Ultrasonographic demonstration of popliteal cysts in rheumatoid arthritis

Ultrasound scanning techniques detected popliteal cysts in 14 of 24 knees affected with rheumatoid arthritis and associated with an anterior effusion. Serial scans demonstrated the persistence of cysts when effusion was not controlled by intraarticular steroid and lidocaine, and regression of cyst following control of effusion with anterior synovectomy. As the technique is noninvasive, painless, and reproducible, ultrasound scanning should be the technique of choice for the detection and assessment of popliteal cysts.     

Unusual echocardiographic manifestation of pericardial effusion.

Echocardiographic and sector scanning examinations were performed in a patient with pericardial effusion. In addition to the demonstration of fluid posterior to the left ventricle and anterior to the right ventricle, as in most significant pericardial effusions, there was an echo-free space representing fluid recorded posterior to the left atrium. Several possible explanations of this finding are offered.     

A case of dermoid cyst ruptured into the lung

Ruptured cystic teratomas (dermoid cysts) are rare and always symptomatic, presenting as haemothorax, pleural effusion or pericardial effusion. We present an extremely rare case of a 45-year-old woman who, during a routine health assessment was noted to have a well-defined anterior mediastinal tumour with peripheral ground glass opacity on chest CT. The patient was asymptomatic. She underwent video-assisted thoracoscopic surgery and a ruptured dermoid cyst was observed and the contents had infiltrated into the right pulmonary parenchyma. There were no complications and no evidence of recurrence 10 months later. Despite most cystic teratomas being asymptomatic and benign, rupture into the pulmonary parenchyma may induce further damage, for which emergency surgical intervention is always necessary.     

Subepicardial adipose tissue producing echocardiographic appearance of pericardial effusion. Documentation by computed tomography and necropsy

An isolated anterior echo-free space is generally regarded as a false-positive echocardiographic finding for pericardial effusion. Even when an anterior echo-free space is accompanied by a posterior echo-free space, the echo-free spaces have been occasionally reported to be falsely positive for pericardial effusion, principally in patients with cardiac neoplasms. The basis for these findings had never been adequately explained. In the present study, evaluation by computed tomographic imaging or necropsy examination of 5 patients in whom there was either an anterior or posterior echo-free space or both demonstrated that subepicardial adipose tissue is the echocardiographic imitator of pericardial effusion.     

Echocardiographic interpretation of pericardial effusion

Echocardiography has proved to be quite useful in the detection of pericardial effusion. As little as 15 ml of fluid within the pericardial space can be detected. Specific signs of pericardial effusion, such as electrical alternans and paradoxical pulse, have become better understood by echocardiographic study. Yet, with all the benefits of echocardiography, the detection of pericardial effusion still may be quite difficult if careful attention is not given to technique. False-positive diagnosis of anterior pericardial effusion can be seen with epicardial fat pad, pericardial cyst, or foramen of Morgagni hernia. False-positive posterior pericardial effusion can be seen in large left pleural effusion, calcified mitral anulus, or excessively medial transducer angulation. New "switched-gain" circuits have helped detection of pericardial effusion by enhancement of pericardial echoes.     

Echocardiographic mimicry of pericardial effusion

Echocardiography is a sensitive technique for the detection of pericardial effusion, but the abnormal echocardiographic patterns seen with effusions are not, however, entirely specific for that diagnosis. This study describes four patients in whom anatomic structures, a coronary artery to coronary sinus fistula (one case) and tumors metastatic to pericardium (three cases), produced posterior and, in two cases, anterior spaces compatible with pericardial fluid. Echocardiographic patterns mimicking pericardial effusion have previously been reported in patients with anatomic abnormalities such as mitral anular calcification, pleural effusions, left atrial enlargement, anterior mediastinal or pericardial tumors, foramen of Morgagni hernia and pseudoaneurysm of the left ventricle. It appears that structures of fluid or tissue density, interposed between the heart and the airfilled lung, can produce echocardiographic patterns simulating pericardial effusion.     

Diagnosis of cardiac tamponade by echocardiography: changes in mitral valve motion and ventricular dimensions, with special reference to paradoxical pulse.

The echocardiographic findings in three patients who presented with pericardial effusion and cardiac tamponade are described. Cyclic respiratory changes affected the diastolic movement of the anterior mitral leaflet, viz., during inspiration its anterior excursion decreased in amplitude and the E-F slope diminished. This inspiratory alteration in mitral valve motion was accompanied by an increase in right ventricular dimensions and a reciprocal decrease in left ventricular dimensions. Pericardial paracentesis confirmed the presence of effusion and relieved cardiac tamponade in all the patients. Repeat echocardiography, performed in two of the patients immediately after the pericardial tap, showed that the E-F slope had become steeper and that phasic respiratory variations in the diastolic motion of the anterior mitral leaflet were no longer present. The compatibility of our observations with the theories which endeavor to explain the mechanism of the paradoxical pulse in pericardial effusion with cardiac tamponade is discussed. We suggest that the abnormalities in anterior mitral leaflet motion defined by echocardiography constitute a useful addition to the study of patients with suspected cardiac tamponade resulting from pericardial effusion.     

An unusual precordial pulse and sound assoicated with large pericardial effusion.

An unusual, high-pitched, early diastolic sound coinciding with a prominent, sharp precordial pulse was observed in a patient with a large chronic pericardial effusion. The pulse and sound coincided exactly with the anterior excursion of the heart within the fluid-filled pericardial sac, suggesting that the sound and pulse result from the ballistic effect of the heart striking the anterior pericardium and chest wall. This finding may be specific for large pericardial effusion with a "swinging heart."     

Diagnostic value of two-dimensional echocardiography in cardiac hydatid disease.

Echinococcal infection of the heart is rare. The preoperative findings, with special attention to two-dimensional echocardiography (2DE), of six patients with cardiac echinococcosis and their surgical and pathological correlations are reported. Cardiac hydatid cysts (HCs) were located in the cardiac apex in three patients, in the upper part of the interventricular septum extending towards the anterior aspect of the heart in one and in the postero-superior right atrial wall in another patient. The remaining patient had multiple intrapericardial cysts. In three patients the cysts presented as well defined, rounded, echolucent masses within the myocardial wall bulging into the cardiac chambers. In two patients, the cysts had ruptured into a cardiac chamber with loss of the characteristic 'cystic' appearance; these cysts presented as an echogenic or solid mass protruding into a cardiac chamber. Finally, another patient had one HC with echolucent appearance and another HC in a different location with echogenic appearance; this last cyst corresponded to a degenerated HC. In two cases the cyst showed a loculated internal aspect. In one patient the myocardial segment involved by the cyst had a dyskinetic movement. In all six patients, 2DE accurately demonstrated the location and morphological details of the cardiac cysts, permitted recognition of the ruptured and/or degenerated cysts and was superior to thoracic computed tomography and angiography in the preoperative assessment of these patients. Nuclear magnetic resonance imaging (one patient) gave no further information to that obtained by 2DE. We conclude that 2DE is the technique of choice for an early diagnosis of this rare entity.     

A new approach to the surgical treatment of parasitic cysts of the liver： Hepatectomy using the liver hanging maneuver

AIM： To review 11 patients with parasitic cysts of the liver, who were treated by hepatic Iobectomy using the liver hanging maneuver （LHM）.
METHODS： Between January 2003 and June 2006, we retrospectively analyzed patients who underwent surgical treatment due to parasitic cysts of the liver, at the Ege University School of Medicine, Department of General Surgery. Of these, the patients who underwent hepatic lobectomy using the LHM were reviewed and evaluated for surgical treatment outcome.
RESULTS： Over a three-year period, there were 102 patients who underwent surgical treatment for parasitic cysts of the liver. Of these, 11 （10%） patients with parasitic cysts of the liver underwent hepatic Iobectomy using the LHM. Presenting symptoms were abdominal pain, dyspepsia, and cholangitis. Cyst locations were as follows： right lobe filled with cyst, 7 （63%）; segmental location, 2 （18%）; and multiple locations, 2 patients （18%）. All patients underwent hepatic Iobectomy with an anterior approach using the LHM. The intraoperative blood transfusion requirement was one unit for 3 patients and two units for one patient. Postoperative complications included pulmonary atelectasy （2, 18%） and pleural effusion （2, 18%）. No significant morbidity or mortality was observed.
CONCLUSION： We concluded that hepatic Iobectomy using the LHM should be considered, not only for hepatic tumors or donor hepatectomy, but also to treat parasitic cysts of the liver.     

Recurrent multiple cardiac hydatidosis.

Cardiac hydatid cyst is an uncommon disease. We report on a woman admitted to our clinic with chest pain and palpitations. The ECG showed anterior ischemia, and coronary anatomy was normal. The diagnosis was: multiple cardiac hydatid cysts, for which she had undergone surgery 4 years earlier for a 5 x 5 hydatid cyst and treated with albendazole. Despite this, there was a recurrence of multiple cysts. Recurrence of intracavitary hydatid cyst is rare, and surgical treatment of multiple, small cysts remains controversial.     

Large parathyroid functioning carcinoma (1,200 g) presenting as a substernal goiter.

Parathyroid carcinoma is a rare tumor responsible for 0.5-5% of primary hyperparathyroidism. It is usually small (not more than 27 g) and the precise diagnosis of malignancy is made when local or distant metastases are found. We describe a case of a 37 yr old male presenting with a substernal goiter and no specific symptoms except hypertension. This mass had cysts and calcifications and it was in the anterior upper mediastinum. The patient had severe hypercalcemia (Ca greater than 14 mg/dl), high PTH levels and mild renal failure. Bone scanning showed signs of hyperparathyroidism. The patient was subjected to total thyroidectomy and removal of the mass en block. The tumor was circumscribed lobulated and mostly cystic. It weighed 1,200 g (380 g after evacuation of cysts) and measured 12 x 9 x 4.5 cm. Histologic examination showed a highly differentiated adenocarcinoma of parathyroid with metastasis in a regional lymph node. Almost 4 years later the patient is alive and well without hypercalcemia and without evidence of distant metastases.     

A modular, flexible training strategy to achieve competence in diagnostic and interventional musculoskeletal ultrasound in patients with hip osteoarthritis

OBJECTIVE: This study sought to establish a model of training and an assessment of competency in musculoskeletal ultrasound (MSUS) diagnosis of hip synovitis and/or effusion and in MSUS-guided injection of the hip. METHODS: The 'trainee' (no previous experience in MSUS) was trained by an 'expert' [a rheumatologist who is a trainer on the European League Against Rheumatism (EULAR) MSUS course] using a modular approach focused on hip ultrasound only. This consisted of (i) a 1.5 h initial tutorial and practical demonstration and (ii) indirectly supervised non-continuous scanning of 40 hips over 5 h. Competency was assessed in three ways: (i) ability to obtain standard EULAR reference MSUS images of the hip of sufficient image quality, (ii) accuracy in diagnosis of synovitis or hip effusion by measurement of the anterior femur-capsule distance, and (iii) accuracy in ultrasound-guided hip aspiration and injection. RESULTS: After a period of scanning of 75 min (10 hips), the images obtained by the trainee were consistently graded as acceptable for routine clinical use. Next, blinded triplicate measurements of the anterior femur-capsule distance performed by the trainee and expert showed agreement regarding diagnosis of hip effusion (>7 mm thickness) in 16/17 cases of hip arthritis (kappa 0.876). The trainee performed 40 MSUS-guided hip injections (seven directly supervised followed by 33 indirectly supervised). After 10 consecutive MSUS-guided hip injections, the novice achieved a subsequent accuracy rate of 25/26 (96%) confirmed by radiographic localization of radiopaque contrast. CONCLUSIONS: Using a modular approach, a learner-centred curriculum and a self-directed learning strategy with a minimum of direct supervision, a trainee achieved competence in MSUS diagnosis of hip effusion/synovitis and in MSUS-guided hip aspiration/injection.     

Enlarged left atrium causing possible false positive echocardiographic diagnosis of pericardial effusion.

Echocardiographic examination in a patient with IHSS, mitral insufficiency, and cardiomegaly suggested the possibility of a pericardial effusion. Echocardiographic M-mode scanning documented the continuity of the space posterior to the pericardium with an enlarged left atrium. Subsequent cineangiographic studies confirmed an enlarged left atrium and the absence of pericardial effusion. Left atrial enlargement may cause a false positive echocardiographic diagnosis of pericardial effusion.     

Scanning and transmission electron microscopic study of human pulmonary pneumocystosis.

Histopathologic examinations were performed in 13 autopsy cases with Pneumocystis pneumonia, five of whom were examined with scanning as well as transmission electron microscope. Findings by scanning electron microscopy were compared with those by light microscopy and transmission electron microscopy. By scanning electron microscopy, two principal structural varieties of Pneumocystis organisms, smooth-surfaced organisms and rough-surfaced organisms, could be classified. It was indicated that rough-surfaced organisms and smooth-surfaced organisms correspond respectively to trophozoite-type organisms and thick-walled cysts, recognized with transmission electron microscope. Intraalveolar honeycombed material was mainly composed of dilated trophozoite-type organisms, containing thick-walled cysts scatteredly.     

Our approach to the management of congenital presacral tumors in adults

This study reviews the recent overall experience in one colorectal surgery department with congenital presacral tumors in adults. 24 patients greater than 21 years of age, who underwent curative resection between January 1980 and August 1992, were analyzed retrospectively. The growths were divided into two broad categories: developmental cysts and chordomas. The most common presenting symptom was pain (19/24). A preoperative evaluation regimen is outlined in the study and includes use of CT scanning, MRI imaging, and possibly the use of endoluminal ultrasound to document the relationship of presacral tumors to pelvic viscera. There were 20 developmental cysts and 4 chordomas treated in this series. 15 of 19 developmental cysts were excised by a posterior approach alone, 2 were excised by an anterior approach alone, and 3 were treated by a combined approach. Trans-sacral excision was carried out in 4 patients with developmental cysts. One chordoma was resected posteriorly and the other 3 through a combined anterior and posterior approach. Three recurrences were diagnosed after excision of developmental cysts at 8, 18, and 41 months postoperatively. Recurrence occurred in 3 of 4 chordoma patients after 25, 32, and 55 months. Reexcision was carried out in all patients. None of the developmental cyst cases developed a second recurrence but 2 of the 3 chordoma patients have recurred, but have undergone local irradiation, which has controlled their disease. A detailed surgical treatment plan is outlined in this article, emphasizing that total excision be the goal surgery, even if this requires a combined anterior and posterior approach. In cases of recurrence of both development cysts and chordoma, re-excision is a reasonable therapeutic option.     

Multiple ovarian cysts in a young girl with severe hypothyroidism.

Case study of a young female patient with severe hypothyroidism due to autoimmune thyroiditis and multiple ovarian cysts is reported. A 14-year 7-month-old girl presented with pelvic and abdominal pain and severe asthenia. Her last menstrual period was 10 months before presentation. Physical examination showed obesity; apathetic and flat expression; periorbital puffiness; pale, cold, dry skin and slow sustained reflexes; swelling in the hands and feet; no galactorrhea; a hardly palpable thyroid gland; and ovaries with a palpable irregular surface. Her heart rate was 90 bpm with a blood pressure within the normal range (110/70 mmHg). Laboratory findings showed severe hypothyroidism (thyroid-stimulating hormone [TSH]: 960 mIU/L), gravis macrocytic anemia, hyperfibrinogenemia, and hyperprolactinemia. Imaging examinations revealed a normal-size thyroid with irregular echogenicity, strongly hypoechogenous area at the neck ultrasonography, bilateral multilocular ovarian masses with cystic components at pelvic ultrasound and computed tomography, and both anterior and posterior pericardial effusion at echocardiography. As soon as thyroid replacement therapy was initiated, all symptoms progressively disappeared and biochemical and hormonal values normalized, while the right ovary did not decrease in size during the follow-up period. For this reason, our patient underwent right ovarian wedge resection 14 months after the initiation of medication replacement. Ovarian histological examination showed a benign ovarian cyst with extensive hemorrhage and myxedematous infiltration. It is concluded that it is important to recognize early in young girls the association between large multiple ovarian cysts and high elevated levels of TSH in order to resolve this disorder with substitutive therapy.     

Routine Echocardiographic Views Miss Significant Pleural Effusions

Objectives: To determine the benefit of adding chest scanning to the routine echocardiographic examination to diagnose pleural effusions. Background: Pleural effusions are common in several cardiac disorders, yet routine echocardiography is insensitive in delineating pleural fluid. Methods: Bilateral chest scanning was performed in addition to the routine echo examination in 100 consecutive inpatients referred for echocardiography with recent chest X rays (CXRs). Detection and quantification of pleural effusion by sonographic chest scanning was compared blindly with CXRs. Identification of pleural fluid was analyzed for correlation with clinical diagnosis of congestive heart failure (CHF) and elevated pulmonary artery pressures if found by echo-Doppler examination. Results: Agreement on presence or absence of pleural effusion occurred in 88 of 100 patients—in 5 patients bilateral chest scanning detected pleural effusion with negative CXRs; in 7 patients CXRs suggested pleural effusion with negative bilateral chest scanning (all 7 patients had minor blunting of the costophrenic angle). Routine echo views only detected 22 of 51 patients (43%) with pleural effusion detected by bilateral chest scanning. In 45 patients with CHF, 29 (64%) had pleural effusion by bilateral chest scanning (25 bilateral, 1 left, 3 right) vs 12 (27%) by routine echo (only left pleural effusion seen). Ejection fraction and estimated pulmonary artery pressure did not differ between CHF patients with and without pleural effusion. Conclusions: Routine echocardiographic views underestimate the presence of pleural effusion in patients referred for study. Bilateral chest scanning is equal to CXRs for pleural effusion detection and provides clinically useful information which may be of particular benefit to patients with CHF.     

A rare cause of pleurisy from subdiaphragmatic origin: epidermoid cyst of the spleen

Subdiaphragmatic diseases are a classical but uncommon cause of pleural effusion. We report here the case of a woman admitted for a left pleural effusion which led to the discovery of a splenic tumour. Pathological examination of the splenectomy specimen showed that the tumour was an epidermoid cyst of the spleen. Cysts of the spleen are exceptionally revealed by pleurisy. Epidermoid cysts account for 10% of all non-parasitic splenic cysts. They remain silent for a long time and are usually disclosed by such complications as compression of surrounding organs, rupture or superinfection.     

Hydatic disease of the heart presenting with pericardial effusion. A case report

The authors report a rare case of multiple mediastinal hydatid cysts which ruptured in a 48 year old man who presented with a pericardial effusion. The diagnosis was confirmed by 2D echocardiography, completed by CT scan and magnetic resonance imaging. The patient was operated as a semi-emergency and the outcome was good. This case underlines the rare pericardial involvement and the severity of the complications of cardiac hydatid disease.