosis in adults. To date, NOACs are not licensed for the treatment of an LV thrombus; however, there are growing evidence whereby there use has shown promise in reducing the risk of embolic events and demonstrate rapid reduction in size/full resolution of an LV thrombus. Large, randomised research trials comparing NOACs and VKAs in the treatment of LV thrombus are needed, which may lead to a change in standard clinical practice that could benefit patients.