Prevalence of Incidental Radiopacities in Panoramic Radiographs

Routine panoramic radiographs often reveal hidden lesions other than those related to the patient's chief complaint [1]. The study aims to determine the prevalence of incidental radiopacities in panoramic views. There are several conditions where calcifications can occur in soft tissue, including major and minor salivary glands, lymph nodes, and blood vessels, such as sialolith, phlebolith, exostosis, dystrophic calcifications, etc. [2]. Interpretation of panoramic radiograph should consider the possibilities of soft tissue calcification super-imposed in bone. Three hundred and sixty (360) panoramic radiographs are included in the study. The prevalence and distribution of radiopacities were documented along with the probable diagnosis. In addition, statistical analysis was done by SPSS software to evaluate the age and gender-related distribution of radiopacities in panoramic radiographs.

Discrimination of MSA-P and MSA-C by RT-QuIC analysis of olfactory mucosa: the first assessment of assay reproducibility between two specialized laboratories

Background Detection of the pathological and disease-associated alpha-synuclein (αSynD) in the brain is required to formulate the definitive diagnosis of multiple system atrophy (MSA) and Parkinson’s disease (PD). We recently showed that αSynD can be detected in the olfactory mucosa (OM) of MSA and PD patients. For this reason, we have performed the first interlaboratory study based on α-synuclein Real-Time Quaking-Induced Conversion (αSyn_RT-QuIC) analysis of OM samples collected from PD and MSA patients with the parkinsonian (MSA-P) and cerebellar (MSA-C) phenotypes. Methods OM samples were prospectively collected from patients with a probable diagnosis of MSA-P (n = 20, mean disease duration 4.4 years), MSA-C (n = 10, mean disease duration 4 years), PD (n = 13, mean disease duration 8 years), and healthy control subjects (HS) (n = 11). Each sample was analyzed by αSyn_RT-QuIC in two independent specialized laboratories, one located in Italy (ITA-lab) and one located in the USA (USA-lab). Both laboratories have developed and used harmonized αSyn_RT-QuIC analytical procedures. Results were correlated with demographic and clinical data. Results The αSyn_RT-QuIC analysis reached a 96% interrater agreement of results (IAR) between laboratories (Kappa = 0.93, 95% CI 0.83–1.00). In particular, αSyn_RT-QuIC seeding activity was found in the OM of 9/13 patients with PD (sensitivity 69%, IAR 100%) and 18/20 patients with MSA-P (sensitivity 90%, IAR 100%). Interestingly, samples collected from patients with MSA-C did not induce αSyn_RT-QuIC seeding activity, except for one subject in USA-lab. Therefore, we found that MSA-P and MSA-C induced opposite effects. Regardless of disease diagnosis, the αSyn_RT-QuIC seeding activity correlated with some clinical parameters, including the rigidity and postural instability. Conclusions Our study provides evidence that OM-αSynD may serve as a novel biomarker for accurate clinical diagnoses of PD, MSA-P, and MSA-C. Moreover, αSyn_RT-QuIC represents a reliable assay that can distinguish patients with MSA-P from those with MSA-C, and may lead to significant advancements in patients stratification and selection for emerging pharmacological treatments and clinical trials.

Cerebral autosomo-dominant arteriopathy with subcortical infarctions and leukoencephalopathy

The article presents an analysis of the literature and a clinical case of a rare disease from the group of diseases of small vessels — cerebral autosomal dominant arteriopathy with subcortical infarction and leukoencephalopathy (CADASIL).It is based on the deposition of osmiophilic granulation material in vessels of small and medium caliber. A mutation in the NOTCH3 gene on chromosome 19p13 leads to significant structural changes in the walls of small arteries due to impaired differentiation and maturation of smooth muscle cells.CADASIL is characterized by four key symptoms: migraines, recurrent ischemic strokes, mental disorders, and cognitive decline. The clinical case study is presented from the standpoint of a multidisciplinary patient-oriented approach of joint work of neurologists and morphologists. On the basis of clinical and laboratory criteria, a probable diagnosis was made. To confirm it, a muscle biopsy was performed (a musculocutaneous flap from the inner surface of the thighs and forearms), in order to conduct light and electron microscopy. The details of the results of the morphological study, which made it possible to verify the patient’s diagnosis, are presented. Differential diagnostic judgments are presented and recommendations for genetic studies in the family, prognosis and treatment of the patient are given.

Algoneurodystrophy in a Patient with Major Depressive Disorder

Introduction. Not infrequently, in patients with a psychiatric illness who have concomitant physical symptoms, these symptoms are often wrongly attributed to a psychiatric illness. Consequently, there is a delay in establishing the correct diagnosis, which may have an impact on the prognosis of the disease. The authors aim to present a case report of a patient with a diagnosis of major depressive disorder and conversion disorder that was later correctly diagnosed with algoneurodystrophy. The authors intend to draw attention to the importance of a careful medical history and this entity. Case Presentation. A patient went to the emergency department multiple times with complaints of decreased strength and pain in the right upper limb, concomitantly with depressive symptoms. The patient was first diagnosed with conversion disorder and major depressive disorder. After the worsening of the clinical condition with the appearance of neuropathic pain and the exclusion of other organic pathologies, the probable diagnosis of algoneurodystrophy was made. At that time, the patient started treatment and a favorable clinical evolution was observed. Discussion. The clinical case highlights the importance of conducting a careful medical history in a patient with a psychiatric illness, so as not to mistakenly exclude the presence of an organic disease. The absence or delay in making a correct diagnosis can have adverse consequences in terms of the prognosis of the disease.

EP.TH.104An interesting case of Post-ITU delirium

A 75-year old golf-player underwent an open radical cystectomy for a grade 3 bladder carcinoma. His medical history was unremarkable. Post-operatively, he was admitted to the ITU for observation and transferred to the ward after 3 days. On the 5th day post-op, he developed sudden SOB, tachypnoea and hypotension. Blood gas analysis revealed T1 respiratory failure and lactate of 3.3. He was commenced on anticoagulants and a CTPA incidentally found multiple small pulmonary emboli- suspected to be chronic. He developed severe HAP and was transferred back to ITU. 10 days later after improvement he was stepped down. His oral intake had significantly reduced and his urine output was low. He was alert but ward nurses found him to be vacant and significantly confused after his second step down. A CXR was unremarkable. He reported hallucinations and was struggling with his memory. A week later, he was transferred to a community hospital for rehabilitation as his delirium was improving. In the community, he experienced ongoing confusion and hallucinations. Nurses noted hematochezia and jaundice and he was re-admitted with abdominal pain and pyrexia. His LFTs were severely deranged and he was initiated on antibiotics for possible cholangitis. USS abdomen, CT and MRCP revealed no obvious cause of obstruction. A probable diagnosis of viral hepatitis was made by the Gastroenterologist which spontaneously resolved. CT head for confusion screen revealed right frontal lobe ischaemia with severe gliosis- possibly post-operative. The psychiatric team reviewed the patient and he was diagnosed with post-ITU delirium.

Pediatric Small Round Blue Cell Tumors: Cytopathological Puzzle or an Intriguing Scientific Window?

<b><i>Background:</i></b> Small round blue cell tumors or more commonly called small round cell tumors (SRCTs) are undifferentiated neoplasms, sharing an overlapping morphological pattern of small round blue cells. Diagnosing these tumors represents a complex challenge for cytopathologists and for general surgical pathologist alike. This stems from the fact that these tumors share not only similar morphological features, but also some immunophenotypic characteristics, thus requiring a broad panel of antibodies, which might not be included in the most basic immunohistochemistry panels, used in the routine work of most pathology laboratories. Furthermore, one should note that the diagnosis, prognosis, and/or therapeutic decision are often dependent on the knowledge of the existence of specific molecular alterations, which requires access to sophisticated molecular ancillary techniques. Cytological diagnosis of SRCT should be systematized. A thorough understanding of the morphological pattern of these tumors, the small details they entail, the background and cellular patterns, and the nuclear and cytoplasmic peculiarities, may hint to the most probable diagnosis. Minor clues, such as the presence of a fibrillar background, the presence of rosettes or a specific “salt and pepper” chromatin, are important clues toward a probable diagnosis of a neuroblastoma, or the presence of a tigroid background is a characteristic of rhabdomyosarcoma and the Ewing family tumors. However, in poorly differentiated tumors, morphology alone will not suffice, making it essential for the access to complementary diagnostic techniques in order to reach the final diagnosis. <b><i>Summary and Key Messages:</i></b> The cytological diagnosis and treatment of SRCTs require an experienced, well-articulated, proficient teamwork, and sophisticated complementary diagnostic techniques, only available in centers of reference.

The value of transbronchial lung biopsy in the diagnosis of lymphangioleiomyomatosis

Background Transbronchial lung biopsy (TBLB) in the diagnosis of lymphangioleiomyomatosis (LAM) is not a common approach, although TBLB is often performed in diffuse lung diseases. We aimed to examine the diagnostic value and safety of TBLB in LAM patients based on the data collected in our center. Methods We reviewed LAM patients registered in our LAM Clinic from December 8, 2006, to December 31, 2019. All patients with definite or probable diagnosis of LAM who had been examined using TBLB were included. All available pathology slides were reviewed by an experienced LAM pathologist. All complications were reviewed by the medical records and confirmed using telephone interviews. Results The pathology results of 86 patients (including 74 definite LAM and 12 probable LAM) were available. The positive rate of TBLB in LAM patients was 49/86 (57.0%). The positive rates of SMA, HMB-45, ER, and PR in LAM patients were 97.6%, 93%, 84.6%, and 78.4% respectively. The positive rate of TBLB was 40%, 60% and 60.8% in patients with CT Grade I, Grade II, and Grade III respectively, and the difference was not significant. Patients who had 3–4 or 5–6 biopsied specimens had a higher rate of diagnosis than those with 1–2 biopsied specimens. Four patients (5.6%) reported pneumothorax. No major hemoptysis was reported. Conclusions TBLB is a feasible and safe procedure for obtaining a pathological diagnosis of LAM. Taking more than 2 samples during the biopsy procedure increased the rate of diagnosis.

Platypnoea–orthodeoxia syndrome after percutaneous treatment of ruptured sinus Valsalva complicated by SARS-Cov-2 pneumonia: a case report

Background Rupture of sinus of Valsalva (RSV) to right atrium (RA) causes significant left to right shunt, tricuspid regurgitation, and right ventricular failure. If left uncorrected it can lead to biventricular heart failure. Hence, early invasive management is advised. To date, there is no report about platypnoea–orthodeoxia syndrome (POS) after device closure of ruptured sinus of Valsalva. Case summary A 50-year-old woman with dyspnoea of exertion and rupture of sinus valsalva to right atrium was referred to our hospital. On admission, chest computed tomography (CT) was normal. After closure of the rupture, she developed orthostatic hypoxemia and frequent cough. A repeat chest CT was suggestive of COVID-19 infection which most probably occurred during the hospitalization. Although COVID-19 was thought to be the only culprit, her symptoms were not solely justified by COVID-19. Transthoracic echocardiography showed patent foramen ovale (PFO) with significant shunt. PFO device closure was performed under intracardiac echocardiography guidance. Discussion Interatrial septum deformation may happen after RSV correction and right to left shunt from PFO may become more significant. POS is an important indication for PFO closure which should be noticed by careful examination. As COVID-19 is the most frequent pathology these days, it may delay other probable diagnosis, and hence detailed history taking and physical examination is mandatory.

The piriformis abscess: a case-based review

This study reports a 43 years-old man diagnosed with piriformis pyomyositis. A literature review was conducted by searching MEDLINE via Pubmed for English language case reports, published from 8 th December 2019 to 20th January 2020. Patients' symptoms, laboratory tests, imaging, treatment, and other comorbidities were evaluated. Thirty-two cases diagnosed with piriformis pyomyositis, of which 21 patients developed piriformis abscess (including one new patient added by us) of which 52.4% were female, and the mean age was 26.98 ± 17.5. The most common manifestations were fever, lower back pain, and limited ambulation with increased ESR, CRP, or leukocytosis. Staphylococcus aureus was the most prevalent (57.14%) pathogen isolated. The authors suggested gynecologic manipulations, muscle overuse, and other co-infections as probable risk factors. However, we fail to find any association between these factors and abscess formation (p>0.05). Piriformis abscess should be regarded as a probable diagnosis in patients with gluteal pain, fever, and limited ambulation that have raised inflammatory markers or leukocytosis. MRI and CT scans are beneficial in diagnosing pyomyositis in early-stage. Full recovery is expected with timely antibiotic and surgical treatments.

Relationship Between Preoperative Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios in the Probable Diagnosis of Malignant or Borderline Ovarian Tumors

Background: The purpose of this study was to investigate whether neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) can be supplementary tools to differentiate benign, borderline, and malignant ovarian tumors.Methods: This retrospective study reviewed the postoperative histopathology in patients with ovarian tumors (220 benign, 59 borderline, and 228 malignant). White blood cell, platelet, neutrophil and lymphocyte counts, percentage of neutrophils and lymphocytes, calculated NLR and PLR were analyzed between groups using complete blood count tests performed before surgery. Results: The platelet count and PLR in borderline ovarian tumors tended to be statistically close to benign ovarian tumors, while the neutrophil and lymphocyte count, NLR tended to be statistically close to malignancy. The diagnostic cut-off value of NLR for differentiating between benign and borderline was 2.42, PLR for differentiating between borderline and malignancy was 140.96. When the NLR was 2.4 or higher, the odds ratio of borderline or malignant risk was 3.264. In the case of PLR, 140 or higher, the odds ratio of malignancy was 1.916. When both PLR and NLR were above each cut-off, the sensitivity of malignancy diagnosis was 51.5%, specificity was 77.0%. Conclusions: In the case of borderline ovarian tumors, the NLR was higher than benign and similarly tend to malignancy, but the PLR was lower than malignancy and similarly tend to benign. We suggest that the NLR and PLR can be used as a supplementary tool for diagnosing benign, borderline, and malignant ovarian tumors in addition to imaging diagnosis and tumor markers such as CA125.