Neutrophilic eccrine hidradenitis: a case report of an unusual annular presentation

Neutrophilic eccrine hidradenitis (NEH) is an acute, self-limited, inflammatory neutrophilic dermatosis. It is most commonly described in patients with acute myelogenous leukemia (AML) following chemotherapy. NEH generally presents as erythematous papules and plaques on the head, trunk, and extremities. Histologically, NEH is characterized by a neutrophilic infiltrate surrounding eccrine ducts and coils with occasional necrosis. We describe a case of NEH with an unusual presentation of annular plaques. A search of the literature revealed only one other case report of NEH presenting as an annular eruption.     

Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report

Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures. Specifically, it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement. Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy. CASE SUMMARYA 74-year-old female presented with jaundice and weight loss. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct (CD) and proximal common bile duct (CBD). The associated distal CBD stricture was dilated and stented with a plastic stent. However she subsequently developed cholangitis, prompting referral for a repeat ERCP. The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture. Despite using multiple hydrophilic guidewires, the stricture could not be traversed due to preferential wire passage into the dilated CD. SpyGlass DS (Boston Scientific Corp, Marlborough, MA, United States) was then used to visualize the orifices of the CD and CBD stenosis, enabling the guidewire to be placed directly through the stricture into the proximal CBD. A WallFlex covered metal stent (Boston Scientific Corp, Marlborough, MA, United States) was successfully placed, resulting in resolution of her cholangitis. CONCLUSIONTo our knowledge, this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.     

Cemento-ossifying fibroma of the left mandible: A case report

Ossifying fibroma is a type of benign fibro-osseous lesion. Most lesions affect the mandible region, particularly the molar and pre-molar areas. It predominantly affects females between the second to fourth decades of life. Larger ossifying fibroma tumors require more extensive resection.CASE SUMMARYA 39-year-old female complained of occasional pain and tumor enlargement on her left jaw for the 3 years prior to presentation. Intraoral examination revealed a firm swelling on her left lower gum. Extraoral examination revealed swelling on the left mandible body with no erythema and superficial ulcer. Computed tomography scan revealed a circular-shaped lesion on the patient’s left mandible body with a well-defined radiolucent border, sized 3.2 cm × 2.8 cm × 0.9 cm. The tumor was removed by marginal mandibulectomy. Biopsy from the resected tumor suggested cemento-ossifying fibroma (COF).CONCLUSIONCOF is often unnoticed, but this slow-growing tumor can cause significant symptoms regarding its distortion into adjacent structures.     

Rare case of perforated giant gastric ulcer with concurrent thyroid storm: A case report

Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate. The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of both the sympathetic and parasympathetic pathways. We present a case of perforated giant gastric ulcer with concurrent thyroid storm who underwent damage control surgery with emergency patch repair with falciform ligament and recovered well. CASE SUMMARYA 53-year-old male chronic smoker, with no previous medical history, presented with severe generalized abdominal pain and vomiting for one day duration. Further history revealed weight loss, diarrhea, and anxiety over the past three months. On clinical examination, patient was febrile with temperature of 38.6 Degrees Celsius and tachycardic at 130-140 beats per minute, his blood pressure was low at 90/50mmHg. His abdomen was tender with generalized peritonism. In view of his clinical history, a thyroid screen was ordered which showed raised thyroxine (T4) levels of 90.3 pmol/L and low thyroxine stimulating hormone (TSH) levels of 0.005 μU/mL. Chest X-ray showed no sub-diaphragmatic free air, but contrasted CT scan revealed pneumoperitoneum with large amount of intraabdominal free fluid. The working diagnosis was perforated peptic ulcer complicated by thyroid storm. An urgent endocrinologist consult was made, and patient was started on beta blocker and intravenous steroids pre-operatively. The patient underwent emergency laparotomy with washout and patch repair of the perforated gastric ulcer. Patient was monitored post-operatively in intensive care unit and required IV hydrocortisone and Lugol’s iodine. Histology of the ulcer edges showed no malignancy. On post-operative day seven, T4 decreased to 20.4 pmol/L, TSH was 0.005 mLU/L. His thyroid function test subsequently normalized 3 mo post-operatively with T4 18.1 pmol/L, TSH 1.91 mLU/L. Patient’s recovery was otherwise uneventful. Thyroid receptor antibody subsequently was positive, and patient was managed for Grave’s disease by the endocrinologist. CONCLUSIONThis case highlights the rare but life-threatening clinical emergency of peptic ulcer perforation complicated by thyroid storm. Multidisciplinary perioperative management is crucial to optimize patient for surgery and damage control principles should be taken for an acute surgical patient with concurrent endocrine crisis.     

Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report

Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.CASE SUMMARYA 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.CONCLUSIONWe present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.     

Superior mesenteric artery syndrome in a patient with esophageal stenosis: A case report

Superior mesenteric artery syndrome (SMAS) is a rare condition, characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery (SMA). Most cases of SMAS are associated with weight loss, and the most frequent clinical manifestations are nausea, vomiting, postprandial fullness, and abdominal pain. Treatment of SMAS is usually conservative, consisting mainly of adequate nutritional support, but in refractory cases surgery may be necessary, with gastrojejunostomy and duodenojejunostomy being the most commonly performed procedures. CASE SUMMARYWe describe the case of a man in his forties with a pre-existing diagnosis of esophageal stricture due to sodium hydroxide ingestion, who suffered significant weight loss after replacement of his jejunostomy tube. He was admitted to the hospital due to pain and abdominal distension. A computerized tomography scan showed significant distension of the stomach and duodenum with narrowing of the duodenum at the point at which it is crossed by the superior mesenteric artery, thus establishing the diagnosis of SMAS. Due to the presence of the esophageal stricture, the patient was incapable of emesis; however, passage of a nasogastric tube for decompression was not possible. Considering the risk of gastric perforation due to distention, we opted for surgical treatment in the form of a surgical gastrojejunostomy after which he showed complete resolution of all symptoms and was discharged from the hospital 5 d after the procedure.CONCLUSIONDiagnosis of SMAS can be challenging in patients with esophageal stenosis, and risk of gastric perforation may preclude conservative treatment.     

Pseudoepitheliomatous hyperplasia - an unusual reaction following tattoo: report of a case and review of the literature

A 59-year-old woman presented with an itchy and uncomfortable raised lesion at a tattoo site (Fig. 1) on the lateral aspect of the left leg, just above the ankle. The tattoo had been placed 2 years before her presentation and the tattoo site was sun exposed. Immediately after she had the tattoo, she noticed redness of the skin. After a week, a pruritic and red scaly nodule developed that continued to gradually enlarge until her presentation. The patient had tried topical vitamin A and D ointment with no relief. The patient also had tattoos on the arms without any noticeable skin changes. The patient reported that the tattoo procedure on her leg was more painful than that on her arms, and was performed by a different (and perhaps inexperienced) tattoo artist. The original tattoo contained red, green, and yellow pigments. A diagnosis of tattoo granuloma was considered; squamous cell carcinoma and fungal infection were included in the differential diagnosis. A punch biopsy was performed, followed by complete surgical excision of the lesion with a split-thickness skin graft from the right thigh. The skin excision specimen showed a 3 x 2.5-cm granular and pitted pink lesion with well-demarcated, somewhat irregular borders. The lesion was raised 0.5 cm above the skin surface. The lesion was present in the center of the original tattoo. Portions of the original tattoo with green and blue-green pigmentation were visible on either side of the lesion. No satellite lesions were identified. Microscopically, the raised lesion demonstrated striking pseudoepitheliomatous hyperplasia, with irregular acanthosis of the epidermis and follicular infundibula, hyperkeratosis, and parakeratosis (Fig. 2). Follicular plugging was present with keratin-filled cystic spaces. There was a brisk mononuclear inflammatory infiltrate in the dermis, composed primarily of lymphocytes, with admixed plasma cells and histiocytes. Giant cells were occasionally identified. Dermal pigment deposition was noted both within the lesion and in the surrounding skin, corresponding to the original tattoo. Variable dermal fibrosis was noted, with thick collagen bundles in some areas. There was no evidence of epidermal keratinocytic atypia, dyskeratosis, or increased suprabasal mitotic activity. Special stains (periodic acid-Schiff and acid-fast) for microorganisms were negative.     

Clear cell papillary renal cell carcinoma: A case report and review of the literature

Clear cell papillary renal cell carcinoma (ccpRCC) was recently established as a distinct type of epithelial neoplasm by the International Society of Urological Pathology Vancouver Classification of Renal Neoplasia. Here, we report a case of partial nephrectomy for a ccpRCC detected during the routine follow-up of a previously treated liposarcoma in a 70-year-old male patient. The patient was referred to the urology department for a right-sided renal mass (size: 2 cm) detected during routine annual imaging follow-up for a malignant right inguinal fibrous histocytoma and liposarcoma that had been diagnosed 6 and 4 years earlier, respectively, and treated with surgery and adjuvant radiation therapy. Following partial nephrectomy, the renal mass was pathologically diagnosed as ccpRCC, and immunohistochemistry revealed carbonic anhydrase 9 (CA9) expression. No recurrences or metastases were detected on follow-up imaging for 6 months. This is the first report of partial nephrectomy for incidentally discovered CA9-positive ccpRCC.     

Tumefactive foreign body giant cell reaction following high‐pressure paint injection injury: A case report and review of literature

High‐pressure paint injection injury is an uncommon but well‐described injury. The histologic features of long‐term paint injection injury with retained material are less recognized. A 46‐year‐old male presented clinically as “recurrent giant cell tumor of tendon sheath.” The right index finger demonstrated fusiform enlargement by a pigmented mass with diffuse infiltration into the soft tissue of the hand. Histologically the tumor showed multiple giant cells in a fibrotic stroma extending into the dermis. There were multiple types of foreign material including diffuse brown black pigment, weakly optically polarizing foreign material and white inclusions with a “train track” appearance. The cells were positive for CD68 and negative for S100 antigen. Further investigation revealed that the patient had a history of high‐pressure paint injection injury to his digit 6 years prior. Foreign material injected under high pressure into tissues may result in a pseudo‐neoplastic foreign body granulomatous reaction that can mimic giant cell tumor of tendon sheath. Our case demonstrates that this reaction can be florid and can have slow growth over years. A high index of suspicion, a good clinical history and careful examination can distinguish these 2 entities.