Aesthetic Resection of the Gastrocnemius Muscle in Postpoliomyelitis Calf Hypertrophy: An Uncommon Case Report

Muscle hypertrophy is a rare finding in neurologic lesions. Infiltration, stretching, and exercise of the muscle are causative factors of enlargement and hypertrophy. We report a case of unilateral calf hypertrophy postpoliomyelitis. The resection of the total medial and partial lateral gastrocnemius muscle was performed to achieve left calf reduction and a symmetrical contour of both legs. The patient is satisfied with the results and has not complained of any instability in walking or running after 2 years of follow-up.     

Painful Unilateral Temporalis Muscle Enlargement: Reactive Masticatory Muscle Hypertrophy

An instance of isolated unilateral temporalis muscle hypertrophy (reactive masticatory muscle hypertrophy with fiber type 1 predominance) confirmed by muscle biopsy with histochemical fiber typing and image analysis in a 62 year-old man is reported. The patient presented with bruxism and a painful swelling of the temple. Absence of asymmetry or other abnormalities of the craniofacial skeleton was confirmed by magnetic resonance imaging and cephalometric analyses. The patient achieved symptomatic improvement only after undergoing botulinum toxin injections. Muscle biopsy is key in the diagnosis of reactive masticatory muscle hypertrophy and its distinction from masticatory muscle myopathy (hypertrophic branchial myopathy) and other non-reactive causes of painful asymmetric temporalis muscle enlargement.     

Unilateral virginal breast hypertrophy

A case of unilateral virginal breast hypertrophy with a review of the etiological factors and treatment modalities is presented. A 16-year-old girl presented with progressive enlargement of the left breast of 5 months' duration. The result of the mammographic examination was consistent with cystosarcoma phyllodes. Fine-needle aspiration biopsy revealed giant fibroadenoma. Although some of the characteristics of the fine-needle aspiration biopsy specimen were suspicious for cystosarcoma phyllodes, there were no adequate epithelial structures, which are obligatory for the diagnosis. The patient was treated with subcutaneous mastectomy and subpectoral insertion of a silicone gel implant. The histopathological examination was consistent with virginal hypertrophy. The breast maintained its volume with no further growth in the affected or in the normal breast after 4 years of follow-up.     

Lip hypertrophy secondary to cyclosporine treatment: a rare adverse effect and treatment considerations.

Gingival hypertrophy is a well-known and extensively documented undesirable side effect of cyclosporine in posttransplant patients. However, severe lip enlargement associated with cyclosporine is less recognized and has seldom been reported in the literature. Lip enlargement may lead to social, physical, and psychological stress, especially in the older childhood and adolescent age groups. We present a case of marked lip hypertrophy and concomitant gingival hypertrophy secondary to cyclosporine (Neoral) treatment in a pediatric bilateral lung transplant recipient. We also discuss the various side effects and treatment considerations available including more recent substitution therapy. Cyclosporine has most effectively and conclusively enabled transplantation of solid organs by reducing transplant-associated morbidity. We believe clinicians should be knowledgeable and aware of lip hypertrophy associated with cyclosporine use. This rare and less understood adverse effect should be recognized during the clinical evaluation of the posttransplant patient.     

Unilateral tonsillar enlargement

Unilateral tonsillar enlargement may result from infection, chronic inflammatory response, or neoplasm. Neoplasms that commonly produce a unilaterally enlarged tonsil include lymphomas (lymphocytic and histiocytic types) and squamous cell carcinomas. Rarer tumors include extramedullary plasmacytomas, Hodgkin's disease, leukemia, and metastatic neoplasms. Sixteen cases of unilateral tonsillar enlargement owing to causes other than squamous cell carcinoma are reviewed. When examining a patient with unilateral tonsillar enlargement, diagnosis of a neoplastic disease must be considered.     

High protein-induced glomerular hypertrophy is vascular endothelial growth factor-dependent

BACKGROUND: Various growth factors and cytokines have been implicated in different forms of kidney enlargement such as renal growth following induction of diabetes, unilateral nephrectomy, and exposure to high protein diet. Vascular endothelial growth factor (VEGF) is essential for normal renal development and plays a role in diabetes-associated renal and glomerular enlargement. METHODS: To elucidate a possible role for VEGF in high protein-induced renal/glomerular enlargement, we examined the effect of a neutralizing VEGF-antibody (VEGF-ab) on kidney weight and glomerular volume in mice fed a high protein diet for up to seven days. RESULTS: At day 2 and day 7 of the experimental period, high protein diet induced a significant increase in the mean glomerular volume. This high protein-induced glomerular hypertrophy was completely prevented by treatment with VEGF-ab. Kidney weight was increased significantly only at day 7, and was not influenced by VEGF-ab treatment. High protein diet and/or VEGF-ab treatment had no effect on body weight, food intake, and liver or heart weight. CONCLUSIONS: The administration of a neutralizing VEGF-ab in mice fed a high protein diet for one week completely abolished the glomerular hypertrophy seen in placebo-treated animals on the same diet, without affecting kidney and body weight. These results demonstrate, to our knowledge for the first time, that high protein-induced glomerular hypertrophy is VEGF-dependent.     

Bilateral phrenic nerve palsy associated with benign thyroid goiter

Phrenic nerve palsy secondary to benign thyroid enlargement is a previously unreported complication. Large goiters, particularly substernal, may impinge upon adjacent structures, often leading to significant symptoms such as dysphagia or dyspnea due to airway compression. The phrenic nerve may be stretched by a large goiter along its course in the neck, but the more likely site of injury is the point at which it enters the thoracic cavity adjacent to the first rib. Such an injury, caused by compression, may go unrecognized if unilateral, as symptoms would be uncommon. However, bilateral phrenic nerve palsy can cause significant dyspnea due to pulmonary insufficiency, particularly in an elderly patient with cardio-pulmonary disease. Early operative treatment of the goiter may prevent this complication or limit its severity, thus avoiding permanent nerve injury.     

颅颌面双侧不对称畸形的综合治疗

目的 探讨先天性及发育性一侧颜面发育不良或萎缩所致颅颌面双侧不对称畸形的综合手术治疗。方法 针对患者的畸形情况，设计相应的手术方案以重建患侧的外形及功能。骨骼畸形不明显而主要为软组织萎缩凹陷者，可采用软组织移植的手段予以充填修复；对同时伴有颅面骨骼发育不良的患者，首先重建面部的骨骼支架，在此基础上，再进一步完成软组织的修复。结果 1998年9月至2004年8月，共治疗各种原因导致的双侧颜面不对称畸形患者42例，其中单侧颅面短小畸形22例，进行性半侧颜面萎缩16例，肿瘤切除后放疗导致的邻近区域软组织及骨骼的发育不良4例。男18例，女24例。年龄16～38岁，平均24岁。2例肿瘤术后放疗患者，因局部软组织条件差，发生钛板及植入骨外露，1例单侧颅面短小畸形患者采用自体下颌骨外板及肋骨行下颌升支重建后发生感染，致手术失败，其余患者双侧不对称畸形均获得明显改善。结论 单侧颜面发育不良或萎缩所致颅颌面双侧不对称畸形，是临床上常见且治疗难度较大的一组畸形，畸形轻重程度不等，涉及软组织和骨组织的治疗。需根据患者的具体情况，合理设计手术方案，综合运用整形及颅颌面外科技术分期手术重建，方可达到最大程度改善外形、恢复功能的目的。     

Failure of bromocriptine therapy to control juvenile mammary hypertrophy.

Rapid massive breast hypertrophy occasionally occurs at the time of puberty or during pregnancy, with breast size eventually becoming burdensome or incapacitating to the patient. Pregnancy-related breast hypertrophy is often arrested or reversed by reducing serum prolactin levels with bromocriptine therapy. Unfortunately, breast enlargement in our 12-year-old patient with massive juvenile mammary hypertrophy was unaffected by bromocriptine therapy despite a reduction of her prolactin to normal levels. Two reduction mammaplasties followed by subcutaneous mastectomy were required to control breast hypertrophy. Breast-tissue hypersensitivity to prolactin appears to be a characteristic of pregnancy-related gigantomastia. Our pubertal patient with juvenile mammary hypertrophy failed to respond to bromocriptine therapy, so the aetiology of this syndrome may involve breast-tissue hypersensitivity to hormones other than prolactin.     

Seminal vesicle cysts with unilateral renal agenesis and contralateral ureteral stenosis in a beta-thalassemic patient: an unknown association by incomplete development of the mesonephric duct

We report the case of a 13-year-old male patient with beta-thalassemic trait who presented for a colic pain. An ultrasound of the abdomen revealed absence of the right kidney with a complex hypoechogenic pelvic mass causing mild pressure on the posterior bladder wall. Urography showed hypertrophy of the left kidney with moderate ureteral enlargement of the distal third due to an insertion defect in the bladder suggestive of a primary segmental nonobstructing megaureter. MR studies showed right multilocular seminal vesicle cysts. One year later an MR examination of the pelvis showed an increase in size of seminal vesicle cysts and open surgery was performed to remove the cystic retrovesical mass. Our case represents a very rare association of seminal vesicle cysts, unilateral renal agenesis and alteration in contralateral ureteral insertion in a patient with beta-thalassemic trait.     

Unilateral atlantal mass hypertrophy in acromegaly. Case report

The authors report an extremely rare case of a patient with acromegaly who had unilateral enlargement of an atlas facet resulting in cord compression and progressive quadriparesis. Although unilateral atlas facet enlargement has been identified in the literature in cases of spondylosis and as a component of congenital malformation, its association with acromegaly has not previously been reported. Resection of the offending facetal bone and atlantoaxial fixation resulted in rapid neurological recovery.     

Proteinaceous lymphadenopathy with hypergammaglobulinemia

Three cases of a morphologically distinctive "sclerosis" of lymph nodes are presented. Two patients experienced recurring lymph node enlargement with associated mild malaise over an extended period. The first patient had unilateral axillary lymph node enlargement, but was asymptomatic and died of chronic obstructive pulmonary disease 17 years later with no evidence of lymph node enlargement at autopsy. Each patient had at least transient hypergammaglobulinemia, one with elevated IgM and IgA, one with elevated IgM, and one (from 1958) not further analyzed. Lymph node biopsies revealed extensive deposition of eosinophilic material in all three patients. Identical changes in lymph nodes have been described in chronic diseases. The eosinophilic material may be related to amyloid, but differs from it histochemically and ultrastructurally. The relationship of this lesion to the few cases reported as amyloidosis presenting as lymph node enlargement is discussed. Malignant lymphoma with sclerosis is the most important consideration in the differential diagnosis.     

Left ventricular hypertrophy is a risk factor independent of hypertension in survival of hemodialyzed patients

Hemodialysis patients have low 5-year survival rates of approximately 60%, and the most common cause of death is cardiovascular diseases. Their population may be considered, therefore, as an accelerated model in analyzing the risk factors for cardiovascular diseases. We previously reported the role of blood pressure, one of the most important risk factors for cardiovascular diseases, in determining the prognosis of hemodialysis patients. In this study, we examined the effect of cardiomegaly detected on chest roentgenogram or electrocardiogram before initiating hemodialysis therapy on survival after introduction to maintenance hemodialysis. One hundred and sixty hemodialysis patients who had no history of ischemic heart disease or arrhythmia were followed up for 88.9 +/- 4.0 months, among whom 69 died. Heart enlargement, defined on chest roentgenogram, was detected in 104 patients, and left ventricular hypertrophy, defined on electrocardiogram, was detected in 105 patients. The presence of either finding shortened their survival. However, Cox's proportional hazards model and logistic multiple regression analysis identified only left ventricular hypertrophy as one of the significant determinants for survival, but heart enlargement was not independent. Correction of systolic hypertension on the maintenance phase had no significant favorable effect on survival in patients with left ventricular hypertrophy, while it improved in those with heart enlargement. This finding, together with those above from Cox's model and logistic analysis strongly suggests that risk from left ventricular hypertrophy is independent of, but one from heart enlargement is dependent on hypertension.     

Unilateral ossified ligamentum flavum in the high cervical spine causing myelopathy

High cervical ossified ligamentum flavum (OLF) is rare and may cause progressive quadriparesis and respiratory failure. Our two patients had unilateral OLF between C1 and C4 levels. MR showed a unilateral, triangular bony excrescence with low signal and a central, intermediate or high signal on all pulse sequences due to bone marrow within. There was Type I thecal compression (partial deficit of contrast media ring). The first patient had a linear and nodular OLF with calcification within tectorial membrane, C2–3 fusion and unilateral C2-facetal hypertrophy; and the second patient, a lateral, linear OLF with loss of lordosis and C3–6 spondylotic changes. A decompressive laminectomy using “posterior floating and enbloc resection” brought significant relief in myelopathy. Histopathology showed mature bony trabeculae, bone marrow and ligament tissue. The coexisting mobile cervical vertebral segment above and congenitally fused or spondylotic rigid segment below the level of LF may have led to abnormal strain patterns within resulting in its unilateral ossification. In dealing with cervical OLF, carefully preserving facets during laminectomy or laminoplasty helps in maintaining normal cervical spinal curvature.     

Unilateral Breast Enlargement 5 Years After Reduction Mammaplasty

A 26-year-old woman presented with unilateral breast enlargement 5 years after bilateral reduction mammaplasty. After careful physical examination combined with a clinical assessment, mammogram, and histologic tissue examination, the patient underwent bilateral reduction mammaplasty using an inferior wedge resection technique. Histologic examination confirmed the diagnosis of a fibrocystic breast disease in both breasts. The most common differential diagnoses are juvenile fibroadenoma, virginal hypertrophy, fibrocystic disease, and cystosarcoma phylloides.     

Preoperative diagnosis of xanthogranulomatous pyelonephritis.

Preoperative diagnosis of xanthogranulomatous pyelonephritis may be correctly made in a significant proportion of affected patients thus preventing unnecessary radical surgery especially in the poor-risk patient. The diagnosis should be suggested in the patient with a history of chronic urinary tract infection and certain radiologic features. These include unilateral renal enlargement (either localized or diffuse), nonfunction on excretory urography, presence of renal and/or ureteral calculi, angiographic demonstration of avascular mass or masses with stretched, attenuated intrarenal vessels, prominent capsular and periureteric vessels, and an irregular impaired nephrogram with prominent avascular areas.     

Juvenile gigantomastia: presentation of four cases and review of the literature

Juvenile gigantomastia is a benign disorder of the breast in which one or both of the breasts undergo a massive increase in size during adolescence. The authors present a series of four cases of juvenile gigantomastia, advances in endocrine management, and the results of surgical therapy. Three patients were treated for initial management of juvenile gigantomastia and one patient was evaluated for a gestationally induced recurrence of juvenile gigantomastia. The three women who presented for initial management had a complete evaluation to rule out other etiologies of breast enlargement. Endocrine therapy was used in 2 patients, one successfully. A 17-year-old girl had unilateral hypertrophy treated with reduction surgery. She had no recurrence and did not require additional surgery. Two patients, ages 10 and 12 years, were treated at a young age with reduction mammaplasty, and both of these girls required secondary surgery for treatment. One patient underwent subtotal mastectomy with implant reconstruction but required two subsequent operations for removal of recurrent hypertrophic breast tissue. The second patient started a course of tamoxifen followed by reduction surgery. While on tamoxifen, the second postoperative result remained stable, and the contralateral breast, which had exhibited some minor hypertrophy, regressed in size. The fourth patient was a gravid 24-year-old who had been treated for juvenile gigantomastia at age 14, and presented with gestationally induced recurrent hypertrophy. The authors' experience has been that juvenile gigantomastia in young patients is prone to recurrence, and is in agreement with previous studies that subcutaneous mastectomy provides definitive treatment. However, tamoxifen may be a useful adjunct and may allow stable results when combined with reduction mammaplasty. If successful, the use of tamoxifen would eliminate the potential complications of breast prostheses. Lastly, the 17-year-old patient did not require secondary surgery, suggesting that older patients may be treated definitively with reduction surgery alone.     

Acquired renal cystic disease mimicking adult polycystic kidney disease in a patient undergoing long-term hemodialysis.

Acquired renal cystic disease (ARCD) is defined as the development of multiple cysts in the renal cortex and medulla in patients with chronic renal failure who are free from congenital polycystic kidney disease. ARCD develops generally in contracted kidneys. We report a case of grotesque enlargement of a single kidney in a patient who had been receiving hemodialysis for 18 years. Although the exact causes of ARCD are not known, 3 factors may contribute to the development of nephromegaly; the sex, the duration of hemodialysis and previous unilateral nephrectomy. As in polycystic disease, when the involved kidney reaches considerable size, ARCD may have a favorable effect on anemia caused by chronic renal failure.     

Unilateral male breast masses: cancer risk and their evaluation and management

Breast cancer is an uncommon cause of breast enlargement in the adult male. Overall, it accounts for <1 per cent of all male cancers. Although most male breast carcinomas are clinically apparent, distinguishing early breast cancer from gynecomastia, the most common cause of male breast enlargement, is considered a difficult task. To overcome this difficulty, many surgeons proceed directly to surgery as their initial diagnostic test. Although appropriate in some cases, the infrequent occurrence of male breast cancer and the diagnostic accuracy of mammography and fine-needle aspiration cytology suggest a modification of our present management. The aim of this study was to assess the incidence of breast cancer in men with unilateral breast masses and to propose a treatment algorithm for unilateral male breast masses. The medical records of 36 male patients who underwent subcutaneous mastectomy for a unilateral breast mass at the Buffalo Veterans Administration Medical Center between 1989 and 1996 were retrospectively reviewed. Data was collected on a standard data form. The median age was 63-years-old (range, 22-82). Gynecomastia was diagnosed in 30 patients (83%), lipoma in 4 patients (11%), invasive breast cancer in 1 patient (3%), and melanoma in situ in 1 patient (3%). Of the 30 patients with gynecomastia, 60% (18 patients) gave a history of a medical condition or use of medications known to cause gynecomastia, compared with 16 per cent (1 of 6) of the patients without gynecomastia (P = 0.08). Half of the patients with gynecomastia presented with an asymptomatic mass compared with 67 per cent of the patients without gynecomastia (P = not significant). The median duration of symptoms for patients with gynecomastia was 3 months. Men with unilateral breast masses have a low incidence of breast cancer. A male patient with a palpable unilateral breast mass consistent with gynecomastia on the basis of historical, physical and mammographic findings does not require surgical biopsy unless other clinical indications prevail. Lack of symptoms (pain) related to the mass is probably not helpful in deciphering gynecomastia from breast cancer.     

Reduced red blood cell carbonic anhydrase activity in a patient with nephrolithiasis.

Low levels of red blood cell (RBC) carbonic anhydrase (CA) activity in hemoglobin-free hemolyzate (HFH) were found in 2 children with nephrolithiasis when compared to age-matched controls. The lowest levels were consistently found over a two year period in a 6 1/2 year old boy (U.P.) whose renal calculi contained uric acid, ammonia, calcium carbonate and oxalate. His RBC CA values ranged from 1.4-2.7 U/g Hb compared with levels of 3.9-5.3 U/g Hb in control subjects. Statistical comparisons of the mean values for U.P., 2.06 U/g Hb, and his age-matched control subjects, 4.46 U/g Hb, revealed a significant difference (P = less than 0.001). Similar reductions in RBC CA activity were found in his father--2.0 and 2.1 U/g Hb compared with 3.3 and 3.9 U/g Hb in adult controls. HFH CA activity was not decreased in the mother or sister. Polyacrylamide gel electrophoresis of HFH from 4 of the children and the father of U.P. was abnormal. However, this abnormal electrophoretic pattern could only be demonstrated when the gel was run for 120 minutes and not when it was run for 80 or 160 minutes. We have identified a patient and his father with low levels of RBC CA activity.