A case of Morgagni's foramen hernia difficult to differentiate from lipoma]

A 61-year-old woman was admitted for chest discomfort. She had been admitted before, in March 1995, because of a lesion detected on chest roentgenograms. At that time, she was given a diagnosis of mediastinal lipoma based on the findings of chest computed tomography (CT) and magnetic resonance imaging (MRI), but was discharged without active intervention due to lack of subjective symptoms. During follow-up, the patient again reported chest discomfort beginning in March 1998. Because chest radiography disclosed. The tumor had enlarged, the patient was admitted to the hospital by our department. Chest MRI disclosed a mass with a signal intensity equal to that of subcutaneous fat in the pericardial space on both T1-weighted and T2-weighted images. Although sagittal images demonstrated continuity of the mass into intraperitoneal fat, a conclusive diagnosis of diaphragmatic hernia could not be made at that time. On April 30, 1998, a thoracotomy was performed on the basis of a preoperative diagnosis of mediastinal lipoma. During surgery, a hernial ring was observed slightly to the right and behind the sternum. The hernia consisted only of greater omentum, and was diagnosed as Morgagni's foramen hernia.     

A case of sigmoid endometriosis difficult to differentiate from colon cancer

Background  

Although endometriosis with sigmoid serosal involvement is not uncommon in women of childbearing age, the mucosal involvement is rare and differential diagnosis from colon cancer may be difficult due to the lack of pathognomonic symptoms and the poor diagnostic yield of colonoscopy and colonic biopsies.     

A case of bronchocentric granulomatosis associated with Aspergillus that was difficult to differentiate from lung cancer]

We encountered a case of suspected bronchocentric granulomatosis (BCG) occurring in a COPD patient. Chest CT on admission showed a nodular shadow with indentation and a notch-like opacity in right S(3)a. Based on these findings, lung cancer was suspected. As we could not establish a definitive diagnosis, video-assisted thoracic surgery was performed. The histological findings of the resected specimen demonstrated BCG with clustering of fungal hyphae in the bronchioles. As the lesion was resected completely, we did not give additional treatment with an antifungal agent. It is difficult to differentiate BCG from lung cancer preoperatively. However, considering the homogeniecity of the nodule, it may be able to differentiate this type of lesion from lung cancer based on the feature. We report a rare case of a solitary nodule caused by BCG with Aspergillosis.     

A case of splenic pseudocyst complicated by acute pancreatitis

Splenic pseudocyst is a rare disease associated with chronic and acute pancreatitis splenic pseudocyst is treated by distal pancreatectomy and splenectomy. A 47-year old woman with a 10-year history of alcohol abuse presented with epigastric and left upper quadrant pain of 3 days duration. Abdominal CT showed a 4.0×4.5 cm sized cystic lesion in the tail of the pancreas. Analgesics was administrated for the relief of abdominal pain. On the 4th hospital day, the patient complained more of left upper quadrant pain, so we took follow up CT scans. On follow up CT, one large splenic pseudocyst with size of 9.5×4.5×10.0 cm was noted. The patient was treated conservatively by percutaneous catheter drainage and discharged on the 13th hospital day. This case is the first case report of splenic pseudocyst treated conservatively, not by surgery in Korea.     

A solitary lung lesion in Wegener's granulomatosis, which was difficult to differentiate from lung neoplasm]

A 35-year-old male was admitted to our hospital because of a persistent nasal obstruction and headache. In the laboratory findings, inflammatory reactions were seen, and anti-neutrophil cytoplasmic antibody (PR 3-ANCA) was positive. He was diagnosed with Wegener's granulomatosis (WG) based on the above symptoms, PR 3-ANCA positivity and pathology of nasal mucosa. Chest radiogram showed a solitary lung lesion in the apex of the left lung. The patient was treated with steroid and cyclophosphamide. Symptoms and inflammatory reactions were improved dramatically, however, the size of the solitary lung lesion did not change. Video-assisted thoracic surgery (VATS) was performed to differentiate the lesion from neoplasm. It showed features consistent with WG pathologically. The solitary lung lesion in WG is sometimes difficult to differentiate from lung neoplasm in clinical course, if the lesion does not improve by the standard therapy for WG. So in these cases, VATS is needed to confirm these lesions pathologically.     

A case of splenic inflammatory pseudotumor]

A 59-year-old man was admitted to our hospital because of continuous C-reactive protein elevation. Abdominal computed tomography scan revealed a low density mass on the surface of the spleen. Magnetic resonance imaging showed low intensity at peripheral area and slightly high intensity in the central area of the mass lesion on T1 and T2-weighted image. Splenectomy was performed since we could not rule out the possibility of malignant neoplasm only by diagnostic imaging. The pathological diagnosis of the tumor was inflammatory pseudotumor. Splenectomy is considered to be significant from the standpoints of both diagnosis and therapy in cases in which diagnostic imaging is difficult to interpret.     

A case of splenic inflammatory pseudotumor]

A 74-year-old woman underwent abdominal echography at a local clinic and a splenic mass was found. She was hospitalized for detailed examinations and treatment. Splenectomy was performed to make a definite diagnosis and for treatment because a definitive diagnosis could not be made, despite various examinations. Histopathological examination revealed that the lesion was infiltrated by polyclonal lymphoid cells and contained proliferating spindle-shaped fibroblasts without any atypical cells, so the splenic mass was diagnosed as an inflammatory pseudotumor. Because some cases of inflammatory pseudotumor can be diagnosed from the clinical course and imaging findings, this possibility should also be considered in the differential diagnosis of a splenic mass.     

A case of hepatic angiomyolipoma difficult to distinguish from hepatocellular carcinoma

We report a case of hepatic angiomyolipoma with uncommon clinical features. A 56-year-old man presented with a hepatic tumor in the caudate lobe. The tumor was hypoechoic on ultrasonography, showed early-phase hyperattenuation on enhanced computed tomography and did not absorb iron on superparamagnetic iron oxide-enhanced magnetic resonance imaging. Hepatocellular carcinoma was highly suspected, and the patient underwent hepatic resection. Histologically, the tumor was mainly composed of smooth muscle cells and contained small amounts of adipose cells and blood vessels. On immunohistochemical staining, the smooth muscle cells were positive for a melanocytic cell-specific monoclonal antibody. In cases with uncommon features of angiomyolipoma, it is quite difficult to distinguish angiomyolipoma from hepatocellular carcinoma.     

A case of mediastinal pancreatic pseudocyst accompanied by pancreatic pleural effusion]

A 52-year-old man was admitted with epigastric and back pain. Chest X-ray and whole body CT scan revealed left massive pleural effusion and cystic lesion in the posterior mediastinal compartment extending to the pancreatic body via the esophageal hiatus. MRCP showed the communication between the cystic lesion and main pancreatic duct which was irregularly dilated. Thoracentesis revealed sterile bloody fluid with markedly elevated amylase activity of 5,770 IU/l (pancreatic isozyme, 100%) and no malignant cells. From these examinations, a diagnosis of chronic alcohol-related pancreatitis accompanied by mediastinal pancreatic pseudocyst and pancreatic pleural effusion was made. We employed conservative therapy including chest tube drainage followed by operation (main pancreatic duct jejunal side-to-side anastomosis). The clinical course has been uneventful for more than 1 year after discharge.     

Pulmonary adenocarcinoma associated with SAPHO syndrome difficult to differentiate from multiple bone metastasis

The patient was a 57-year-old man with a chief complaint of anterior chest pain who was diagnosed with clinical stage IV (c-T2N2M1) non-small-cell lung cancer (adenocarcinoma). Tenderness in the sternoclavicular joint, acne, periodontitis, and palmoplantar pustulosis were evident, and SAPHO syndrome was diagnosed. SAPHO syndrome is a rare disorder that results in synovitis, acne, pustulosis, hyperostosis, and osteomyelitis. Bone scintigraphy showed tracer accumulation in the costal cartilage, sternoclavicular joint, and cervical vertebrae 6-7. Although the bone lesions of SAPHO syndrome were difficult to differentiate from bone metastasis of pulmonary adenocarcinoma, metastatic bone tumors were ruled out by magnetic resonance imaging, computed tomography, and fluorodeoxyglucose positron emission tomography. There have been no previously reported cases of lung cancer with comorbid SAPHO syndrome. We report such a case and discuss the relevant literature, particularly that concerned with the evaluation of bone lesions.     

Increased pleural fluid adenosine deaminase in brucellosis is difficult to differentiate from tuberculosis

Pleural involvement in brucellosis is very rare. Current knowledge on brucella pleuritis is limited to a few case studies, and pleural adenosine deaminase (ADA) in brucellosis has not been studied previously. We report the pleural fluid characteristics, including ADA, of two cases with brucella pleurisy. Analysis of the pleural fluids revealed exudative effusions with increased ADA level, decreased glucose concentration, and lymphocyte predominance. The similarity with tuberculous pleurisy was remarkable. We suggest that brucellosis should be considered in the differential diagnosis of tuberculosis, especially in regions endemic for both diseases.