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Monday, 5 April 2021

CASE 610: Multiple Brown Tumour. Dr Phan Thanh Hai Phuong, Dr Ly Van Phai, Dr Hoang Thi Thanh Phuong (Oncology hospital)

Patient came to clinic with history of 3 years worsen polyarthralgia. He has been diagnosed and managed as degenerative arthritis in BacLieu Province Hospital for a year. The pain localized in left shoulder, right knee, hips and left ankle. Patient also experienced general fatigue and weight loss (5kg a year). MSK Ultrasound is indicated as first tool, goes along with blood tests.

Ultrasound of right knee: shows patient area of pain doesn’t come from joint but the bone. It exists erosion of periosteal of proximal tibia and  hypervascularity in surrounding soft tissue. By switching to more penetrative linear probe, a hyperechoic bone mass is seen beneath periosteal erosion. Mass is homoechogeneity and has anechoic cysts inside.







Image 1: Erosion of periosteal of proximal tibia and hypervascularity in surrounding soft tissue

 

 

 



Image 2: A hyperechoic bone mass is seen beneath  periosteal erosion. Mass is homoechogeneity with  anechoic cysts inside. Second images shows normal articular cartilage and not fit for degenerative arthritis.

Ultrasound of left ankle:

Same condition as proximal tibia as in the distal end. Mass is better demonstrated with infiltrative border. During examination, patient feels imminent pain at place that probe compresses. Ankle joint is normal.



Image 3:  Mass is better demonstrated with infiltrative border in distal end of tibia

Ultrasound of shoulder:

Shoulder rotator cuff are normal. Area of pain is at left A-C joint. In comparison to normal right side, same apperance of bone mass revealed at clavicular end.






Image 4: Shoulder rotator cuff are normal. Area of pain is left A-C joint. In comparison to normal right side, same bone mass at clavicular end revealed.

Conclusion : Multiple distal bone masses suggest few differential diagnosis: Metastasis, Multiple myeloma metastasis.

Those could be pseudo-mass  coming from bone erosion in osteclastic hyperactivity  in hyperparathyroidism. Althought the lesions are common in middle diaphysis but not in the distal/proximal end. Radiologist did a quick check on the neck to rule out tumor of parathyroid gland.


Ultrasound of the neck: detected at right lower lobe of thyroid a parathyroid tumor, 3.7x1.4mm, enlarged with capsule and hypervascular on colour Doppler mode.

 



Image 5: Right parathyroid tumor, 3.7x1.4mm, enlarged with capsule and hypervascular signals on colour Doppler mode.









Image 6: Pelvis X-Ray: shows multiple scattered oval-shaped bone radiolucent, losing bone general density.






Image 7 : Right ankle XRay:  radiolucent oval-shaped lesion at distal tibia end in comparison to ultrasound.

 



Image 8:  Right ankle XRay:  radiolucent erosion lesion at distal clavicular end as compared to ultrasound.

Patient is preferred to endocrinologist and  full body scan to perform looking for bone fracture as common complication because patient suffering illness for a long time.

 


Patient blood tests confirmed diagnosis: hypercalcemia and normal RF quantitative. Serum PTH value elevated >1200

 


Patient underwent surgery to remove the tumor. Pathological result : Parathyroid adenoma.





After the surgery, PTH value drops to normal value, serum calcium also drops below normal line and had been got oral calcium supply as he discharged from hospital. 

Follow up on 3 months later, patient recovered and experienced no pain. He has already can go back to work.


Discussion and conclusion:

Primary hyperpaprathyroidism is caused by parathyroid tumor excretes PTH. That activates re-absortion calcium in kidneys, increase absorption in colons and bone loss. Osteoclastic hyperactivity produces subperiosteal erosions, endosteal cavitation and replacement of marrow spaces by vascular granulations and fibrous tissue. Brown tumor is known as Osteoitis fibrosa cystica. Pseudo-tumour, fluid-filled cysts contents hemorrhage and giant cell wrap within fibrous stroma. Giving rise to brownish, tumour-like masses. The lesion can be single or multiple. Well-defined and commonly affecting the facial bone, pelvis, ribs and femoral bone. The classical which should always be sought is sub-periosteal cortical resorption of middle phalanges.

But bone lesions in tibia end and clavicle ends of this case seem not to be so classical findings (in diaphysis instead).

  

Wednesday, 17 March 2021

CASE 609: INTERESTING GASTRIC TUMOR, Dr LÊ THANH LIÊM, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male patient 54 yo, with hemorrhagia due to gastric ulcer for 2 years. From late 2 months patient got pain  from neck to epigastric area, loss of appetite and weight. (Weight=58 kg, height=160 mm).

Ultrasound detected some nodes in both 2 lobes=10-38mm with halo sign and without Doppler signal. No thrombus in portal vein,  IVC and hepatic veins. None lymph node. Small amount fluid in pelvic area.



Stomach= Irregular thickening wall, d#27-69 mm of  nearly total gastric wall of corpus and fundus  that formed hypoechoic mass d# 161x166x163mm, hypervascular which takes wide place of lumen and  compressed cardia. Though about Gastric GIST with hepatic metastases.






MSCT with contrast confirmed  gastric GIST # 16 cm, adhesing around and liver metastases. Some low signal liver lesions 10-35 mm were in lower density than liver parenchyma. Corpus of stomach has lesion d= 16 cm with soft tissue density and has big ulcer at center. Lesion was adhesive and compressed around. Pelvic area has a little of fluid.







Blood tests= Severe anemia Hb 6.0 g/dl; Hct 25%; MCV 57.6 fL; MCH 13.9 pg; WBC slight raised=11.90 x 10^9/L; PLT high raised 794x10^9/L. HP Test-IgG (Elisa) POS 69.88 U/mL; HP Test-IgM (Elisa) POS 68.48 U/mL.


In Binh dan hospital, gastroendoscopy shows big  gastric tumor in fundus with deep ulcer having hard border and compresses lower 1/3 part of esophagus.



Histopathologic results= Infiltrating of lymphocytes and plasmocytes gastric mucosa proliferates fiber tissue and fibrosis. Masses of cells line in band with fusiform nucleii on base of fiber tissue. Follow up  GI GIST.

Waiting for histoimmunostaining.





CONCLUSION= Interesting diffuse appearance of entire gastric wall tumor helps diagnosing gastric GIST based on ultrasound and MSCT findings.

Saturday, 6 March 2021

CASE 608: APPENDICOLITH, Dr NGUYỄN NGHIỆP VĂN, Dr VÕ NGUYỄN THÀNH NHÂN, Dr NGUYỄN PHÚ HỮU, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 Male patient 17yo, RLQ pain at 01:00 a.m. March 6, 2021.

Ultrasound at Medic Center at 10:00 a.m. detected an 33x10 mm swollen appendix at RLQ with fecolith =11 mm inside which has echo rich pattern and posterior shadowing. No free fluid around. A diagnosis of acute appendicitis with fecolith was made.





Lab results= WBC with neutrophil raised and CRP raised.




Later MSCT of abdomen confirmed an acute appendicitis with fecolith.






Patient was hospitalized  at 12:00 p.m. in Binh dan hospital. Endoscopic operation performed at 12:30 p.m..

And surgical macroscopic specimen (received via email at 03:00 p.m.).




Reference:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072212/



Sunday, 21 February 2021

CASE 607: ISOLATED ABDOMINAL AORTA DISSECTION (IAAD) in YOUNG ALDULT, Dr LÊ THANH LIÊM, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC,VIETNAM.

Male patient 38yo with sputum coughloss of weight #10kg, no fever, no abdominal painloss appetite for 2 months without trouble of passing out of water and waste.

Gastroendoscopy shows gastritis and esophagitis

due to Candida. 





Normal chest-X-Ray. 




MSCT of chest and abdomen detected dissecting 

IAA from lower kidney part to left iliac artery while AA diameter suprarenal =21mm and infrarenal =22mm

Enlarged lymph nodes at both 2 lung hiliimediastinalleft axillary nodes

and in abdomen, lymph nodes of celiac artery, nearby 

pancreatic headand periaotic in epigastric area.

Thought about lymphoma infiltrating nodes. 

  





POC Ultrasound findingsSplenohepatomegalies 

and enlarged nodes of celiac arterynearby 

pancreatic headand periaotic in epigastric area. 


Thank to MSCT results, POCUS showed a dissecting isolated abdominal

aorta, d# 25 x 18mm from lower kidney to aortic bifurcation, which has  two lumens, right lumen with Doppler flow and no flow 

in left lumenRight and left iliac arteries with normal

lumen and Doppler flow. 

 




Video Clip= Doppler  isolated AA dissection.




Neck ultrasound  shows left side neck nodespoor  

echogeneicityloss of nodal hilus, no calcification 

nor necrosis sign

Nothing abnormal on thyroid scanning. 






Lab tests = Slight anemia,Hb=11.4g/dLLeucocytes= 8.95x10^9/L, normal FBG= 4.77 mmol/L, HP Test-IgM - IgG (Elisanegative; β2 Microglobulin = 4250 μg/L; HIV Elisa (+).


Biospy of neck nodes and histopathologic result 

Loss structure of nodeMany smallmedium and big size cellules in vessels with high endothelial cellshyalinized vessel walls

Many eosinophyl leucocytescytoplasms and 

epitheloid hystiocytes in the base.


Suspect T lymphoma on node specimen

 



 

Chemohistoimmunostaining result is TB node.









Conclusions 

1/ Pay attention of dissecting isolated abdominal aorta may exist in young patient.

2/ Complete examination and using all imaging

 diagnostic modalities may help detecting

 patient of risks and his/her illness. 


Reference:

Isolated Abdominal Aorta Dissection,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3926414/