Microwave ablation of a large renal aspergilloma

Increasing numbers of immunocompromised patients have led to a corresponding rise in the incidence of invasive Aspergillus infections. Despite advances in antifungal therapy coupled with reduction in immunosuppression, invasive aspergillosis is associated with significant morbidity and mortality. Although surgical debulking has proven effective in difficult‐to‐treat cases, patient comorbidities may prevent such intervention. Non‐invasive alternatives to surgery are needed. Microwave ablation has many advantages over other ablative techniques, including convection profile, faster heating time, and higher intra‐lesion temperatures, which may be associated with greater therapeutic efficacy. We report a case of microwave ablation as an adjunct to medical therapy in angioinvasive renal aspergilloma.     

Presentation of ureteral colic in a patient with a ureteroinguinal hernia

The presence of ureter within an inguinal hernia is an uncommon occurrence. We report on the presentation of a patient with ureteral colic and subsequent discovery of a herniated ueter in the inguinal canal. Surgeons must be aware of this condition in order to carefully preserve ureteral integrity and avoid complications during hernia repair.     

A young man with a renal colic

We report the case of a 35-year-old man with no cardiovascular morbidity, presenting with acute flank pain, microscopic haematuria and normal blood pressure. Initially diagnosed as a ureteral colic, the patient was recovered 6 weeks later with severe hypertensive crisis. Further investigations revealed a massive renal infarction secondary to medial fibromuscular dysplasia (FMD). Several aspects of this presentation are intriguing. Renal infarcts are usually seen in older patients having cardiac problems and/or major atheromatous plaques. In addition, FMD is mainly observed in young females and rarely progresses to renal artery occlusion. Furthermore, in this case, FMD remained silent until the acute renal infarction occurred, despite a significant kidney size reduction at the time of diagnosis. Finally, the observation of a delayed hypertensive response to a major renovascular insult provides incentives to discuss possible pathophysiological mechanisms involved in renovascular hypertension.     

An aspergilloma in an echinococcal cyst cavity

Aspergilloma is a saprophytic infection which can colonize preexisting lung cavities. The most common underlying diseases are tuberculosis, sarcoidosis, cavitary lung cancer, etc. Although aspergilloma can also occur in operated hydatid cyst cavities, only a few cases have been reported in literature. A 32-year-old female patient underwent cystectomy for the diagnosis of perforated intraparenchymal giant hydatid cyst located in the right upper lobe, reaching down to the hilum. Capitonnage was not performed and it was observed that a residual cavity remained in the cystectomy area. The patient was discharged; however, during clinical and radiological follow-ups, it was found that the residual cyst cavity had expanded. As it was thought that one of the drainage bronchi in the cyst cavity could have opened, the patient was reoperated. During the operation, it was noted that purulent fluid and necrotic tissues were present in the cystic cavity. It was seen that the posterior upper lobe segment was consolidated and not ventilated. Contents of the cavity were removed and the posterior upper lobe segment was resected. Histopathological examination revealed that the tissue in the cavity was that of an aspergilloma, and that chronic organized pneumonia and diffuse interstitial fibrosis were present in the resected segment. Refraining from surgical obliteration (capitonnage) of cyst cavities in cases of giant hydatid cysts extending to the hilum can lead to opportunistic infections such as aspergilloma.     

Localization of an obstructing esophageal lesion

There are many opinions as to the accuracy of a patient's subjective localization of an obstructing esophageal lesion. However, there are few studies specifically examining this issue. Over a 35-month period, all patients evaluated by our gastroenterology service undergoing endoscopy for dysphagia were prospectively identified. The patient's subjective localization for the level of obstruction was evaluated by an investigator blinded to the results of prior barium esophagography and recorded on a schematic of the bony skeleton. At the time of endoscopy, the most proximal level of the obstructing lesion was documented. In all, 139 patients with dysphagia and an esophageal stricture were evaluated. Barium esophagograms were performed prior to endoscopy in all but nine patients (6.5%). The most common lesions causing dysphagia were carcinoma (34.5%), gastroesophageal reflux disease (22.3%), and a Schatzki's ring (15.8%). The level of obstruction was localized exactly in 30 patients (21.6%), within ±2 cm in 72 (52%), and within ±4 cm in 31 additional patients (74%). Eight patients (15%) with a distal esophageal lesion localized the obstruction to the proximal esophagus, whereas only two patients (5%) with a lesion in the proximal esophagus localized the level of obstruction to the distal esophagus. Overall, patients with distal obstructing lesions were more likely to have referral >6 cm proximally than proximal lesions with referral to the distal esophagus (P=0.003). There were no significant differences in accuracy based on the cause of dysphagia. In conclusion, a patient's subjective localization of the level of an esophageal stricture is highly accurate. Patients appear to be most accurate in localizing proximal rather than distal lesions.     

Intralobar pulmonary sequestration with aspergilloma in an adult

Intralobar pulmonary sequestration most often manifests with recurrent bacterial infections and fungal infections are rare. We report an unusual case of intralobar pulmonary sequestration with aspergilloma in a 49-year-old woman who presented with chronic cough and intermittent haemoptysis. The diagnosis of intralobar pulmonary sequestration was established by the multidetector computed tomographic angiography and the pathologic appearances of sequestrated lung tissue. The aspergilloma was detected postoperatively through histological examination of the resected lung tissue. Aspergilloma may occur as a superadded infection in any case of intralobar pulmonary sequestration presenting with chronic cough and recurrent bacterial infections.     

Acute biliary colic. Etiology,diagnosis and therapy

Acute biliary pain represents the main symptom of gallbladder stones, less frequently of common bile duct stones or functional disorders of the biliary tract. The pain lasts at least 15 minutes, is typically localized to the epigastrium or the right upper quadrant of the abdomen and my radiate to the right shoulder. Diagnosis of biliary pain is primarily based on clinical criteria, ultrasound allows detection of causative gallstones with high sensitivity and specificity. Analgesics and laparoscopic cholecystectomy are widely accepted as standard therapy for the majority of patients.     

Endoscopic resection of an obstructing antral web in an infant

Summary An antral web was discovered during the work-up of postcibal vomiting in an 18-month-old infant. An omphalocele repair had been performed previously and altered intraperitoneal anatomic relationships favored an endoscopic approach to web resection. The method devised was successful in removing the web; however, six weeks later laparotomy was necessary because of recurrent vomiting. At surgery the web was completely gone, although a circumferential ulcer was now present at the site of the prior web. Antroplasty was curative. An endosopic approach to antral webs is feasible and may in certain cases obviate laparotomy.