Bilateral persistent sciatic arteries complicated with acute left lower limb ischemia.

Persistent sciatic artery (PSA) is a rare congenital malformation. In the early embryonic stage, the sciatic artery is the major blood supply for the lower limb bulb and is later replaced by the iliofemoral artery as the limb develops. Its failure to regress, sometimes associated with femoral arterial hypoplasia, and therefore becoming the dominant inflow to the lower extremity is called PSA. This anomaly is often associated with a higher rate of aneurysm formation or thromboembolic complications causing lower extremity ischemia. Here, we describe a 79-year-old male patient who presented with acute left lower extremity ischemia. He was treated initially with conventional embolectomy through inguinal and popliteal incisions. The bilateral PSA with thrombosed aneurysms was not identified at first on computed tomographic angiography. It was later diagnosed intraoperatively due to the discontinuity of the superficial femoral artery and popliteal artery found with embolectomy catheter, and was managed successfully with ePTFE graft bypass. Careful interpretation of the imaging study may be helpful in preoperative diagnosis.     

Postmenopausal hyperandrogenism caused by a benign cystic teratoma: a case report

BACKGROUND: Mature, benign cystic teratomas of the ovary are common in reproductive-age women, but they are very rarely associated with androgen production and subsequent development of hirsutism or virilization. We describe a case of postmenopausal hirsutism and hyperandrogenism caused by a mature cystic teratoma as well as the 7 previously reported cases. CASE: A 55-year-old, postmenopausal woman presented with hirsutism and unilateral lower extremity edema. Pelvic ultrasound showed a complex cystic mass in the left ovary measuring 6.0 x 7.0 x 10 cm, and laboratory evaluations revealed progressively increasing testosterone levels. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, with resection of a large, complex mass originating in the left ovary. The pathology department found 2 left, mature ovarian cystic teratomas containing a layer of Leydig cells. Postoperatively the patient experienced rapid normalization of the elevated testosterone level. CONCLUSION: Although rare, ovarian production of androgens resulting in hirsutism or virilization can occur with a hormonally active mature cystic teratoma.     

Peripartum cardiomyopathy presenting as lower extremity arterial thromboembolism. A case report

BACKGROUND: Although venous thromboembolism has been associated with peripartum cardiomyopathy, there have been no prior reports of lower extremity arterial thromboembolism complicating cardiac failure. CASE: A 38-year-old woman, gradiva 5, para 5, presented on postpartum day 9 with left pedal parasthesia. Lower extremity angiography found acute thrombotic emboli in the left popliteal artery, right tibial artery and right peroneal artery. When respiratory decompensation ensued, a transthoracic echocardiogram revealed global hypokinesis and a left ventricular ejection fraction of 30%. The patient had an uneventful recovery after treatment with digoxin, furosemide and intravenous heparin. CONCLUSION: Lower extremity arterial thromboembolism may be the initial manifestation of peripartum cardiomyopathy.     

Intraoperative positioning during cesarean as a cause of sciatic neuropathy

BACKGROUND: Sciatic nerve compression has been well documented as a cause of perioperative sciatic neuropathy but rarely during cesarean. CASE: A parturient complained of left foot drop after cesarean delivery for twins performed under spinal anesthesia. Intraoperatively, her right hip was raised with padding under the right buttock to tilt the pelvis approximately 30 degrees to the left. Postoperatively, the patient had weakness, sensory changes, and diminished reflexes in the left lower extremity. Electrodiagnostic studies supported a diagnosis of neurapraxia and partial denervation in the distribution of the sciatic nerve. By postpartum week 6, she had full recovery. CONCLUSION: Elevating the right buttock during cesarean can cause compression of the underlying structures of the left buttock and result in sciatic neuropathy. Decreasing the duration of time the patient is in the left lateral position may reduce the risk of this uncommon but debilitating complication.     

Uterus-like mass of ovarian ligament: Image diagnosis and management by laparoendoscopic single-site surgery

Uterus-like mass composed of a cavity lined by mucosa resembling endometrium and surrounding smooth muscle layer simulating myometrium is an extremely rare disease entity of which the histogenesis is presently unknown. A 39-year-old, gravida 2, para 2, woman presented with sudden onset of lower abdominal pain and was found to have left adnexal mass with unusual image diagnostic appearance. The adnexal mass arising from the left ovarian ligament was excised by laparoendoscopic single-site surgery. Histopathological diagnosis was uterus-like mass of ovarian ligament.     

May-Thurner syndrome resulting in acute iliofemoral deep vein thrombosis during the second trimester of pregnancy

Described is a 27-year-old pregnant woman with May-Thurner syndrome who experienced extensive pelvic and lower extremity thromboses during the antepartum period. The patient was referred for a symptomatic deep venous thrombosis at 23 weeks of gestation. Ultrasonography demonstrated a massive thrombus in the left iliofemoral vein. Heparin was given intravenously. Due to the possibility of pulmonary embolism during or immediately after delivery, a temporary inferior vena cava filter was inserted at 36 weeks of gestation. Labor was induced at 37 + 5 weeks of gestation; labor proceeded uneventfully and a male infant was born. Postpartum computed tomography (CT) demonstrated compression of the left common iliac vein by the right common iliac artery and lumbar vertebra. CT venogram demonstrated poor flow through the common iliac vein and well-developed collateral vessels. Critical stenosis at the origin of the left common iliac vein was consistent with a diagnosis of May-Thurner syndrome.     

Ovarian Carcinoma Presenting as Intra-abdominal Hemorrhage

Ovarian carcinoma commonly has an insidious onset. By the time the diagnosis is made, advanced disease is usually present. Rarely does a patient have acute symptoms which require immediate medical attention and lead to the correct diagnosis. A 40-year-old white female presented with lower abdominal pain, nausea, and light-headedness. Physical examination revealed a markedly tender lower abdomen with the right lower quadrant slightly more tender than the left. Hemoglobin level was noted to have decreased 2.6 g/dl over 16 hr. At exploratory laparotomy, 1500 cc of blood and a ruptured right ovarian mass were found. Pathologic analysis revealed a malignant mixed mesodermal tumor of the right ovary and an endometrioma of the left ovary. In conclusion, ovarian carcinoma may present as an acute abdomen because of intra-abdominal hemorrhage. It should be part of the differential diagnosis in a woman with an acute surgical abdomen and a hemoperitoneum.     

Primary Retroperitoneal Müllerian Adenocarcinoma: Report of Two Cases Treated With Radical Surgery

BackgroundPrimary retroperitoneal Müllerian adenocarcinoma (PRMA) is a very rare type of primary retroperitoneal tumour.Case 1A 45-year-old woman presented with left lower extremity swelling and pain. Imaging revealed that the tumour had invaded the left common iliac vein and artery, internal and external iliac arteries, sciatic and obturator nerves, and pelvic wall.Case 2A 37-year-old was admitted with pelvic pain. Imaging showed the tumor at the left iliac bifurcation infiltrating the internal iliac artery and left sciatic, obturator, and femoral nerves.Both of these patients were treated with radical surgery that achieved no visible tumour at the end of the operation.ConclusionThere is no guideline for the diagnosis and management of this entity due to its rarity. These cases should be managed at highly specialized centres with expertise in radical surgery.     

Deep venous thrombosis associated with large leiomyomata uteri. A case report

BACKGROUND: The association of deep venous thrombosis (DVT) with uterine leiomyomata has been reported only rarely in the English-language literature. These concomitant findings occurred in a woman with no other known risk factors for development of DVT. CASE: A 49-year-old, Caucasian woman, gravida 3, para 3, with a past medical history significant for large uterine leiomyomata, menorrhagia and anemia, presented with acute edema of the left lower extremity. Doppler studies revealed compression of the left iliofemoral vein with associated thrombosis. No risk factors for DVT were identified. Intravenous heparin was initiated, with eventual preoperative placement of an inferior vena cava Greenfield filter. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed without complications. CONCLUSION: Large uterine leiomyomata are a potential cause of lower extremity venous stasis and resulting thrombosis and can be treated with hysterectomy.     

Isolated torsion of the fallopian tube during pregnancy: a case report

BACKGROUND: Isolated fallopian tube torsion during pregnancy is a rare condition, and only 16 cases have been reported. In all but 1 case the right tube was affected. We report the second case of isolated left fallopian tube torsion during pregnancy. CASE: A 23-year-old primigravida presented at 22 weeks of gestation with left lower abdominal pain. Sonography depicted a simple cystic mass adjacent to the left uterine border. Laparotomy revealed torsion of the left hydrosalpinx together with a paraovarian cyst. The patient delivered a healthy infant at term after an otherwise-uneventful pregnancy. CONCLUSION: As the gravid uterus increases the risk for fallopian tube torsion, this condition should be included in the differential diagnosis of lower abdominal pain during pregnancy.     

Laparoscopic Radical Excision of Primary Round Ligament Perivascular Epithelioid Cell Tumor Mimicking Leiomyoma

Perivascular epithelioid cell tumors (PEComas) are a group of rare mesenchymal tumors including angiomyolipoma, clear cell sugar tumor, lymphangioleiomyomatosis, and other unusual clear cell tumors at various locations. We describe a 45-year-old female patient presenting with a painless mass at the left lower abdomen. Computed tomography showed a circumscribed mass 8 × 7 × 8 cm in the left round ligament of the uterus. The provisional diagnosis was leiomyoma. The patient underwent initial laparoscopic excision. The histological and immunohistochemical diagnosis was malignant PEComa. She subsequently underwent laparoscopic radical excision of the residual left round ligament and surrounding tissue. At 18 months after surgery, she remained well without clinical and radiographic evidence of recurrent disease. According to this report, primary PEComa of the round ligament can mimic leiomyoma. Laparoscopic radical excision might be a feasible and safe alternative treatment of this tumor with a favorable outcome.     

Severe gestational edema

Lower extremity edema is an almost universal finding in late pregnancy, occurring secondary to increased venous pressure in the legs, obstruction of lymphatic flow, and reduced plasma colloid osmotic pressure. ¹ Varney describes gestational edema as the development of an excessive accumulation of fluid in the tissues without coexisting hypertension or proteinuria. ² Midwives are familiar with this common condition in an otherwise uncomplicated pregnancy and are comfortable reassuring clients that lower extremity edema is non‐pathologic. The patient with severe lower extremity edema, however, presents the provider with a clinical challenge. Is the presenting symptom a sign of an underlying disease process, or simply a normal physiologic process with extreme manifestation/expression? Lower extremity edema that rises to include the labia presents an intrapartum challenge of managing tissue integrity during the birth. A case of severe gestational edema is reported. Discussion explores broader considerations in differential diagnosis and management.     

Delayed Diagnosis of Iliac Vein Thrombus in a Sexually-Active Adolescent with Klippel-Trénaunay Syndrome

BackgroundAlthough iliac vein thrombus is uncommon in adolescents, it can present with pelvic inflammatory disease (PID) symptoms.CaseA 19-year-old sexually active female with Klippel-Trénaunay syndrome (KTS) presented with fever, abdominal and lower extremity pain. Physical findings included cervical motion tenderness and left lower extremity swelling and erythema. The patient was admitted for PID and cellulitis. Despite antimicrobial treatment her pain continued. Neisseriae gonorrhea and Chlamydia trachomatis cultures were negative. Abdominal and pelvic computed tomography scans revealed a left internal iliac vein thrombus. Anticoagulation therapy was initiated; her pain improved. On hospital day 7 she developed pulmonary emboli.Summary and ConclusionIn sexually active adolescents with known risk factors for thromboembolism such as KTS, symptoms and signs considered characteristic for PID can be present in association with an iliac vein thrombus.     

Postpartum paravaginal hematoma and lower-extremity infection.

We report a case of infection of the lower extremity after a normal vaginal delivery. The infection originated in an occult obturator internus muscle hematoma, and diagnosis was based on a clinical suspicion and characteristic findings on computerized tomography scan. These findings permitted prompt surgical drainage, debridement, and antibiotic therapy and resulted in a successful outcome.     

Diagnosis and management of leiomyosarcoma arising from ovarian vein: case report and literature review

Primary leiomyosarcomas arising from the ovarian vein are extremely rare and are associated with high morbidity. A 49-year-old nulliparous woman presented with a left lower abdominal mass. Although extremely rare, the radiological appearance is able to preoperatively identify malignant retroperitoneal masses, such as leiomyosarcomas originating from the ovarian vein; thus, the patient underwent a simple total excision of the mass-adjacent organs, as well as complete resection of the uterus, bilateral adnexae and the left ovarian vein. Adjuvant postoperative combination chemotherapy with gemcitabine and docetaxel was administered. At 22 months, she had no recurrence or metastasis. Delayed diagnosis and high metastatic potentiality are associated with the high morbidity of vascular leiomyosarcomas. The preoperative radiological appearance is useful for early diagnosis, and radical treatment with adjuvant chemotherapy consisting of gemcitabine and docetaxel may improve the poor prognosis of patients with leiomyosarcoma arising from the ovarian vein.     

Management of advanced-stage primary carcinoma of the fallopian tube: case report and literature review

Primary carcinoma of the fallopian tube is a very unusual gynecologic malignancy that accounts for less than 1% of all malignancies of the female genitalia. A 55-year-old, gravida 7, para 3 woman presented with no gynecologic complaints other than backache. TVS demonstrated a 35 x 25 mm heterogeneous mass that was not clearly separated from the left ovary, and another 31 x 14 mm cystic septated lesion in the left ovary region. Pelvic MRI demonstrated a 35 x 35 x 20 mm left adnexal mass that enhanced with contrast and a neighboring tubular-cystic mass. Upper and lower gastrointestinal endoscopy revealed no malignancy. Serum CA 125-level was merkedly elevated at 369 U/ml (normal < 35 U/ml). Laparotomy revealed left hydrosalpinx and a papillary-fimbrial mass. Pelvic lymph node metastases were observed. Frozen-section analysis identified the mass as a serous adenocarcinoma. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, pelvic and para-aortic lymph node dissection, and peritoneal washing were performed. The definitive histopathological diagnosis was primary serous adenocarcinoma of the fallopian tube with six of 25 lymph node biopsies showing metastasis. Six cycles of paclitaxel (175 mg/m2) plus cisplatin (75 mg/m2) combinatin chemotherapy were administered with 3-week intervals between cycles. Second-look laparotomy was performed; there was no evidence of disease. At the time of writing 12 months after the second-look laparotomy, she was still disease-free.     

妊娠合并卵巢幼年型颗粒细胞瘤一例报告及文献复习

目的：分析妊娠合并卵巢幼年型颗粒细胞瘤（juvenile granulosa cell tumor,JGCT）的临床特点、诊断要点、治疗及预后,提高鉴别诊断水平。方法：回顾性分析 1 例妊娠合并JGCT病例资料,复习相关文献。结果：患者27岁,因停经39+3周,间断右下腹疼痛3 d入院。彩色超声提示右下腹部一8.5 cm×6.1 cm囊实混合回声。查糖类癌抗原125（CA125） 32.3 U/mL, CA19-9为19.1 U/mL,诊断为先兆临产,盆腔包块（性质待排）,行剖宫产术+剖腹探查术,探查见右侧卵巢一囊性肿物,已破溃,行右侧卵巢肿物切除术,术后病理诊断为卵巢JGCT。行二次手术,给予右侧卵巢输卵管切除术+左侧卵巢活检术+盆腔淋巴结取样术+部分大网膜切除术+阑尾切除术+盆腔粘连松解术。术后予顺铂+长春新碱+博莱霉素（PVB方案）化疗3个疗程,随访8个月,肿瘤无复发。结论：JGCT是一种罕见的恶性肿瘤,发生于妊娠期者更为罕见,确诊需依赖病理及免疫组化检查。     

Association of fallopian tube cancer and polymyositis. Apropos of 1 case

A 51-year-old woman consulted for pelvic pain, metrorrhagia and leukorrhea. Physical examination revealed a renitent and mobile mass in the pelvis. A right lateral uterine mass with hydroxalpinx was found at ultrasonography. Pathology examination of the right annexectomy specimen provided the definitive diagnosis: fallopian tube cancer with polymyositis. No residual tumor was found at total hysterectomy with total bilateral annexectomy. The patient was lost to follow-up for three years without complementary treatment then consulted later for functional disability of the upper then lower limbs with myalgia, swallowing disorders and left supraclavian node enlargement resulting from pelvic relapse of the right fallopian tube adenocarcinoma and left supraclavian metastasis with paraneoplastic polymositis. The patient was given 6 courses of chemotherapy with radiotherapy (45 Gy) centered on the left clavian region. The patient exhibited a spectacular response, and remains in complete remission 50 months after diagnosis. The association of a fallopian tube tumor with polymyositis is exceptional, requiring rapid anticancer treatment effective against the cancer and the paraneoplastic polymyositis.     

Venous gangrene of lower extremities and Staphylococcus aureus sepsis.

This is a study of the venous gangrene of lower extremities and Staphylococcus aureus sepsis. We report on a premature infant who developed phlegmasia cerulea dolens (PCD) in both lower extremities in association with S. aureus sepsis, resulting in gangrene of the right foot. Non-pitting edema and cyanosis of the digits of the right lower extremity were noted 48 hours after hypotension and severe shock due to S. aureus sepsis. Intravenous antibiotics, isotonic fluids, and heparin were administered. Twenty-four hours later, edema and ischemic changes of the first and fifth left toes were also noted. Doppler flow study showed flow signals in both right and left popliteal arteries. However, there were no Doppler signals in neither right nor left popliteal vein. Emergency fasciotomies were performed on both lower limbs. The progression of the gangrene was limited to the right foot. There was complete resolution of PCD in both lower extremities. To the best of our knowledge, the association of S. aureus sepsis with PCD and venous gangrene in an infant has not been reported previously. This case illustrates the need for early recognition of PCD and aggressive intervention.     

Large paravaginal pelvic lipoma. A case report.

BACKGROUND: Pelvic lipoma is an extremely rare problem. Current imaging techniques are very helpful in diagnosis and assessment. CASE: A 36-year-old woman, gravida 2, para 3, presented with pelvic pressure and a bulging perineum on the left side. Pelvic examination revealed an 8 x 10-cm, soft mass filling the left hemipelvis. Pelvic ultrasound and computed tomography delineated the mass and suggested a fatty tumor without invasion of surrounding structures. Via laparotomy, a 400-g lipoma was removed from the left paravaginal/ paravesical/pararectal space. The patient had an uneventful recovery. CONCLUSION: Pelvic lipoma should be considered in the differential diagnosis of a soft, solid tumor filling the lateral pelvis. Ultrasonography and computed tomography are very helpful in assessing the nature of the mass. Removal can be done with a transperineal approach.