Endometriosis: sonographic spectrum

Endometriosis is the presence of functional endometrial tissue outside the uterine cavity and the myometrium. It is an important cause of infertility and pelvic pain in women older than 25 years. Endometriomas are relatively common and can mimic other adnexal masses, and ultrasonography is often the first choice of imaging. This pictorial essay presents the sonographic appearance of endometriomas and similar-appearing adnexal masses and their characteristics, which may aid in their differentiation on routine ultrasonographic examination.     

Nitazoxanide: a new broad spectrum antiparasitic agent

Nitazoxanide (Alinia^®, Romark Laboratories) was synthesized based on the structure of niclosamide. In vitro studies have demonstrated activity against a broad range of parasites as well as some bacteria. Three controlled trials demonstrated efficacy in cryptosporidiosis, however, the efficacy in advanced AIDS patients (CD4 cell counts = 50) at approved doses was limited. Trials have also demonstrated efficacy comparable to metronidazole (Flagyl^®, GD Searle and Co.) in giardiasis with fewer side effects. Nitazoxanide is also effective versus intestinal helminths and tapeworms as well as in chronic fascioliasis. Side effects in clinical trials have been similar to placebo. Nitazoxanide is the first agent proven to be effective in cryptosporidiosis. It has also proven efficacy in giardiasis. Nitazoxanide is efficacious again intestinal helminths. Additional indications may be developed in the future.     

Nitazoxanide: a new broad spectrum antiparasitic agent

Nitazoxanide (Alinia, Romark Laboratories) was synthesized based on the structure of niclosamide. In vitro studies have demonstrated activity against a broad range of parasites as well as some bacteria. Three controlled trials demonstrated efficacy in cryptosporidiosis, however, the efficacy in advanced AIDS patients (CD4 cell counts = 50) at approved doses was limited. Trials have also demonstrated efficacy comparable to metronidazole (Flagyl, GD Searle and Co.) in giardiasis with fewer side effects. Nitazoxanide is also effective versus intestinal helminths and tapeworms as well as in chronic fascioliasis. Side effects in clinical trials have been similar to placebo. Nitazoxanide is the first agent proven to be effective in cryptosporidiosis. It has also proven efficacy in giardiasis. Nitazoxanide is efficacious again intestinal helminths. Additional indications may be developed in the future.     

Trophoblastic disease with coexistent fetus: a sonographic and clinical spectrum.

The sonographic and clinical spectrum of coexistent live fetus and trophoblastic disease is illustrated and discussed. Two patients with a single placenta with trophoblastic change and one patient with two placentas, one normal and one with a hydatidiform mole, are described. The clinical and sonographic abnormalities in all three patients were characteristic. In the two patients with single placenta, the histologic findings were minimal. The clinical and sonographic presentations of coexistent mole and fetus are described and etiology is discussed. The implication of the lack of histologic confirmation of hydatidiform mole suggests a spectrum of findings in trophoblastic disease.     

Splenic tuberculosis: an unusual sonographic presentation

Tuberculosis (TB) of the spleen is rare, especially in the immunocompetent. Recently there has been an increase in the incidence of splenic TB, primarily attributable to the raging HIV epidemic. Almost all cases of splenic TB present as multiple hypoechoic foci (< 2 cm) on ultrasonography. We present a case of a large solitary splenic tuberculoma in a middle-aged, non-immunosuppressed female, an employee at the local TB hospital. To the best of our knowledge, only two such cases have been described on ultrasound before. We suggest that, regardless of immune status, splenic TB should be considered as a diagnostic possibility when dealing with the solitary nodules of the spleen, especially when there is a history of exposure to or evidence of tuberculous foci elsewhere in the body.     

Anticoagulation with rivaroxaban: covering a broad spectrum of thromboembolic disease

Traditional anticoagulants such as heparin and vitamin K antagonists have been the mainstay of antithrombotic therapy for many years. However, these drugs have a number of well-recognized drawbacks: unfractionated heparin, low molecular weight heparins and fondaparinux are administered parenterally, and vitamin K antagonists require routine coagulation monitoring. Novel, single-target oral anticoagulants have been developed that do not need routine coagulation monitoring, including the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban, and the direct thrombin inhibitor dabigatran. Rivaroxaban is the most advanced in its clinical development. Across all ten Phase III/IV trials, rivaroxaban met the primary efficacy end points and generally had similar incidences of bleeding, with a comparable safety profile to standard-of-care.     

Adrenal and extra-adrenal pheochromocytomas: an ultrastructural and formaldehyde-induced fluorescence study with catecholamine content

Twenty-one adrenal and 6 extra-adrenal pheochromocytomas were studied by light and electron microscopy, and formaldehyde-induced fluorescence (FIF). These morphological findings were compared to the content of tumor catecholamines. Based on predominancy of the cell types, pheochromocytomas were classified into three groups: basophilic, chromophobic and oxyphilic (oncocytic) types. The basophilic type was characterized by basophilic cytoplasm of the tumor cells with hematoxylin and eosin (H & E) stain, green cytoplasmic fluorescence with FIF and numerous epinephrine type of electron dense granules with electron microscopy. Its epinephrine content was compatible to the normal adrenal medulla. The basophilic type was only of adrenal origin. Chromophobic and oxyphilic tumors contained predominantly norepinephrine, and showed yellow-green or light brown cytoplasmic fluorescence by FIF. By electron microscopy, various granules of different sizes and shapes of the norepinephrine type were noted. Extra-adrenal pheochromocytoma cells demonstrated dark brown cytoplasmic fluorescence by FIF. Morphological findings of the extra-adrenal tumor corresponded to those of chromophobic type adrenal pheochromocytoma. The tumors contained only norepinephrine.     

Transvaginal sonographic appearance of endometriomata: spectrum of findings

The spectrum of transvaginal sonographic findings was evaluated in 37 surgically proved endometriomas. Sonographic features assessed included lesion size, acoustic enhancement, wall thickness, wall contour, presence of a fluid-fluid level, and presence of internal echoes. A very characteristic finding seen in 31 (82%) cases is the presence of a homogeneous hypoechoic "carpet" of low-level echoes. This may be present diffusely or in one or several loculations of a multiloculated cystic mass. We consider this finding characteristic of an endometrioma, although not pathognomonic, as on occasion we have encountered other pathologic conditions that have the same appearance.     

Adrenal hypertrophy: possible pitfall in the sonographic diagnosis of renal agenesis

Six cases are presented in which the sonographic appearance of adrenal enlargement in the fetus or neonate mimics that of renal tissue. When normal renal tissue is not present, the adrenal preserves its characteristic echogenic medulla and anechoic cortex but enlarges, loses its characteristic "V" or "Y" shape, and appears more elliptical on ultrasound scans. The average length of the adrenal was 3.4 cm on the right and 2.9 cm on the left in these cases, with adrenal thickness increased to an average of 5 mm. Care must be taken not to mistake the enlarged adrenal for renal tissue. Conversely, an elongated adrenal gland without adjacent renal tissue does not necessarily imply renal agenesis, but may occur with renal ectopia.     

Abnormal endometrial echoes: sonographic spectrum of endometrial pathology

This report reviews the cases of 12 patients in whom ultrasound examination revealed endometrial cavity echoes that were more prominent than expected. Dilatation and curettage or hysterectomy, or both, in these patients revealed a spectrum of endometrial pathology in 83 per cent of the patients, including carcinoma in 33 per cent and normal findings in 17 per cent.     

Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation.

OBJECTIVE: To determine the spectrum of sonographic findings on gray scale and color Doppler sonography in a series of pathologically proven cases of ovarian and adnexal torsion. METHODS: The study population included 15 patients with surgical confirmation of ovarian or adnexal torsion, or both, who underwent sonographic examination before surgery. All sonograms were reviewed retrospectively. RESULTS: Gray scale abnormalities included the following: complex masses in 11 (73%) of 15 patients, cystic masses in 3 (20%), and a solid mass in 1 (7%). Cul-de-sac fluid was present in 13 (87%) of 15 patients. Adnexal neoplasms were present in 4 (27%) of 15 (1 granulosa cell tumor and 3 dermoid cysts) on pathologic examination. Doppler findings were abnormal in 14 (93%) of 15 patients and normal in 1 (7%). Abnormal Doppler findings included no arterial and no venous flow in 6 (40%) of 15, decreased venous flow with no arterial flow in 5 (33%), decreased venous flow and decreased arterial flow in 2 (13%), and decreased arterial flow with no venous flow in 1 (7%). Small amounts of cul-de-sac fluid were present in 13 (87%) of 15 patients. CONCLUSIONS: The diagnosis of ovarian and adnexal torsion remains challenging. It cannot be based solely on the absence or presence of flow on color Doppler sonography, because the presence of arterial or venous flow does not exclude the diagnosis of adnexal torsion. Comparison with the morphologic appearance and flow patterns of the contralateral ovary will aid in diagnosis.     

Moxifloxacin (Avelox): a novel fluoroquinolone with a broad spectrum of activity

Moxifloxacin (Avelox) is a recently-developed fluoroquinolone that has a broad spectrum of antimicrobial activity, including typical respiratory pathogens, atypical and intracellular respiratory pathogens, Gram-negative pathogens and many anaerobes. This spectrum of activity makes moxifloxacin particularly suitable for the therapy of community-acquired respiratory tract infections. It also has enhanced activity against specific bacteria, such as Mycobacteria spp. and Legionella. Moxifloxacin has pharmacologic characteristics that support once-daily dosing regimens and dual routes of excretion that require little or no adjustment for renal or hepatic insufficiency. The drug has maintained an excellent safety profile based upon broad global usage, and no adverse events have occurred that were unanticipated. Streptococcus pneumoniae, which are resistant to earlier fluoroquinolones, are less likely to be resistant to moxifloxacin.     

Chest pain in the emergency department: the broad spectrum of causes.

We performed a prospective study to describe the broad spectrum of causes of chest pain in patients presenting to the emergency department and to compare the diagnoses in referred patients, self-referred patients and patients rushed in by ambulance. The final diagnosis in a consecutive case series of 578 chest pain patients was established after discharge from the hospital. The underlying disorders were grouped into cardiac, respiratory, gastro-oesophageal disorders, musculoskeletal pathology, somatization disorders, other diseases and unknown. For comparison of the frequencies of the disease categories the Chi-squared test was used. Out of 578 patients, 161 (27.9%) were self-referred, 369 (63.8%) were referred by the general practitioner and 48 (8.3%) were rushed in by ambulance. Cardiac diseases represented 51.7% of the cases, myocardial infarction and unstable angina 19% and 12.8% respectively Cardiac diseases were statistically significantly less common in self-referred patients (p<0.0005). Pulmonary diseases encompassed 14.2% of the population, followed by somatization disorders (9.2%), musculoskeletal pathology (7.1%) and other causes (4.3%). In 11.1% of the cases no definite final diagnosis could be established. Somatization disorders were significantly more frequent in self-referred and ambulance patients. Cardiac and pulmonary problems are the most frequent underlying disorders in acute chest pain patients in the emergency department. Somatization disorders and musculoskeletal pathology represented respectively 19.1% and 14.8% of the non-cardiac causes. The referral pattern influenced significantly the distribution of the disease categories with more cardiac and less psychiatric disorders in referred patients.     

Hepatic focal nodular hyperplasia: CT and sonographic spectrum

Fifteen patients with pathologically proven focal nodular hyperplasia (FNH) of the liver had abdominal computed tomography (CT) (15) and ultrasound (11). In seven patients, the lesions were incidentally found during gallbladder or renal examination, whereas the other eight had a primary neoplasm and the liver was studied for possible metastasis. In 11 unenhanced CT scans, the ratio of isodense to hypodense lesions was 8 to 3. In 15 contrasten-hanced CT scans, seven were isodense, six were hypodense, and in two, the lesion enhanced (hyperdense). In seven patients a hypodense lesion on unenhanced CT became isodense with contrast injection. Delayed images in three showed the lesions appearing as hypodense in two and displaying a rim of enhancement in one. In one case, unenhanced CT was normal and only enhanced CT showed an area of homogeneous increased density. Ultrasound was done in 11 patients, the lesion was hypoechoic to the liver in five, echogenic in four, and isoechoic in two. Findings of central scar were seen on CT and ultrasound in three cases. Pathologic diagnosis was available in all cases, seven by needle aspiration and eight by surgical resection. In our experience, FNH has many CT and sonographic features that can mimic hemangioma or metastasis. While the presence of a central scar increases the specificity, in a cancer patient, the findings should be interpreted with caution and needle aspiration should be obtained.     

Adrenal insufficiency in primary adrenal lymphoma: Innocuous presentation of a rare sinister illness

Adrenal insufficiency can often manifest with nonspecific complaints. Primary adrenal lymphoma is a rare cause of adrenal insufficiency. We present the case of a 55-year-old female who presented with nonspecific complaints of abdominal pain, pallor and weight loss and was found to have primary adrenal lymphoma. The case highlights the need to expeditiously initiate steroid replacement in patients with adrenal insufficiency, while efforts are made to establish the etiology of adrenal insufficiency.