Management of splenic abscess in a critically ill patient

Because of the increased number of immunocompromised patients within the general population, the incidence of splenic abscesses has increased over the last decade. This cohort of immune-deficient patients with splenic abscesses engenders a distinct evolution in the pathogenesis and microbiology of the disease process. Moreover, the morbidity and mortality rates for splenic abscesses are increased in this unique population. Clinically, these patients do not have a characteristic presentation. Diagnostically, computed tomography of the abdomen is the test of choice. Antibiotics and splenectomy remain the standard of care in most clinical settings. However, percutaneous drainage is reported with solitary and unilocular abscesses and in poor operative candidates. An unusual case of a patient with a splenic abscess awaiting heart transplantation is presented. This patient was successfully treated with percutaneous drainage and antibiotics. The literature regarding the presentation, diagnosis, pathogenesis, and treatment of splenic abscesses is reviewed as well.     

A novel endolaparoscopic intragastric partitioning for treatment of morbid obesity

Morbid obesity is a burgeoning health crisis. Significant morbidity is associated with the current gastric bypass, and, therefore, alternative surgical modalities are desired. A novel minimally invasive surgical technique, endoluminal gastric partitioning, is presented. Ten mongrel dogs underwent endolaparoscopic placement of intragastric mesh. Each circular prosthesis (Surgisis or prolene mesh) was 8 cm in diameter with a 1.5 cm central aperture. The mesh was passed transorally into the gastric lumen and secured with a laparoscopic, intragastric suturing resulting in a 30 to 50 mL proximal gastric reservoir. The operation was successfully completed in all 10 animals. Nine of 10 animals were healthy at the scheduled sacrifice date. In 2 dogs, the intragastric mesh was 100% adherent to the gastric mucosa after 7 days. Four of the final 5 dogs demonstrated some degree of mucosal adherence after 1 week. Endoluminal placement of intragastric mesh appears feasible and safe. Long-term studies are necessary to demonstrate the efficacy and long-term weight loss of this, or alternate intraluminal gastric partitioning techniques.     

Chronic lithium nephropathy: MR imaging for diagnosis

PURPOSE: To evaluate the appearance of lithium nephropathy at magnetic resonance (MR) imaging. MATERIALS AND METHODS: Sixteen patients with renal insufficiency and clinical and laboratory evidence of nephropathy secondary to therapy with lithium salts were examined with a 1.5-T MR imaging unit with T1-weighted, T2-weighted fast imaging with steady-state precession (true FISP), rapid acquisition with relaxation enhancement, half-Fourier turbo spin-echo, and gadolinium-enhanced (FISP three-dimensional MR angiographic) sequences. Renal size and the presence, number, location and size of parenchymal cysts were analyzed. The cysts in each kidney were defined as rare (fewer than 10 cysts), sparse (between 10 and 30 cysts), abundant (30-60 cysts), or very abundant (more than 60 cysts). RESULTS: The mean length of both kidneys was 104 mm +/- 9 in seven cases, and one or both kidneys were less than 90 mm in length in nine cases. Renal microcysts measuring from 1 to 2 mm were detected in all patients. They were either very abundant (n = 12), abundant (n = 2), or sparse (n = 2). The cysts were located with equal abundance in both the cortex and the medulla in 11 cases and were predominantly located in the renal cortex in five cases. No renal artery stenosis was present. CONCLUSION: Microcysts secondary to long-term lithium therapy can be detected with MR imaging.     

Pulmonary arteriovenous malformations

OBJECTIVE: Helical CT scan (HCT), a noninvasive method, can detect pulmonary arteriovenous malformations (PAVMs). Its sensitivity is superior to that of global digitalized angiography, but patients receive a significant dose of radiation during diagnostic HCT. We compared HCT to contrast-enhanced pulmonary magnetic resonance angiography (CEMRA), a new noninvasive radiation-free method, in the diagnosis of PAVMs. PATIENTS AND METHODS: Five consecutive patients with PAVMs underwent HCT, CEMRA, and pulmonary artery digital subtraction angiography (PADSA). CEMRA was performed during the pulmonary arterial phase of an IV bolus of gadolinium. PADSA was performed during the embolization procedure. All images were examined for PAVMs. The site and size of aneurysms were specified, as well as the diameter of the vascular pedicles. RESULTS: Thirty PAVMs were detected by CEMRA and 38 by HCT. All 20 PAVMs at least 5 mm in diameter and 10 of the 18 PAVMs < 5 mm in diameter identified on HCT were also identified by CEMRA. Whatever the site, all PAVMs with a feeding artery diameter of at least 3 mm (ie, PAVMs with clinical consequences) were detected by CEMRA. No false-positive results were obtained with CEMRA. CEMRA therefore had a sensitivity of 78% and a specificity of 100%. CONCLUSIONS: CEMRA, a nonionizing and noninvasive procedure, has high sensitivity and specificity for the diagnosis of clinically relevant PAVMs.     

Sinonasal glomangiopericytoma: A clinicopathologic study

Sinonasal glomangiopericytoma (SNGP) is a neoplasm arising in the nasal cavity and paranasal sinuses that shows perivascular myoid differentiation. The diagnosis of SNGP may be diagnostically challenging due to a large number of potential mimics. In the present study, we sought to characterize the histological and molecular features of six cases of SNGP found in prior surgical pathology records over a 15-year period. The average age at diagnosis was 48.5 years (range: 31–78 years), and the male-to-female ratio was 1:1. Imaging studies in all six cases demonstrated avidly enhancing, lobulated soft tissue masses in the nasal cavity, extending into the sinuses and nasopharynx. Histologically, the tumors were unencapsulated and composed of a proliferation of closely packed, bland, and uniform spindle cells growing deep to an intact surface respiratory epithelium. The cells were separated by a distinctive vascular network ranging from capillaries to large vascular spaces. All cases demonstrated strong positivity for smooth muscle actin, cyclin D1, CD99, and β-catenin (100%). Targeted sequencing revealed recurrent CTNNB1 missense mutations in all cases tested. Additionally, TLE1 was positive in all cases which has not been previously reported. No tested cases harbored SS18 translocations. We found that while no single marker resolves immunohistochemical overlap between SNGP and its histologic mimics, an extended immunohistochemical panel that includes β-catenin, cyclin D1, STAT6, smooth muscle actin, pan-cytokeratin cocktails, S100, and SOX10 helps to support the diagnosis of SNGP in diagnostically challenging cases without the need for molecular studies.