CASE 363: MURPHY'S SIGN POSITIVE, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman  32 yo,  3 days ago, fever and pain at  right  upper quadrand of abdomen with  MURPHY SIGN  POSITIVE  in clinical palpation.

Report of ultrasound in emergency from  a province hospital   was cholecystitis necrosis and peritonitis ( US picture).

At MEDIC, reviewed ultrasound shows US 1: CDI revealed big gallbladder and edema of the wall, no stone, no perforation. CBD is  no dilatation, no hypervascular.

US 2: fluid collecting in Morrison’s space extending to right iliac fossa.

US 3: normal scanning  at pancreas area.

Patient reports painful in pressing of ultrasound probe over gallbladder area .

Sonologist  suggested  edema of the gallbladder wall  and ascites maybe  due to hemorragic fever reaction.

Blood tests  confirmed  low WBC, low platelets, and Dengue test  IgG positive.

Based on  ultrasound  picture and  blood tests, diagnosis was infected Dengue; gallbladder edema only due to reaction. And the management for the case  is  medical follow-up in progress of disease.
Reference:
Acute Acalculous Cholescystitis and Ascites [Dengue Fever stage III]

Hình ảnh siêu âm sốt xuất huyết Dengue

CASE 362: ACUTE FEMALE PELVIS PAIN, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Women 21 yo, single, acute  hypogastric pain, polykiuria, normal urine analysis. 

Ultrasound  scanning  in pelvis  shows uterus  normal in size with endometrium thickening, fluid collecting arround  uterus looked like  blood (US 1)  

and  on right  site of uterus exists  one  round mass, size  of 5 cm  with multiple cystic (US 2), 

US 3 =  Color Doppler of  this mass is  normal vascularization, 

US 4 = PW Doppler of  right uterine artery  with RI =0.82.

Sonologist  alerts  bleeding  intrapelvis and  suspected  rupture of right ovary cyst.

MSCT with CE : Non intrauterus pregnancy ( CT1), and this mass  at right parameter  is  cystic in  central part and  thickening wall  with  blood arrounding.  

Radiologist  diagnosis  is  hemoperitoneum due to rupture of luteinic corpus  of  right ovary;  blood collecting volume  arround 100ml.

Blood test  makes sure negative beta HCG.

Clinical finding  is acute pelvis pain in single female  patient, ultrasound  quickly detected  bleeding  intra pelvis  and blood test ruling out a case of ectopic pregnancy.

Ultrasound is  best diagnosis and follow up this case,  no need  CT.

This patient was admitted  OBGY hospital for survey in  3 days and discharged later.

Conclusion:   In female patient,  of acute  pelvis pain case,  ultrasound  is first choice of imaging modalities  for diagnosis about  luteinic corpus   rupture in bleeding, and  beta HCG to  confirm diagnosis of  MITTELSCHMERZT  SYNDROME.

CASE 361: TUMOR of MUSCLE RECTUS ABDOMINIS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 33yo, 4 months after cesarian operation  detected a  mass near umbilicus on right side, fixed  palpation, 

Ultrasound.scanning of   this mass revealed  intra abdominal wall mass, from lower part of  rectus abdominis muscle. ( US 1, US 2, US 3 ( linear probe), video) . Video clip  shows this tumor  from anterior abdominal wall ).

On MRI, this tumor is solid, size of 12 cm, structure looked like  uterine  myoma.

( MRI1, MRI2, MRI3).

Discussion:

At first,  diagnosis from one  OBGY  doctor is endometriosis  post c-section. But  another  sonologist  from  Obgy hospital is pediculate fibroma of uterus. One  radiologist  looking  MRI  says tumor of rectus abdominis muscle  same as  fibromuscular mass.
Operation for remove this tumor; operator reported  this tumor was well bordered,  hard,
and developered from  rectus muscle, not  from the middle line if c-section.
Macroscopic view of  section surface look like  fibroma.

Discussion 2: In past history she had been first c-section for first delivery 3 years ago. During second pregnancy, this patient known having fibroma of uterus from doctor ObGyn. It is mistaken prenatal diagnosis. Her past history is very important issue for diagnosing today.

Discussion 3 from pathologist: based on HE staining slices, 3  pathologist professors say  surely that not  endometriosis, 2 prof say  maybe  a desmoid tumor  but one  is  say  fibroma. 

Microscopic result with imunohistochemistry  staining is desmoid tumor.

Reference: Desmoid tumor of abdominal wall.

CASE 360: RIGHT KIDNEY TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Man 38yo 2 years ago  intermittent  hematuria, today  acute right renal colicky pain. 

Ultrasound in emergency detected big right kidney and fluid collection arround  kidney.

Pelvic kidney  has a collected  hyperechoic mass which made  dilated ureter.

CDI ultrasound detected  no Doppler signal in  vascular renal cortex ( US 2)

MSCT with CE=CT1: frontal view=  right kidney  too big without contrast  supplying.

CT 2: frontal view, pelvis of right kidney  is covered by enhanced contrast mass  just to dilated ureter. 

CT3, CT 4: cross- sectional view: pelvis and ureter detected  intralumen  one enhanced  contrast structure  liked  a tumor.

CT 6: 3D vascular view= no vascular supplying to right kidney.

Report  by radiologist  is  bleeding intra  right urinary system with  ureter obstruction  by  tumor, suspected  TCC.(TRANSITIONAL CELL CARCINOMA)

Emergency operation  of right nephrectomy and  ureterectomy.

Macroscopic specimen showed  tumor in obstruction of distal ureter.

Microscopic report TCC  ( transitional cell carcinoma hight grade malignancy.

CASE 359: RIGHT HIP PAIN, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Women 72 yo, pain at right hip  in walking for 2 months , no trauma, no fever.

Ultrasound of right hip joint ( us 1 scan,  us2, us 3  cross- section).

Plain XRay in AP view  for comparison of right to left hip joint ( XRay image)  no abnormal detected.

CT scanning  ( CT 1 : cross section of  head of  femoral  bone deformation  at right side, CT 2: frontal view,  CT3  3D view).

MRI  of hip joint  in comparison of  right to left  femoral head bone.

Final diagnosis is AVN ( avascular necrosis of femoral head)

Reference  case: http://radsource.us/avn-of-the-hip/ 

CASE 358: LESSER OMENTUM TUMOR, Dr PHAN THANH HAI , Dr VAN UYEN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Women 30yo, general check- up .

Ultrasound detected a tumor on border of liver near gallblader which deplaces left gastric curvature and is from retroperitoneal space. Its structure are solid and cystic parts,  size arround 10cm ( see ultrasound  us1.. cystic part tumor  in border  liver; us 2..near gallblader;  us 3..long scan  left lobe liver and tumor.). Sonologist cannot  diagnose this tumor  from lesser omentum.

MSCT with CE of this tumor  is mixed structure, cystic, fatty, and calcification [ CT1..section, CT 2  frontal section , CT3  sagital ). Suggession from radiologist  is teratoma tumor or  lipoma necrosis.

MRI   with gado ( MRI 1..struture is more fat tissue., MRI 2..with  fat suppression ,  MRI  3 frontal view).  Radiologist  says  teratoma of retroperitoneum, in lesser omentum area.

Blood test  of all  cancer markers are normal.

Laparo-operation= 

picture 1( retrogastric tumor well bordered)

picture   2macro

picture  macro 3, opened specimen,   solid and cystic tumorand  fluid inside  like milk)

Microscopic report of this tumor is teratoma maturation.