Diffuse granulomatous mesenteric disease caused by intravesical bacillus Calmette-Guérin instillation masquerading as peritoneal carcinomatosis

Intravesical instillation with bacillus Calmette-Guérin is the most common therapy used for nonmuscle invasive bladder cancer in North America. Although local side effects are common, systemic side effects are rare when it is administered correctly. We present a case of diffuse mesenteric granulomatous disease resulting from inappropriate instillation of this agent. This patient was thought to have peritoneal carcinomatosis. One must be cognizant of the possibility when evaluating patients with similar findings and images after bacillus Calmette-Guérin therapy.     

Misdiagnosis of trigger finger? Flexor seed ganglion masquerading as closed FDS rupture

The authors present the case of a 25-year-old right-handed female warehouse worker who presented to the emergency department complaining of an inability to flex her left index finger and an associated painful lump on the volar surface of her left index finger over the metacarpal–phalangeal joint following a hyperextension injury. Clinical examination suspected a closed flexor digitorum superficialis (FDS) injury; however, on surgical exploration, the FDS tendon to the left index finger was intact. A flexor sheath seed ganglion was identified. This case, although rare, identifies the modality of specialist ultrasound scan (USS) by those with an interest in musculoskeletal radiology to be used in cases where the history is unclear or diagnosis in doubt. Level of Evidence: Level V, diagnostic study.     

Doença de Kikuchi‐Fujimoto antes do diagnóstico de lúpus eritematoso sistêmico juvenil

Kikuchi‐Fujimoto disease (KFD) is a self‐limiting histiocytic necrotizing lymphadenitis of unknown origin. Of note, KFD was infrequently reported in adult systemic lupus erythematosus (SLE), with rare occurrence in childhood‐SLE (C‐SLE) patients. To our knowledge, the prevalence of KFD in the paediatric lupus population was not studied. Therefore, in a period of 29 consecutive years, 5,682 patients were followed at our institution and 289 (5%) met the American College of Rheumatology classification criteria for SLE, one had isolated KFD (0.03) and only one had KFD associated to C‐SLE diagnoses, which case was reported herein. A 12 year‐old female patient had high fever, fatigue and cervical and axillary lymphadenopathy. The antinuclear antibodies (ANA) were negative, with positive IgM and IgG herpes simplex virus type 1 and type 2 serologies. Fluorine‐18‐fluoro‐deoxy‐glucose positron emission tomography/computed tomography (PET/CT) imaging demonstrated diffuse lymphadenopathy. The axillary lymph node biopsy showed necrotizing lymphadenitis with histiocytes, without lymphoproliferative disease, compatible with KFD. After 30 days, she presented spontaneous regression and no therapy was required. Nine months later, she developed malar rash, photosensitivity, oral ulcers, lymphopenia and ANA 1:320 (homogeneous nuclear pattern). At that moment the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI‐2K) score was 10 and she was treated with prednisone (1.0 mg/kg/day) and hidroxychloroquine showing progressive improvement of hers signs and symptoms. In conclusion, KFD is a benign and rare disease in our paediatric lupus population. We also would like to reinforce the relevance of autoimmune diseases diagnosis during the follow‐up of patients with KFD.     

Duodenojejunal junction web masquerading as Wilkie’s syndrome: Report of a case

Wilkie’s syndrome (superior mesenteric artery syndrome) is a rare cause of obstruction to the third part of duodenum due to compression between the superior mesenteric artery and the abdominal aorta. Pathologies like malignant growth in the mesenteric root, the presence of a lymph nodal mass compressing the terminal duodenum, dissecting aortic aneurysm, and intestinal malrotation may mimic the condition, but are not true etiologies of the syndrome. A duodenojejunal web causing narrowing of the duodenojejunal junction and mimicking Wilkie’s syndrome has not been described before in the literature. We herein report a case of gastroduodenal obstruction due to a web in the duodenojejunal junction in a young female patient, which closely mimicked Wilkie’s syndrome but was finally diagnosed postoperatively. We highlight the first case of its kind in an adult and discuss the challenges in both the diagnosis and management.     

Primary cardiac lymphoma masquerading as right atrial myxoma causing complete heart block—a case report

Secondary involvement of the heart and pericardium by systemic lymphoma is well documented. Primary Cardiac lymphomas (PCL) are extremely rare. Incidence of PCL is increasing in immunocompromised patients. However PCL in immunocompetent is much rarer. We report such a case of PCL in an immunocompetent elderly female masquerading as right atrial myxoma causing complete heart block which was surgically debulked successfully. Her rhythm resumed to Sinus rhythm following surgical debulking. Immunohistochemistry of the excised tumour revealed Diffuse Large B cell lymphoma. With combination chemotherapy, she is symptom free on six months follow up.     

Pulmonary hemorrhage complicating Goodpasture’s disease in the course of pulmonary tuberculosis

A 72-year-old man with ESRD on hemodialysis was referred to the hospital because of hemoptysis. A chest radiograph showed diffuse infiltration in the right lung field. Laboratory data showed hematuria and proteinuria. A kidney biopsy revealed diffuse crescentic glomerulonephritis with linear staining of IgG along the glomerular basement membrane (GBM). However, circulating IgG anti-GBM antibodies were not detected. Because the findings of renal biopsy suggested Goodpasture’s disease, the patient was treated with plasmapheresis and pulse steroid therapy, which resulted in a rapid resolution of his pulmonary symptoms and chest radiograph abnormalities. However, sputum culture on admission yielded Mycobacterium tuberculosis 3 weeks later. Therefore, immuosuppressive agents were discontinued and antituberculous agents were administered. There was no relapse of pulmonary hemorrhage during the next 1-year period of follow-up, but the patient did not regain renal function and remained on hemodialysis.     

Brushite stone disease as a consequence of lithotripsy?

The incidence of calcium phosphate (CaP) stone disease has increased over the last three decades; specifically, brushite stones have been diagnosed and treated more frequently than in previous years. Brushite is a unique form of CaP, which in certain patients can form into large symptomatic stones. Treatment of brushite stones can be difficult since the stones are resistant to shock wave and ultrasonic lithotripsy, and often require ballistic fragmentation. Patients suffering from brushite stone disease are less likely to be rendered stone free after surgical intervention and often experience stone recurrence despite maximal medical intervention. Studies have demonstrated an association between brushite stone disease and shock wave lithotripsy (SWL) treatment. Some have theorized that many brushite stone formers started as routine calcium oxalate (CaOx) stone formers who sustained an injury to the nephron (such as SWL). The injury to the nephron leads to failure of urine acidification and eventual brushite stone formation. We explore the association between brushite stone disease and iatrogenic transformation of CaOx stone disease to brushite by reviewing the current literature.     

Metatarsal leiomyosarcoma masquerading as acute osteomyelitis – A diagnostic trap unveiled by vigilant clinical,radiologic and pathologic analysis

Due to overlapping clinical and radiological features, the differentiation between osteomyelitis and bone tumor can be challenging. A 48-year-old lady presented with intermittent left foot pain for a few months. Plain radiographs showed an osteolytic lesion affecting the proximal diaphysis of the left fourth metatarsal bone, with thinning and irregularities of the cortex and focal periosteal reaction. Ultrasonography revealed diffuse subcutaneous edema in the dorsum of the left foot, cortical irregularities along the mid-shaft of the left fourth metatarsal bone, and surrounding periosteal collection. Computed tomography showed medullary expansion along the shaft and base of the left fourth metatarsal bone with cortical irregularities and defects suggestive of cloaca, and focal mild periosteal new bone formation. The clinico-radiologic diagnosis was acute osteomyelitis with periosteal collection. During open biopsy, the finding of intramedullary fleshy tissue in the absence of significant inflammatory edema and purulent discharge, and subsequent negative culture result prompted a review of the histologic slides which was initially reported as benign fibroblastic tissue proliferation. Careful analysis of the histomorphology disclosed a spindle cell sarcoma for which ray amputation of the fourth and fifth metatarsal was performed. The final diagnosis was grade 1 leiomyosarcoma and the patient remained well 33 months after the operation.     

Neuro-Behçet's disease manifesting as a neoplasm-like lesion--case report

A 50-year-old man presented with neuro-Beh?et's disease (NBD) manifesting as a large neoplasm-like lesion affecting the brainstem, basal ganglia, and white matter of the cerebral hemisphere. He had no history of disease except for psychoneurosis. On admission, neurological examination found left hemiparesis and dysarthria. Magnetic resonance (MR) imaging showed multiple small ring-like enhancement in the basal ganglia, brainstem, and deep white matter. Biopsy of the mass was performed. Histological examination revealed invasion of inflammatory cells in the white matter, especially around the blood vessels. After the brain biopsy, the patient developed oral aphthae, genital ulcers, and skin eruptions, which are indicative of Beh?et's disease. MR imaging after three courses of steroid pulse therapy revealed that the edematous lesion had become smaller with minimum midline shift. NBD should be considered in the differential diagnosis of lesions with multiple ring-like enhancement extending from the basal ganglia to the brainstem, because dermatological manifestations are sometimes obscured during periods of remission.     

Nephrectomy as a cause of chronic kidney disease in the treatment of urolithiasis: a case–control study

Objective

To analyze the clinical course of nephrectomized patients due to complications related to nephrolithiasis and ascertain the prevalence of chronic kidney disease (CKD) in this population.

Methods

From 2005 to 2010, 658 patients were treated with urolithiasis. Among these, 30 (4.6%) were nephrectomized. For each case, a control was selected and matched to the case by age, sex and disease duration. All data were collected from medical records, which contained the clinical, laboratory evaluation and diagnostic imaging.

Results

Age of the study group was 51.5 ± 10.4 years and the control group 47.1 ± 5.2 years. There were 17 (85%) women and three men in each group. Patients from the study group reported 3 (range, 1–5) episodes of acute renal colic before nephrectomy. Urinary tract infection and hematuria was detected in 70% of cases before surgery. In addition, half of the patients had at least one previous urological procedure. The control group showed higher urinary levels of calcium (216.1 ± 114.3 vs. 130.9 ± 72.2), uric acid (530.2 ± 197.4 vs. 424 ± 75.2) and citrate (755 ± 533 vs. 380.2 ± 260.7), p < 0.01, 0.03 and 0.01, respectively. The creatinine clearance was lower in the study group, 52.5 ± 18.8 ml/min vs. 92.9 ± 24.2 ml/min in the control group (p < 0.001).

Conclusions

There was a decrease in kidney function in nephrectomized patients compared to a control group of stone-forming patients with both kidneys. Prospective studies are needed to assess the incidence of CKD in patients with nephrolithiasis submitted to nephrectomy.     

Male–female differences in the risk of tuberculosis in dialysis patients

Aim  To define any gender-related differences in the prevalence and risk for tuberculosis (TB) in hemodialysis (HD) patients. Methods  All active TB cases were recorded during a 36-month follow-up of 272 (193 male and 79 female) HD patients. Entering the study, HD patients were tested with tuberculin and 2,4-dinitrochlorobenzene, and a cell-mediated immunity (CMI) index was estimated. Relative risks (RR) for TB were calculated considering subjects from the background general population as a reference group. The independent effect of age, BMI and tuberculin sensitivity was determined using Cox’s proportional hazard model. Results  Female HD patients presented significantly lower CMI indices and rates of positive Mantoux tests, but higher rates of DM, as compared to males. The male:female ratio in TB for the general and HD patients population was 1.8 and 0.6, respectively. There was a significantly lower TB prevalence in male as compared to female HD patients (7.7% vs. 11.3%), and a subsequent female predominance in risk for TB in those HD patients aged <49 and 50–69 years (M:F adjusted relative risk 0.67 and 0.53) was recorded. Conclusions  In contrast to the general population, there is a female predominance among dialysis TB patients younger than 70 years associated with the coexistence of DM. Female gender should always be considered as a risk factor when evaluating diabetic HD patients for active TB.     

Tumors masquerading as type 2 papillary renal cell carcinoma: pathologists’ ever-expanding differential diagnosis for a heterogeneous group of entities

Although papillary renal cell carcinoma has historically been classified as either type 1 or type 2, data from The Cancer Genome Atlas (TCGA) has demonstrated significant genomic heterogeneity in tumors classified as “type 2 papillary renal cell carcinoma” (T2PRCC). Papillary renal cell carcinoma is expected to have a favorable clinical course compared to clear cell renal cell carcinoma (CCRCC). However, tumors with poor outcome more similar to CCRCC were included in the T2PRCC cohort studied by the TCGA. The differential diagnosis for T2PRCC includes a variety of other renal tumors, including aggressive entities such as TFE3 translocation-associated renal cell carcinoma, TFEB-amplified renal cell carcinoma, fumarate hydratase-deficient renal cell carcinoma, high-grade CCRCC, and collecting duct carcinoma. Accurate classification of these tumors is important for prognostication and selection of therapy.