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Wednesday 28 December 2016

CASE 410: SOLITARY PULMONARY NODULE (SPN), Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM






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Man  66yo  diabetic, former smoking patient. Chest X-ray  is  nothing  abnormal detected.
CT total body  non CE   detected  one SPN which has size of  0.94 cm at  the left lung ( cT1, CT3).  CTCE  with dynamic scan  showed CE  rise from 14 HU to 74 HU.
Blood tests =  CYFRA 21-9,09  and  WAKO TEST  AFP=3.9;   AFP L3=19.3; DCP =25) another cancer markers  are normal.

What is your  suggestion for diagnostic and  therapy?
Operation thoracoscopy lobectomy, this tumor is hard and black central, tumor size  smaller than 1 cm.


Microscopic report is adenocarcinoma moderate differentiated.

REFERENCES:
NEjM 2006:355:1761.71





Sunday 25 December 2016

CASE 409: ECTOPIC FASCIOLIASIS, LÊ ĐÌNH VĨNH PHÚC, PHẠM CHÍ TOÀN, VÕ NGUYỄN THÀNH NHÂN MEDIC MEDICAL CENTER, HCMC, VIETNAM

31 year-old female patient,  accountant,  in Gia Lai province. Onset 2 months with scattered body itching, no skin lesions, no fever, no abdominal pain. A private clinic in Gia Lai, with blood tests, diagnosed Toxocara sp infection, and gave her albendazole 800mg/day x 21 days.  No itching she went down to an another private clinic in Quy Nhon province, and with another blood tests, she was diagnosed infected Cysticercosis, being treated with albendazole 800mg/day x 10 days. Then appearing right abdominal pain, ultrasound suspected liver damage caused by Fasciola spp. She went to Institute of  Parasitology and Entomology  in Quy Nhon province and then came to Medic Hoa Hao in Ho Chi Minh city.
Ultrasound detected right liver lesion with mixed echo, d = 5 cm, clear border, within a few of hypoechoic nodules, and no liver tissue edema around (Fig 1, 2). Further ultrasound detected colon wall thickness at liver region, hypoechoic,  not lumen narrowing (Fig 3).

Endoscopy showed transverse colitis.
Blood tests: WBC 14,500 cells/mm3 (Neutrophil 61.9%, Eosinophil 15.8%), hsCRP 14.53 mg/L. HBsAg (-), antiHCV (-), AFP (-), CEA (-), Fasciola sp IgG (+), stool exam (-).


Biopsy tissue in colon lesion was done and microscopic report was eosinophil mucosa colitis. 
MSCT CE presented liver lesion d = 4x6cm and transverse colon lesion with wall thickness d = 20mm (Fig 5, 6).


We diagnosed: liver abscess and pseudotumor colitis by Fasciola spp (Ectopic Fascioliasis) treated with Triclabendazol 10mg/kg/day x 2 days.
Re-examination 4 weeks later, WBC 8,800 cells/mm3 (Eosinophil 2.5%), hsCRP 1.3 mg/L.



Liver lesion in ultrasound and MSCT,  wall thickness d = 8mm in MSCT (Fig 8, 9).



We represented an ectopic  Fascioliasis with hepatic and transverse colon lesions and an undifferential serodiagnosis. Endoscopic biopsy result helped ruling out a colon tumor. But based on ultrasound findings of liver and colon lesions which were confirmed by MSCT we could chosed a concordant diagnosis for this case.

Monday 12 December 2016

CASE 408 : DIFFUSE SKIN MACULAR MASTOCYTOSIS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM


Baby 6 month old, onset with fever and skin eruption for 3 months, starting in the legs and going to face and full body.  
Itching, in beginning lesion is red skin papula  and  progressing  to macular  shape (see foto of  face,  body).  Dermatologist  represented the lesion with crash and trap which  is  swelling  as  bullus (foto). Darier ‘s sign positive).




Blood tests  are normal .
Ultrasound  of this skin lesion detected  intra dermal hypoechoic infiltration, hypovascular pattern ( US 1, US 2).



Biopsy  of the  skin lesions and  microscopic report with histobiochemistry staining is  MASTOCYTOSIS. So this case is thought  Diffuse skin macular  mastocytosis.





Saturday 3 December 2016

CASE 407: LIVER INFARCTION, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM


Man 35 yo,  onset   epigatric pain and fever. Ultrasound  of abdomen detected  one mass  at left lobe of liver,  size 10cm,   structure looked like target..ring (US 1),  US 2:  color Doppler  shows  the left portal vein branch thrombosis; US 3=   normal flow  of hepatic vein.





Blood tests:    WBC = 16,9k with  neutro  12,9k, CRP= 243 ng/ml;   sero amibe is negative,   Wako test  triple negative, dDmer  is very high.
MSCT CE..presented the mass has  central necrosis   ( CT1), CT 2= thrombosis of  left  branch of portal vein  (CT3, CT 4).





What is your suggestion for diagnosis,based on clinical status of  US, LAB, CT.

Operation for left hepatectomy showed   big  liver tumor  not  changing the liver surface and peritoneum.



Microscopic report  is necrosis aseptic liver (liver infarction).





REFERENCE=
HEPATIC INFARCTION.pdf


Sunday 20 November 2016

CASE 406: NERVE TUMOR, Dr PHAN THANH HAI- Dr LE TU PHUC, MEDIC MEDICAL CENTER, HCMC, VIETNAM


 

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Description: https://mail.google.com/mail/u/0/images/cleardot.gif


Man 35 yo with  pain  at lateral of right leg.
In  examination detected   one  round  structure  along the  peroneal  bone which  is painful at palpation (photo).



Ultrasound  of right  leg revealed   this struture   hypoechoic, size of 1.2 cm in diameter and long # 10cm, lobulated ( US 1, US 2) and   rule out  venous thrombosis.




MRI  with  gado contrast...( MRI 1, MRI 2, MRI 3.)





Radiologist suggested  neuroma  tumor of peroneal  nerve.
Operation  removed this mass  wich is well bordered  like a snake ( foto)





Wait for microscopic report.
MICROSCOPIC  REPORT IS  SCHWANNOMA OF PERONEAL NERVE.


REF  CASE.


Sunday 13 November 2016

CASE 405: MATERNAL and INFATILE CHORIOCARCINOMA, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Baby 01month-old with huge abdomen and having an abdominal wall bleeding ulcer. In hospital ND No2 this case was suspected bleeding metastasis of abdominal wall from liver tumor and thrombocytopenia.




In MEDIC,  ultrasound detected many liver nodules which was thought liver metastasis or diffuse primary liver tumors. AFP values in 2 times decreased in week after week. Meanwhile beta HCG raised over 200,000 UI. TOCE was done by French doctor for hemostasis for baby.






At that time her 41 yo mother  presented cough and chest pain with normal chest X-rays film, but chest CT and MRI revealed lung metastasis.






Blood beta HCG= 39,132 UI and urine beta HGC=40,000UI.
AFP= 2.5 UI, CEA 125= 20.3, CYFRA=7.57

Ultrasound of uterus and anexal detected no tumor.

CONCLUSION: Postpartum choriocarcinoma in infant and mother.

Update of case  405: Today, Feb 15, the baby came back to ND 2 hospital for continuing of chemotherapy; baby got weight well while the mother remains well also in Tu Du hospital post hysterectomy. 

It is the first case of maternal fetal choriocarcinoma published on internet from Vietnam that we taken part in helping baby and mother getting more healthy.
Reference:

 From Yale uni.