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Wednesday, 22 July 2020

CASE 592: FOCAL NODULAR HYPERPLASIA of LIVER (FNH), Dr PHAN THANH HẢI, Dr TRƯƠNG ĐÌNH KHẢI , Dr NGUYỄN SÀO TRUNG, Dr HỒ CHÍ TRUNG, Dr NGUYỄN THÀNH ĐĂNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM


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Female child 11 yo, with abdominal pain and diarrhoe 1/2 day.

Abdominal ultrasound detected  a solid tumor # 45X48X52mm between liver and stomach which is look like hepatic tissue.




MRI with contrast shows tumor from left lobe of liver #50x42mm, regular boder, with hepatic signals, strong enhancement in arterial phase and wash out same liver tissue in late phase. A  FNH in left liver lobe was been made in diagnostic.


Blood tests=

Open surgery to remove tumor for the child .






HISTOPATHLOGY RESULT=


REFERENCE=


Tuesday, 21 July 2020

CASE 591: RIGHT LUNG MULTIPLE NODULES, Dr PHAN THANH HẢI, Dr LÊ THANH LIÊM, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Female patient 47yo without fever, coughing, no history of diabetis.  In general check-up in Camau hospital nothing abnormal detected but lung MSCT detected multiple nodules 5-28mm at base of right lung.





02 days after at Medic Hòa Hảo Center= BK(AFB)/Sputum (-). Blood tests= AFP, CEA, CA 125, CA 15-3, CA 19-9, Cyfra 21-1 in normal range.

Lung ultrasound detected an oval lesion # 22x29x23mm at posterior peripheral area of  right inferior lobe maybe a cystic pleural effusion; and some small nodules  = 6 - 9mm at anterior base of right lung.

No lymph node at neck, axilla, inguinal regions and inside abdomen.





                                               
Endoscopic surgery removed partial right  lobe in Pham Ngoc Thach lung hospital. A lung tumor#3x4cm belongs S6 segment, solid, smooth surface. Result of biopsy on- site are TB inflammation with caseum necrosis  inside.



DISCUSSION:
A rare clinical case of lung ultrasound for peripheral lesion shows that ultrasound could inform details to discribe findings inside and helps diagnosing and management in contribution with  clinical and other imaging modalities.


Reference:

 Ritesh Agarwal et al, Parenchymal pseudotumoral tuberculosis: Case series and systematic review of literature, Respiratory Medicine, Volume 102, Issue 3, March 2008, Pages 382-389.



Monday, 20 July 2020

CASE 590: INFECTIOUS THORACIC AORTIC ANEURYSM, Dr PHAN THANH HẢI, Dr CHÂU NGỌC MINH PHƯƠNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM.


A 44 years-old male patient, complaint of substernal chest pain for one week, increased with cough and inspiration. He also had mild fever, dry cough, and dyspnea. He was first seen on July 4th 2020, and was followed up at home with an initial diagnosis of Suspected Pericarditis – Urinary Infection. He was then readmitted 7 days later at ER department. 
ECG on July 4th, 2020 showed ST changes associated with pericardial effusion.




Blood test on July 4th, 2020 showed highly elevated white blood counts, marked increase of hsCRP, and urinary infection. The serum troponin was normal.

Echocardiography showed minimal pericardial effusion.


Chest X-ray was normal.


He was given oral antibiotics (Levofloxacin) and anti-inflammation for 7 days.
On July 10th, 2020, he was admitted to ER due to severe chest pain, mild fever, and dyspnea. Physical examination at ER showed tachycardia, normal BP, and no heart murmur.

Repeated ECG on July 10th, 2020 showed flattened T-wave on DIII.


Second blood test showed persistent elevated WBC, hsCRP and elevated D-dimers.


Chest CT-scan on July 10th, 2020 showed suspected mediastinum abscess surrounding the ascending aorta, with saccular aneurysm at the beginning of the aortic arch, and mild pericardial effusion. The differential diagnosis was thoracic aortic aneurysm with surrounding hematoma.








The patient was then transferred to Binh Dan Hospital. He was operated on the very next day, and surgery report showed inflammation and necrosis of the aortic aneurysm’s wall. The necrotic tissues were removed, and the aortic arch was partially replaced with a Vascutek 16 graft.



During his hospital staying, pericardial fluid culture came back positive for Staphylococcus aureus. He was treated with a combination of Vancomycin and Imipenem.

He’s currently stable with minimal pain at the surgical site. His white blood count went down to almost the normal range.  

CONCLUSION=

Echocardiography and EKG detected pericardial effusion, CT revealed infected aneurysm and mediastinal abscess and patient remained well post-op ; that is a great success for saving patient life  came from an interesting combination of clinical and imaging of diagnosing and surgery.

Wednesday, 1 July 2020

CASE 589: TB OF TESTIS, Dr PHAN THANH HẢI-Dr LÊ THANH LIÊM, MEDIC MEDICAL CENTER, HCMC, VIETNAM



Male 28yo, with swelling and scrotal pain in thrombophlebitis management and spermatic vein thrombosis for 2 months but nothing change that a hospital in HCM city made decision to surgery because of not ruling out a sarcoma?

US and MRI cannot rule out a spermatic tumor.






At Medic Center utrasound detected edema of epidydimal head, hypervascular #36x24mm with some calcium nodules, scrotal skin edema and small amount of  fluid in scrotum while seldom revealed lymph nodes that are poor echoic  in necrosis and calcified  at left neck=10-31mm that made  thought about TB abscess of left epidydimis










Blood tests: WBC 10.900 / mL;  CRP 13.63 mg/L; AFP 1.94 ng/ml; BetaHCG blood < 0.2  mUI/ml.


Chest X-Rays detected fibrotic lesion in right subclavian area and suspected TB lesion of right lung.






FNAC for left neck lymph node thinks about TB node.







Pulmonary and TB PNT hospital suspected TB testis and peripheric nodular disorders.




For 4 months of TB treatment, on ultrasound in Medic Center, head of epidydimis decreases volume #24x16mm, hyperechoic pattern, non hypervascular irrigation with existing a small abscess of 16x11mm, and scrotal skin slightly thickend with small amount of fluid in scrotum.








Decreasing of volume of left neck lymph nodes =10-29mm.



TB of epidydimis is a rare entity. Ultrasound findings is painful or painless area, hypoechoic homogenous or inhomogenous pattern due to necrotized, granulomatic and fibrotic changes.