CASE 275: LUNG MASS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

BOY 5 YO   3 DAYS AGO   FEVER AND COUGH.

PEDIATRIC DOCTOR  REQUESTED  BOOD TESTS  FOR  RULE OUT  DENGUE FEVER AND  CHEST  XRAY.

RESULT   RETURNED  QUICKLY (SEE   BLOOD TESTS  AND CHEST XRAY).

DISCUSSION:

FEVER AND RISING OF WBC  WITH  MORE NEUTRO CELLS  ARE  ACUTE
INFECTION, WE CAN RULE OUT  DENGUE FEVER.

BUT THE CHEST X-RAY WAS ABNORMAL, ONE RADIOLOGIST  SUGGESTED  LUNG TUMOR. AND HE  REQUESTED THORAX CT SCAN.

ULTRASOUND  OF  THE CHEST  BY TRANSTHORACIC  DETECTED THIS MASS AT THE LEFT LUNG  WHICH WAS  SOLID  ECHOTRUCTURE  LIKE HEPATIC TISSUE.
IT HAD AIR IN THE MASS AND  VESSELS  WERE NOT BENDING ( SEE ULTRASOUND  IMAGES  WITH  CDI AND VIDEO)

  

Sonologist suggested consolidation pneumonia.
For make sure diagnosis we performed low dose CT Scan  without CE (see CT pictures).

Radiologist reported that a lobular pneumonia in  consolidation phase of the left lung.
Antiobiotic treatment is in urgency.

After one week treated with antibiotic, the clinical of patient recovered very well. CRP  dropped to 32ng/mL. Chest X-Ray has got near normal status and lung ultrasound  had changed  structure. (See  chest X-Ray and ultrasound pictures of the left lung).

CASE 274: PTA OR NOT, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

WOMAN 50YO, AFTER 5 YEARS TREATED HYPERTHYROIDISM AS STABLE STAGE,  BUT  BLOOD TESTS DETECTED  PTH VALUE VERY HIGH  AND  HYPERCALCEMIA. IT  SUGGESTED HYPERPARATHYROIDISM (SEE BLOOD TEST RESULT).

ULTRASOUND DETECTED ONE MASS AT  RIGHT LOWER LOBE, HARD WITH
ELASTO, AND HYPOVASCULAR, SIZE OF 2 CM.

MRI WITH GADO CE, ALSO CONFIRMED  ONE MASS AT  LOWER  POLE OF
THYROID GLAND, SUSPECTING  PTA, SIZE ARROUND 2 CM.

IN PREOPERATION  ENDOCRINOLOGIST  REQUESTED GAMMA SPECT  MIBI.
BUT THE REPORT WAS  NOT ABNORMAL ISOTOPE, MEANING  NOT  PTA.
(SEE  SCAN MIBI UPTAKE) . 

Discussion:
This case  is  very complexe; the clinical onset  was hyperthyroidism , medical treatment was   good response. But  in biology  blood test is evident about hyperparathyroidism. Ultrasound  and MRI  made the same  diagnosis of  PTA.   But  gamma SPECT scan MIBI is  negative; it cannot  rule out  PTA , so operation was done  for  remove this tumor.

And  pathologist  diagnoses PTA ( see  pathology report).

Review  in internet:  many  cases with  SPECT scan MIBI  were  negative.. And  indication  for   this scan helps to make  clear  Indication and Interprettation..

Conclusion:

For  diagnosis  PTA , the gamma scan MIBI cannot  rule out  clinical  diagnosis.

REFERENCE:

CASE 273: FOREIGN BODY on HEAD, Dr LÊ THỐNG NHẤT- Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male patient 33 yo from Ca mau province.

For 20 days before Medic admission, patient had been hurt by a stabbing wound by bamboo chopstick at his right temporal region.

But after a first-aid bandage, the wound was getting swollen and infected, then he came up to Medic Center .

Ultrasound at Medic detected foreign body into the wound which was correlated to a part of bamboo chopstick.

MSCT of the head showed a tubular object  in the right temporal region.

Patient  underwent  a surgery to remove the foreign body at the same day. Specimen was a part of bamboo chopstick of 6cm length.

Download : US Guided Procedures-V Foreign Body Localization

CASE 272: EOSINOPHILIC GASTROENTERITIS and ASCITIS , Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Patient 42 yo, labor of the load of bread, one  month ago  complaint by  periumbilical pain crisis.durring 1-2  minutes, no  fever  no  diarrhea,   more and  more frequent.
Ultrasound  abdomen  first time detected  free fluid ascitis in  large amount of volume  but unknown origine (see  ultrasound  images).

Gastroendoscopy showed gastritis with  negative HP test,

MSCT no CE also made sure this  liver  no cirrhosis and ascitis unknown origine.

Blood test report = WBC  rising.

What is your  diagnosis for the case and what do you do next ? 

Ultrasound guided punction of ascitis which was removed the yellowish  clear fluid  and biochemistry and cytology analysis.

RECENTLY LAB  REPORT of  BLOOD TEST from THIS PATIENT.

DISCUSSION:

 This case  was represented unknown  ascitis  at first  time by  ultrasound and CT scan, and blood test  report was  eosinophil  rising  too much,  43%, that many doctors were looking for a  parasite infected cause.

But, ascitis  analysis was  transudate fluid  and hypoalbumine,   while  CA125  was very high, of 1380 UI/mL  in the male patient. So it was  difficult to explain that.

Cytology of  ascitis fluid  showed  that  many  white blood cells  of eosinophil  in  one staining microscopic champ.

Second report  of blood test today  ruled out parasite infection, but IgE very high,  of  1168 UI/mL, that  suggested an  eosinophylic gastroenteritis.

For  review and  make sure  this  diagnosis, an other  ultrasound scanning of  abdomen perfomed  to  detect   thickening of  intestine wall.  And  cytology  smear of ascitis  fluid  was more eosinophil cells. 

A course of  corticotherapy was started today. Wait for  clinical response.

After 2 days treatment with 50mg prednisolone, the blood test spectacularly responsed.

Today 9/9/2014

Update case 272:  After one week treated with corticoid,  clinical status of the patient remains well in recovery.
Ultrasound of abdomen  shows  completetly  dissapearing ascitis  ans blood test returns  nearly to  normal values ( see 2 ultrasound images, and blood test report).

REFERENCE:

CASE 271: BOCHDALECK HERNIA, Dr PHAN THANH HẢI, Dr VÕ NGUYỄN THÀNH NHÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 43 yo,  after a great meal, his comments were vomitting  and epigastric pain.
Emergency  abdomen ultrasound  was nothing abnormal detected (NAD).
Standing  chest abdomen X-rays showed that  left lung pneumonia in suspicion (see  chest X-ray film).

MSCT of chest-abdomen detected left  diaphragm in rupture and the  great omentum  going up to the  lung (see CT foto).

For  make sure  the colon was still  in abdomen,  Xray colon enema was done (see foto).

It was an emergency  case  with no  history of trauma.
Laparo and  thoracoendoscopy detected  a big defected wound  of posterior left  diaphragm;  great omentum  going up to the lung.
It is  BOCHDALEK HERNIA, need to suture for repairing left diaphragm (see foto).

REFERENCE:   anatomy of diaphragm.

History about Bochdalek.

CASE 270: MASS nearby STOMACH, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman  44 yo,  epigastric pain for one  month. Ultrasound first  of abdomen detected one round hypechoic mass,  size of 2-3 cm at the border of antrum ( see 2 pictures of ultrasound) .and  sonologist suggested it a  GIST of stomach.

Gastroscopy  detected nothing.
MSCT with CE of this mass:  Mass was not far from the wall of antrum, enhancement with
contrast,  but  in position of  rotation,  so CT cannot  make sure that  from the wall of antrum (see CT pictures with CE) or not.

Radiologist suggested that a lymph node, size of  2,4 cm  near antrum.
Blood  test  nothing abnormal.

CLINICAL AND  RADIOLOGY CANNOT  MAKE SURE DIAGNOSIS FOR THE MASS.

IN LAPAROSCOPY FOR BIOPSY THIS MASS,  IT  IS NOT  FROM THE WALL OF ANTRUM.  (SEE OPERATION FOTO 1,2,3)  

REMOVING COMPLETLY THIS ROUND SOFT  MASS. 
SEE  MACRO  PHOTO. 

Pathologic microscopic report with IHC is  neurilemnoma.

REFERENCE case report.