A case of multiple small pulmonary arteriovenous fistulas with chronic hepatitis and abdominal vessel abnormalities

A 63-year-old female was admitted with dyspnea on exertion. She had previously suffered from a large amount of epistaxis. Chest X-ray showed the bilateral diffuse granular infiltrates. Arterial blood analysis revealed severe hypoxemia and pulmonary function test showed reduced function of diffusing capacity. Dynamic radionuclide perfusion scintigraphy performed with 99mTc-labeled MAA demonstrated passage of microspheres through the pulmonary vasculature into the systemic circulation, indicating a right-to-left shunt. Although selective pulmonary wedge angiography did not directly demonstrate pulmonary arteriovenous fistulae, the histopathological findings of TBLB specimens revealed multiple dilated alveolar vessels that microspheres could pass through. In addition, chronic hepatitis, dilatation of splenic vein and spleno-renal anastomosis had been present. This type of pulmonary arteriovenous fistula is said to be a rare dispersed telangiectasic type, associated with a part of Rendu-Osler-Weber syndrome and a cause of hypoxemia in liver cirrhosis. We consider that in this case, the chronic hepatitis may have played an important role of developing multiple small pulmonary arteriovenous fistulas.     

An unusual case of a pleural effusion with an abdominal mass

A 38-year-old man presented to us with a left sided pleural effusion. Pleural fluid was aspirated and analysis revealed it to be an exudate with predominant lymphocytes and an elevated ADA level. He was discharged on antituberculous treatment. Patient returned with re-accumulation of pleural fluid. Computed tomography done in our institute picked up not only parenchymal disease in the lung which was not evident on chest radiographs but also picked up an abdominal mass in the left renal fossa. Pathological examination of excised mass revealed its tuberculous nature. The repeated recollection of pleural fluid was attributed to a "paradoxical response"; the patient was reassured and his anti-tuberculous treatment continued. Recognition of the fact that evidence of tuberculosis at distant sites may occasionally be needed to substantiate the diagnosis of tuberculous pleural effusion in a difficult and bacteriologically "negative" case prompted us to report this case.     

A case of autoimmune pancreatitis with multifocal mass lesions

We present a case of a 73-year-old man with multifocal autoimmune pancreatitis (AIP) in the pancreatic head and tail, and who had undergone sigmoidectomy and rectectomy 28 months before presenting to our department. Upon presentation, his serum IgG4 level was elevated at 267mg/dl, but tumor marker levels were within normal ranges. CT and MRI showed two localized pancreatic masses with delayed enhancement, but endoscopic retrograde pancreatography revealed neither stenosis nor dilatation of the main pancreatic duct. FDG-PET examination showed intense uptake in regions concordant with both tumors. The possibility of atypical AIP was a concern, but malignant tumor could not be clinically or radiologically excluded. Endoscopic ultrasonographic fine-needle aspiration biopsy was performed, but no malignant cells were detected. The patient underwent subsequent distal pancreatectomy. Histological evaluation of the tumors showed the presence of many IgG4-positive plasma cells without any evidence of malignancy.     

A case of cysticercosis with multiple intracerebral and intramuscular nodular lesions

A 47-year-old Chinese woman with no significant medical history admitted for sudden-onset seizures and transient right homonymous hemianopsia had moved from China to Japan 4 years previously. Contrast brain computed tomography (CT) showed multiple calcified nodular lesions with surrounding edema, one in the left parietal lobe being likely responsible for her visual symptoms. After admission, two painful intramuscular nodular lesions were found in her left lower limb. Histopathologically biopsy specimens from these lesions were not diagnostic. Serum antibody testing (ELISA) for Taenia solium, however, was positive, yielding a diagnosis of (neuro) cysticercosis. The woman responded well to albendazole and prednisolone treatment. In the two years since discharge, she has not developed any new symptoms or seizure recurrence. With increasing global travel, clinicians must thus consider the possibility of neurocysticercosis in cases of nodular brain lesions in subjects from areas where Taenia solium remains endemic.     

软骨肉瘤肺转移1例及文献复习

目的提高对软骨肉瘤肺转移的认识。方法结合一例软骨肉瘤肺转移患者的临床资料和文献复习,详细分析该病的病因、临床表现、诊断、鉴别诊断等。结果该病临床症状无特异性,确诊有赖于病理检查。结论软骨肉瘤肺转移罕见,极易误诊,应予重视。     

A case of an undifferentiated small cell carcinoma of the esophagus with a primary abdominal mass

This paper reports a case with an undifferentiated carcinoma of the esophagus which primarily developed symptoms due to metastatic lesions. The case was a 59-year-old woman with a primary manifestation of an abdominal mass and with subsequent dysphagia. A protruding lesion with ulceration was found at the lower third of the thoracic esophagus by endoscopic examination and was histologically proved to be an undifferentiated carcinoma by biopsy. The abdominal mass was initially thought to be due to metastasis to an abdominal lymph node based on the diagnosis image finding at admission, but it was consequently found by autopsy to be a metastatic tumor in the liver. Therefore, undifferentiated carcinoma of the esophagus should be take into account for differential diagnosis of an abdominal mass.