CASE 596: SEVERE STENOSIS of ILIAC ARTERY, Dr PHAN THANH HẢI, Dr NGUYỄN NGHIỆP VĂN, Dr VÕ NGUYỄN THÀNH NHÂN, Dr VÕ HIẾU THÀNH, Dr HỒ KHÁNH ĐỨC, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Male patient, 51yo, from Kien giang province,  with asthenia of right leg in walking about a distance of 100 meter.

At Medic Center, vascular ultrasound revealed aliasing spectrum of  right common iliac artery in stenosis # 80% due to atherosclerosis.

Right common femoral artery shows Doppler spectral biphasic pattern.

Right pedial artery with tardus parvus pattern and decreasing severely of arterial flow.

CT Angio later comfimed diagnostic.

Transferred to Binh Dan hospital, by via DSA, patient went to arterial dilatation and stenting to recover flow of root of right common iliac artery.

DSA before arterial dilatation= Confirmed diagnostic of 80% stenosis of right iliac artery root.

After arterial dilatation and stenting= Well recovered arterial flow, and no more arterial stenosis on controlled film.

Patient remains well and discharged in healthy status one day later.

CONCLUSION: Atherosclerosis causes severe stenosis #80% of right common iliac artery which had been rapidly diagnosed, and safety of management by arterial dilatation and stenting. Only one day lasting for treatment in hospital, patient finely discharged without intermittent claudication symptom.

CASE 595: HCC WITH NEGATIVE WAKO TEST, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER,HCMC,VIETNAM

Male patient 58yo, with HCV infection that had been treated by interferon for several months.

In check-up, ultrasound detected one round mass # 3cm look like a cyst.

WAKO tests= AFP=5.7, L3= 0.5, DCP=16.

MSCT with CE detected non tumor.

Gado MRI of  liver reported HCC.

MR image shows a lesion in hepatic segment V; with the size 24mm, well-defined. The lesion demonstrates high signal intensity on T2WI and low signal intensity on T1WI.

The lesion had restricted on Diffusion Dynamic MRI: On arterial phase image demonstrates unequivocal arterial enhancement relative to the surrounding liver; On the portal venous phase has decreased in enhancement relative to the surrounding liver (washout); On the delay phase has decreased in enhancement relative to the surrounding liver and enhance capsule is found which helps further solidify the imaging diagnosis of HCC.

-This patient has negative Wako test. Volk et al (2007) and Hann et al (2013) demonstrate of  Wako test with sensitivity (83%) and specificity (>90%) for detecting HCC.

Operation removed the liver tumor.

 Histopathologic report= HCC well-differentiated.

CASE 594: LUNG TUMOR ON PATIENT WITH CORONARY STENTS, Dr PHAN THANH HẢI, Dr DƯƠNG PHI SƠN, MEDIC MEDICAL CENTER,HCMC VIETNAM

Male patient 66yo with 6 year stenting 2 coronary branches  now left chest pain and dypsnea.

Chest CT for check-up. Coronary stents in good condition, but detected left lung tumor while expands FOV

Ultrasound of liver detected hypoechoic solid mass # 46x30mm at subsegment VII, well-bordered, basket shape vascularized that was  thought a metastasis lesion maybe from left lung tumor.

Lung biopsy and  histopathological result= adenocarcinoma poor differentialized invasive in lung [C34].

CONCLUSION=Coronary CTA helps revealing exactly coronary lesions, but detecting other lesions nearby heart if enlarging FOV.  In this case, coronary CT detected left lung tumor that confirmed later by lung biospy with histopathological result.

CASE 593: HYPERTHYROIDISM and DIARRHEA, Dr PHAN THANH HẢI, Dr TRƯƠNG CÔNG THÀNH, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Female patient 36yo with diarrhea and loss of weight # 9 kg for 11 months. After being failed of treatment as diarrhea in 4 other hospitals she came to Medic Center.

In clinical examination, P=101 bpm, BP =126/79mmHg, she got diarrhea, tachycardia, slight goiter,  hand tremor, hyperpigmentation and humid skin­.

Hyperthyroidism proved on color Doppler ultrasound, rapid sinusoid heart rate on EKG, low TSH and raised free T4 on lab results.

With Grave's disease management [methimazole 5mg] for one month, free T4 downs from 3.61 to 1.9, patient remains well and stop diarrhea.

Diarrhea for a long time due to many items of etiology including a thyroid mass.

According to Robbin's Pathology, hyperthyroidism leads to an overactivity of the sympathetic system. It also goes on to mention that this sympathetic hyperstimulation in the gut leads to increased motility leading to diarrhea and malabsorption.

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

.

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=

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.

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 4^th 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 4^th, 2020 showed ST changes associated with pericardial effusion.

Blood test on July 4^th, 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 10^th, 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 10^th, 2020 showed flattened T-wave on DIII.

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

Chest CT-scan on July 10^th, 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.