Simultaneous inflammatory pseudotumors of the coronary arteries and abdominal aorta

We herein report a rare case of cardiac and abdominal aortic inflammatory pseudotumors (IPTs). A 64-year-old male presented with a loss of appetite, abdominal distension and general fatigue. A cardiac tumor was suspected on the basis of computed tomography scans. A needle biopsy was performed, but it did not lead to a definitive diagnosis. At the same time, a 70-mm abdominal aortic aneurysm (AAA) was also detected. A full sternotomy was performed, and a huge, elastic hard tumor was found around the bilateral coronary arteries, anterior side of the right atria, ascending aorta and pulmonary artery. The pathological diagnosis was IPT, which was judged to be inoperable because of its anatomical location and the fact that the patient was a Jehovah's Witness, which precluded the administration of heterologous blood transfusions. The AAA was surgically treated, and the pathological diagnosis of the aneurysmal tissue also revealed IPT. Perioral steroid therapy was initiated, and the size of the tumor did not change for 1-2 years, but then gradually increased. The patient eventually died 8 years later, and the cause of his sudden death was considered to be heart failure caused by the pressure on the right atrium and ventricle due to the enlarged cardiac tumor.

IgG4 related cardiac disease

IgG4-related systemic disease is an inflammatory disorder that can affect many organs. This case report describes a patient who in 2004 was found to have an inflammatory pseudotumor with IgG4 pathology. Over the next 3 years, visual symptoms responded well to recurrent courses of prednisone. In 2009, the patient developed chest pain and bradycardia with subsequent third-degree heart block, necessitating placement of a pacemaker. A subsequent PET scan showed extensive involvement of multiple organs as described in IgG4 disease as well as involvement of the myocardium and SA node. Pseudotumors involving the heart have been reported but have not been shown to be related to IgG4 disease. Although there was no pathology confirmation of heart involvement, the nature and extent of the organ involvement led us to conclude that it was due to IgG4-related disease. The use of the PET scan may help identify involvement of the myocardium.

Necrotic hepatocellular carcinoma occurring within an inflammatory pseudotumor-like nodule

Hepatocellular carcinoma (HCC) and inflammatory pseudotumor of the liver (IPL) are often difficult to differentiate before surgery. To date, colocalization of IPL and HCC has not been reported. We experienced a case of necrotic HCC surrounded by IPL-like tissue. The raised levels of alpha-fetoprotein and PIVKA-II declined to within the normal ranges after resection of the tumor. The IPL-like nodule most likely developed as a process of an inflammatory reaction such as abscess formation after the spontaneous destruction of the HCC. Our case is a warning that the presence of a 'pseudotumor' does not rule out the possible simultaneous presence of carcinoma.

[An inflammatory pseudotumor of the liver]

BACKGROUND

Inflammatory pseudotumours are rare benign tumours that can present as solid and potentially malignant tumours on diagnostic images.

CASE DESCRIPTION

A 59-year-old male presented at the emergency department with continuous pain in his right upper abdomen, attacks of colic and intermittent fever. CT scans of the abdomen revealed a solid lesion in the liver. Histopathological analysis of a biopsy showed an inflammatory pseudotumour. Since the pain persisted and a malignancy could not be excluded with certainty, surgical resection of the tumour was performed. The specimen showed an inflammatory pseudotumour with an increase in IgG4 positive plasma cells as well as a purulent infection around aggregates of Actinomyces.

CONCLUSION

It is important to realise that a pseudotumour caused by an inflammatory reaction can mimic a malignancy.

A rare case of fever of unknown origin: inflammatory myofibroblastic tumor of the liver. Case report and review of the literature

We present the case of a rare cause of fever of unknown origin (FUO). FUO is challenging for patients as well as for physicians as there are more than 200 differential diagnoses of FUO (1,2). Pointing out a diagnosis often requires numerous noninvasive and invasive procedures that sometimes even fail to explain the fever. Our patient was admitted twice to our hospital due to remitting fever rising up to 40 degrees C without any subjective discomfort. At the first presentation no clinical focus could be identified. This included the examination of multiple blood and urine cultures, serology, autoimmune serology, transesophageal echocardiography, CT-scan of the lung and the abdomen, and bone scintigraphy. Elevated C-reactive protein (268 mg/l) decreased spontaneously and fever disappeared after 4 weeks. However, the patient was re-admitted 4 months later with identical symptoms. Multiple blood and urine cultures, serology, bone marrow examination, CT-scan of the lung and the abdomen, esophago-gastro-duodenoscopy and colonoscopy still showed no pathological findings. MRI-scan of the abdomen identified a liver tumor of 3.3 cm in diameter in segment 6 without typical signs of an adenoma, focal nodular hyperplasia or hepatocellular carcinoma. Biopsy of the suspect liver lesion revealed an inflammatory myofibroblastic tumor (inflammatory pseudotumor). After surgical resection of the tumor elevated inflammation markers as C-reactive protein normalized and fever disappeared. One year after surgery no more episodes of fever re-occurred. An inflammatory myofibroblastic tumor of the liver can be a rare cause of fever of unknown origin. MRI-scan can be an additional imaging tool to identify previously not recognized liver tumors.

[Abdominal pseudotumoral tuberculosis]

Introduction

L’objectif de ce travail est de rapporter cinq cas de tuberculose abdominale pseudo-tumorale afin d’en souligner les aspects diagnostiques et thérapeutiques. Cinq observations sont colligées dans le service de chirurgie générale de l’hôpital militaire Avicenne de Marrakech au cours de l’année 2007. Les aspects cliniques sont disparates. Ainsi, les auteurs ont noté un syndrome péritonéal dans un cas, une masse épigastrique dans un cas, une lésion suspect du sigmoïde dans un cas, une masse de la fosse iliaque droite dans un cas et une altération de l’état général avec fièvre dans le dernier cas. Un seul patient avaient bénéficié d’une biopsie scano-guidée et les quatre patients restants avaient été opérés. Une masse du méso côlon était notée dans le premier cas. Dans le second cas, l’aspect de la masse épigastrique et son siège avaient orienté vers une tumeur du grand omentum. Une localisation tuberculeuse péritonéale et sigmoïdienne avait été trouvée dans le troisième cas. Le diagnostic d’une tumeur du côlon droit était hautement suspect chez le patient séropositif qui avait présenté une péritonite post-opératoire et décédé à J + 3 dans un tableau de choc septique. Le siège et l’aspect nécrotique des lésions trouvées à la tomodensitométrie chez la seule patiente de l’étude avaient fait discuter en premier un lymphome. Même en l’absence d’antécédents de tuberculose pulmonaire, le diagnostic tuberculose abdominale pseudo-tumorale doit être évoqué surtout dans un pays d’endémie comme le notre et le recours à une laparotomie est justifié chaque fois que persiste un doute diagnostique ou en cas de complication.

Surgical treatment of the haemophilic pseudotumour: a single centre experience

PURPOSE

Haemophilic pseudotumour was defined by Fernandez de Valderrama and Matthews as a progressive cystic swelling involving muscle, produced by recurrent haemorrhage into muscles adjacent to the bone. The pseudotumour mainly occurs in the long bones and the pelvis. The treatment of the haemophilic pseudotumour poses a challenge, and extensive clinical experience is essential to appropriately address this serious complication in patients with haemophilia. Consequently, the aim of this study is to present our own clinical experience and treatment results of the haemophilic pseudotumour.

METHODS

We retrospectively reviewed the records of 87 patients with bleeding disorders treated between 1967 and 2011 for musculoskeletal complications of congenital bleeding disorders. We identified six patients with a haemophilic pseudotumour who were treated at our department.

RESULTS

The mean age at surgery was 45.9 (range, 40-61) years. The iliac bone was affected in three patients (one right, two left), the right tibia (distal diaphysis) in one, the right thigh in two and the right ulna (proximal part) in one patient. One patient had two pseudotumours. The perioperative course was easily controllable with adequate factor VIII substitution. At the latest follow-up after 8.4 (range, 4-24) years, normal healing with no recurrence was observed.

CONCLUSIONS

The haemophilic pseudotumour is a rare but severe complication of hereditary bleeding disorders. In the international literature the resection and postoperative course are described as challenging and difficult, requiring detailed preoperative planning. It is advisable to perform such operations in specialised centres with close co-operation between surgeons and haematologists.

Long-term outcome of an unusual haemophilic pseudotumour

Haemophilia, a lifelong congenital bleeding disease, is a highly demanding disorder, due to the costs of its replacement therapy. In the absence of this pivotal treatment, life expectancy and quality of life are deleteriously affected. As illustration, we present a 14 years long follow-up of a patient with severe haemophilia A, treated sporadically with fresh plasma, cryoprecipitate and factor concentrates, who developed a giant iliopsoas pseudotumor. Since he was an infant, under on demand therapy with fresh frozen plasma, cryoprecipitate and low doses of factor concentrates he presented many spontaneous bleedings, developing multiple disabling arthropathies. At the age of 14 years, an iliopsoas hematoma occurred, which relapsed several times, developing an iliopsoas pseudotumour. After 5 years, sepsis with Klebsiella was diagnosed. A CT scan revealed fistula between the pseudotumor and the gut. Under antibiotics, the evolution of sepsis improved, but over a period of 10 months 5 episodes of haematemesis and melena, followed by one episode of macroscopic haematuria occurred; two months later he developed an inguino-crural mass, which fistulized through the abdominal wall. A mixt german-romanian team solved the clinical concern. After 108 hospitalization days and consumption of 104840 IU factor VIII he left the clinic in good condition. One year later, the temporary colostomy with anus praeter was closed. The follow-up reveals now, after almost 10 years with favourable outcome, that the patient is well, active within his family and profession.

[A case of IgG4-related disease with deterioration in pulmonary and pituitary involvements during a 10-year clinical course of inflammatory pseudotumor]

A 71-year-old man underwent pleural biopsy due to left pleural effusion and pleural thickening in August, 2001. An inflammatory pseudotumor (IPT) was diagnosed, and therefore systemic oral steroid therapy (prednisolone [PSL] 30 mg/day) was initiated. However, after tapering PSL to 7.5 mg/day, a complication of secondary central diabetes insipidus due to hypophysitis developed in 2008. As his pulmonary condition deteriorated over time and he began to experience exertional dyspnea, he was admitted to our hospital for re-evaluation of the disease in October, 2010. High-resolution CT (HRCT) revealed pulmonary involvements distributed in the interstitium and a high serum IgG4 level (240 mg/dl). Upon re-evaluating the pleural biopsy specimens of the first visit, we found lymphoplasmacytic-type IPT with approximately 10% IgG4-positive plasma cells in the affected areas. After increasing the PSL dose up to 0.6 mg/kg/day, his serum IgG4 levels decreased, his dyspnea improved, and the radiological findings of his pulmonary and pituitary involvements improved. This case was diagnosed as lymphoplasmacytic type IPT which appeared to be highly homologous with IgG4-related disease due to high serum levels of IgG4, pituitary involvements and the observed efficacy of PSL.

Vanek's polyp or inflammatory fibroid polyp. Case report and review of the literature

BACKGROUND

Intussusception in an adult must make us suspect the presence of a tumor (benign or potentially dangerous) as the most frequent cause. Accurate diagnosis is of great importance in order to provide appropriate treatment and improve patient prognosis.

CLINICAL CASE

We report the case of a 42-year-old male with abdominal pain. We performed a CT and found a small bowel intussusception. Definitive diagnosis according to the surgical specimen was inflammatory fibroid polyp (Vanek's polyp).

CONCLUSIONS

Vanek's polyp is a benign lesion that occurs most frequently in the stomach and secondarily in the small bowel. Generally, it is uncommon, and its etiology is not completely known. Accurate diagnosis is done with immunohistochemistry. Because of the consequences that depend on the size and location of the lesion, it may be considered a malignant lesion. Treatment is resection.

Adult intussusception with perforation and secondary peritonitis. Case report

BACKGROUND

Intussuception is an uncommon condition in adults. It is usually secondary to an organic lesion that may be malignant. The most common clinical presentation is as a partial bowel obstruction that requires surgical management. Preoperative diagnosis remains difficult; therefore, this paper presents a case report and a brief review of adult intussusception.

CLINICAL CASE

We present the case of a 24-year-old female with a 36-h evolution of lower abdominal pain with nausea, vomiting and diarrhea and a previous episode 8 days earlier. Pneumoperitoneum was observed on chest x-ray and surgery was decided upon. Peritonitis due to ileoileal intussusception was found, caused by an inflammatory fibroid polyp with microperforations. Small bowel resection with end-to-end anastomosis was performed and the patient had an uneventful recovery.

CONCLUSIONS

Adult intussusception is an infrequent condition with nonspecific symptoms such as pain, nausea and vomiting. With more frequent use of tomography in patients with abdominal pain, correct diagnosis can be achieved. Treatment requires resection of the involved bowel without attempted reduction.

Inflammatory myofibroblastic tumor of the liver in an elderly woman following a second liver biopsy: a case report

Inflammatory myofibroblastic tumor (IMT) is a rare benign lesion of unknown etiology reported in numerous anatomic sites. Hepatic IMT is rare. It is composed of a dominant spindle cell proliferation with a variable inflammatory component that has unique histological appearance. The tumor is more common in women, who often present with fever of unknown origin or other vague, nonspecific symptoms. A 74-year-old female presented with fever of unknown origin. Abdominal CT-Scan showed focal mass effect with luminal narrowing at the distal sigmoid colon, highly suggestive of a sigmoid neoplasm as well as numerous hypodense lesions scattered throughout the liver, likely representing metastatic disease. Liver biopsy revealed an IMT. Patient was treated conservatively and remained without symptoms. It is extremely difficult to differentiate an IMT from neoplastic disease. Most cases require complete resection to obtain an accurate diagnosis. This entity should be considered in the differential diagnosis in patients with hepatic lesions to avoid unnecessary surgical procedures.

Inflammatory myofibroblastic tumor of the trachea

This report described a 2-year-old boy who presented with severe respiratory distress and stridor. Bronchoscopy and CT revealed a mass in the left anterolateral tracheal wall and histopathology showed a tracheal inflammatory myofibroblastic tumor. Initial removal by rigid bronchoscopy resulted in prompt recurrence of the tumor. Therefore he underwent tracheal surgical resection. A bronchoscopy at 12 months after surgery did not show any recurrence sign.

Plasma cell granuloma of the sigmoid colon associated with diverticular disease and accompanying IgM-type monoclonal gammopathy

Plasma cell granuloma is a pseudoneoplastic lesion composed of reactive plasma cells of a polyclonal nature and must be distinguished from plasmacytoma. We report a case of plasma cell granuloma in the sigmoid colon associated with diverticulosis. In this case, the lesion consisted of multiple submucosal tumors with prominent infiltration of polyclonal plasma cells. Although the patient exhibited IgM-type monoclonal gammopathy, the expression of a monoclonal immunoglobulin was not detected in the sigmoid colonic lesion, but in the bone marrow cells. Plasma cell granuloma in the lower alimentary tract has been rarely reported. Recurrent inflammatory process with diverticular disease was considered as a pathogenesis of the pseudoneoplasm and a possible cause of monoclonal proliferation of IgM-producing lymphoid cells in this case.

[An abdominal inflammatory pseudotumor in a 9-year-old girl with newly diagnosed diabetes mellitus type 1--a case report]

An inflammatory tumor is a rare, benign pathology with a variable natural course. The hypotheses of the etiology of the inflammatory tumor are associated with trauma, infections or the immune mechanisms. To our knowledge, in the literature are described some single cases of solid omental and peritoneal masses as an uncommon cause of abdominal lump in children. We describe a case of a 9-year-old girl with clinical symptoms at onset of type 1 diabetes and accidentally diagnosed omental and peritoneal tumor.

Inflammatory myofibroblastic tumor of the right ventricle causing tricuspid valve regurgitation

Cardiac inflammatory myofibroblastic tumor is a rare lesion consisting of inflammatory cells and myofibroblastic spindle cells. We describe a case of inflammatory myofibroblastic tumor that involved the right ventricle, thereby causing tricuspid valve regurgitation in an 18-year-old man who presented with a fever of unknown origin and of 1 month's duration. With the patient on cardiopulmonary bypass, we excised the lesion and replaced the tricuspid valve without serious intraoperative or postoperative sequelae. The patient had a favorable outcome.

Inflammatory myofibroblastic tumor of the small intestine: a case report of a 2 month-old infant

Benign intestinal tumors are rare in children; however, the authors describe an inflammatory myofibroblastic tumor (IMT) of the terminal ileum in a 2-month-old infant who presented with an intestinal obstruction. During laparotomy, an annular mass around the terminal ileum was resected, from which a histological diagnosis of IMT was made. A review of the literature for this rare condition was done to delineate the natural history of this tumor and to do a histological confirmation of its benign nature. Because of the risk of local recurrence, IMT cases should have a long-term follow up.

Pseudotumoural hypertrophic neuritis of the facial nerve

In a retrospective study of our cases of recurrent paralysis of the facial nerve of tumoural and non-tumoural origin, a tumour-like lesion of the intra-temporal course of the facial nerve, mimicking facial nerve schwannoma, was found and investigated in 4 cases. This was defined as, pseudotumoral hypertrophic neuritis of the facial nerve. The picture was one of recurrent acute facial palsy with incomplete recovery and imaging of a benign tumour. It was different from the well-known recurrent neuritis, hypertrophic neuropathy and perineuroma. A portion of the intra-temporal course of the nerve with concurrent dilatation of the osseous walls was diagnosed pre-operatively as facial nerve schwannoma. The pathological picture showed inflammatory hypertrophy which was not a schwannoma but was likely of viral origin, with degeneration-regeneration of fibres and new connective tissue. Resection of the involved portion of the facial nerve and autologous graft in two cases was performed, decompression with biopsy in the other two. No recurrence of new episodes of paralysis after surgery was observed.