Hysterosalpingography and Ultrasonography Features of Herlyn-Werner-Wunderlich Syndrome Detected during Infertility Workup

The Herlyn-Werner-Wunderlich syndrome (HWWS) is a very rare congenital anomaly of the urogenital tract. It is characterized by a combination of didelphys uterus, unilateral vaginal obstruction, and ipsilateral renal agenesis. MRI imaging is usually used for diagnosis; however, the authors present a case of HWWS diagnosed by ultrasonography (HSG) and hysterosalpingography (HSG) in a 22-year-old lady who has undergone an imaging workup of infertility.

Relationship of age and gender with cytopathological findings of thyroid nodules diagnosed by FNAC: a retrospective study

In Afghanistan, there are no reliable epidemiological data available about thyroid cytopathology and its possible relationship with the age and gender of patients. Therefore, we conducted this study to outline this relationship and the importance of fine needle aspiration cytology in this regard. A retrospective review study was conducted including 686 consecutive medical records of thyroid nodules diagnosed by fine needle aspiration cytology in a span of five years. Out of 686 consecutive patients with thyroid nodules included in this study, 566 were females and 120 were males. Most of the thyroid nodules diagnosed were benign lesions with female predominance. These nodules were commonly arising in between 3rd and 6th decades of life in both the genders with mean age of 42 ± 13 years in females and 52 ± 15 years in males. Thyroid malignancy was commonly diagnosed in middle-age females, however in males, it was frequently diagnosed in older age with a peak at 7th decade. Most of the malignant nodules were solid and complex with no purely cystic nature. In both the genders, thyroid nodules were commonly arising in the right thyroid lobe (52.3%), followed by left (35.7%), isthmus (8.7%) and bilateral (3.2%). Fine needle aspiration cytology remains the modality of choice for the diagnostic evaluation of nodular lesions of thyroid. In contrast to the data reported around the world, thyroid malignancies, in our study, were diagnosed in relatively older age groups with peak incidence in the 5th decade of life for females and 7th decade for males.

Proteus mirabilis: A rare cause of pneumonia, radiologically mimicking malignancy of the lung

Key clinical message

Lesions that are suspected for malignancy need be managed by a multidisciplinary team. Utilization of radiological as well as pathological diagnostic modalities ensures correct diagnosis and thus timely intervention.

Abstract

Introduction

Proteus mirabilis is a Gram-negative rod. It is a highly motile bacterium that belongs to the Enterobacteriaceae. Lung infection and pneumonia caused by p. mirabilis is extremely rare and occurs in patients with chronic debilitation or chronic lung disease.

Case Presentation

A 65-year-Old Woman presented with dry cough, dyspnoea on exertion, and chest pain of 4 months' duration. She received multiple medications including antibiotics but without any resolution of her symptoms. Computed Tomography scan of the chest was performed reported a tumor in the upper lobe of the left lung with multiple associated pulmonary nodules. The impression was that of metastatic lung disease with superimposed acute infection. Accordingly, the patient was reevaluated and a diagnostic bronchoscopy with multiple endobronchial biopsies and broncho-alveolar lavage was done. The gram stain showed Gram-Negative Bacilli and the bacteria identified P. mirabilis.

Conclusion

Mass lesions suspected for malignancy should be managed with involvement of multiple medical disciplines, to ensure correct and timely diagnosis. This is to avoid miss-management.

A rare nasopharyngeal foreign body (detached beverage can stay-tab): A case report

Foreign body ingestion and inhalation is a very common problem in children while nasopharyngeal foreign body aspiration in children is rare but can present; therefore, timely diagnosis of the nasopharyngeal foreign body is crucial and vital for the patient. Authors present a rare case of nasopharyngeal foreign body (detached beverage can stay-tab) in 1-year-old male child. Authors suggest that although nasopharyngeal foreign body aspiration is a rare entity, but should be considered as a crucial diagnosis in pediatric patients with history of foreign body aspiration.

Misdiagnosis of Budd Chiari syndrome, a case report from Afghanistan

Introduction

Budd-Chiari syndrome is a rare disease characterized by hepatic venous flow obstruction. The obstruction may be thrombotic or non-thrombotic anywhere along the venous course from the hepatic venules to the inferior vena cava (IVC) junction to the right atrium. In clinical practice, cases can be misdiagnosed, particularly in regions where resources are limited, unless the clinician pays special attention to such diagnosis.

Case report and clinical discussion

Here, we would like to present a misdiagnosed case of Budd Chiari syndrome. This reported case is a case of 30 years old female patient complaining of dull abdominal pain and swelling. Initially, the patient consulted a local health facility where the patient was diagnosed with tuberculous peritonitis and subsequently treated with an anti-TB regimen empirically. Within a few days of taking medicine, she developed mild jaundice and lower limb edema. At this stage, the patient came to us, which after taking history, her physical examination unveiled mild jaundice, ascites, abdominal tenderness, and mild lower limb petting edema. The patient was recommended an abdominal CT scan with contrast, which revealed early enhancement and enlargement of the caudate lobe and non-opacification of hepatic veins with narrowing of the hepatic part of the inferior vena cava consistent with Budd-Chiari syndrome. The patient was started on warfarin and referred for a hepatic decongestive procedure. After four months of performing a transjugular portosystemic shunt, the patient came to us for follow-up. She had an excellent clinical improvement and was started on rivaroxaban 20 mg daily orally.

Conclusion

The main takeaway lesson of this particular case is to consider the differential diagnosis of ascites from an etiologic point of view and not to overemphasize a single etiology.

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Budd-Chiari syndrome misdiagnosed with tuberculous peritonitis

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SARS-CoV-2 virus infection must be bear in mind as a possible etiology

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Detailed patient history and an accurate physical examination are crucial to guide us to the exact diagnosis.

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It is necessary to check liver function tests before prescribing any hepatotoxic drug to avoid any future misconception.

Ruptured middle cranial fossa arachnoid cysts after minor trauma in adolescent boys presenting with subdural hygroma: two case reports

Background

Intracranial arachnoid cysts are common, cerebrospinal fluid-filled, innocent lesions that are usually detected incidentally on brain imaging. They may rupture and complicate due to subdural hematoma or hygroma after minor trauma.

Case summary

Authors present two cases of ruptured middle cranial fossa arachnoid cysts in adolescent (12-year-old and 15-year-old) Afghan boys presenting with subdural hygroma after minor trauma.

Conclusion

Imaging work-up is necessary for symptomatic patients following minor head trauma as incidentally detected ruptured intracranial arachnoid cysts can be responsible for the symptoms.

Infantile presentation of the canal of Nuck hernia containing uterus and ovary: a case report

Indirect inguinal hernias of the canal of Nuck containing the uterus and the ovary is rare entity in girls presenting as labia major masses at infancy and early childhood. Authors present a case of the canal of Nuck hernia in a 5-month-old girl presented as palpable lump in the right labia majora which was diagnosed by ultrasonography. Ultrasound is the noninvasive diagnostic modality of choice in for evaluation of palpable external genital masses in children.

Computed tomography features and surgical treatment of superior mesenteric artery syndrome: A case report

Introduction: Superior mesenteric artery (SMA) syndrome is described as compression of the third part of the duodenum between SMA and aorta with resultant obstruction and dilatation of proximal duodenum and stomach. Virtually, any condition associated with weight reduction may predispose the patient to SMA syndrome. Case presentation: A 17-year-old boy complaining from persistent vomiting, dull abdominal pain, anorexia, and weight loss for long time presented to the pediatric surgery department. Computed tomography (CT) of the abdomen was prescribed to look for the cause of persistent vomiting and bulging of the epigastrium. Contrast Enhanced CT revealed decreased aortomesenteric angle and aortomesenteric distance causing compression of third part of duodenum with resultant marked distension of proximal duodenum, stomach, and even esophagus. The patient underwent laparotomic gasterojujenostomy. Conclusion: SMA syndrome is a rare clinical entity. CT can well delineate this abnormality. SMA syndrome can be treated with both conservative and surgical approaches.

Brain ectopic tissue in sacrococcygeal region of a child, clinically mimicking sacrococcygeal teratoma: a case report

Background

Mature brain heterotopic tissue in sacrococcygeal region is a very rare benign congenital abnormality of newborn. To date, only two cases of mature heterotopic brain tissue in the sacrococcygeal region is reported by literature. Heterotopic brain tissue in other areas such as lung, nose, face and retroperitoneal region are also rarely reported. Meanwhile, rather than brain heterotopic tissue in sacrococcygeal region, a case of adrenal gland heterotopic tissue in sacrococcygeal region also has been reported.

Case presentation

A 3.5 month-old male baby presented with history of sacrococcygeal mass since birth. Clinical examination of the child was good with no other problem. Sacrococcygeal region revealed an elevated round mass with no discharge. Computed tomography reported a large sacrococcygeal teratoma type-III arising from the sacrococcygeal region extending intra-abdominally to the level of L2 vertebral body. The mass was excised by the impression of sacrococcygeal teratoma (SCT). On gross examination, a gray-white irregular tissue fragment with 5 cm in greatest dimension was examined. Cut sections showed homogenous yellowish white appearance. Histological examination revealed solid fragments composed of mature neural tissue comprising glial cells and astrocytes with no other germ cell layer component.

Conclusion

Mature brain heterotopic tissue in sacrococcygeal area is a rare benign disease. Two ectopic brain tissue in sacrococcygeal region were previously also reported. Sacrococcygeal teratoma is the most common congenital tumor, but this current rare case of heterotopic brain tissue in sacrococcygeal region should also be in the differential diagnosis.

Congenital heart disease frequency in children undergoing MDCT angiography; a 4-year tertiary care hospital experience from Kabul, Afghanistan

Objectives:

Echocardiography and cardiac angiography are two main imaging modalities used for evaluating congenital heart diseases (CHDs). Evaluation of CHDs is now possible with Multidetector CT (MDCT) angiography in Afghanistan. To the best of researchers' knowledge, no published data is available on frequency of CHDs among children undergoing chest MDCT angiography in Afghanistan; hence, this study is first of its nature to be conducted in this context. To describe the frequency of CHDs among children who underwent chest MDCT angiography in radiology department at French Medical Institute for Mothers and Children (FMIC) from April 2010 to July 2014.

Methods & materials:

A retrospective, cross-sectional descriptive study was conducted at radiology department FMIC in Kabul, Afghanistan. The study population consisted of all paediatric patients (aged 1 day–17 years) who underwent chest MDCT angiography at radiology department FMIC from April 2010 to July 2014. All examinations were performed in arterial phase by 128 slice Siemens scanner after intravenous administration of non-ionic water-soluble contrast material (Omnipaque 350) at a volume of 2 ml/Kg. CT setup included non-electrocardiogram gated CT, CT dose index 5–10 and dose–length product 120–200, with post-processing following initial scan. CT reports were reviewed from Radiology Information System. Data collection tool was developed and data were analysed using SPSS v. 22. Frequencies and proportion were calculated for various CHDs.

Results:

A total of 942 cases of contrast enhanced chest MDCT examinations were performed during this period. Out of these, 212 cases with CHDs were recruited, from which 29 cases were excluded because of undergoing previous surgical procedures or had incomplete CT reports. Remaining 183 cases (n = 183) of CHDs were included for further analysis. A total of 107 patients (58.5%) were male and 76 (41.5%) were female. The patients aged 1 day–17 years (mean age 4.47 + 4.76 standard deviation). A total of 87 patients (47.5%) had solitary anomalies while 96 patients (52.5%) had more than one defect. In terms of location, 20 cases (10.9%) were isolated intracardiac anomalies, 116 cases (63.4%) were isolated extracardiac anomalies and 47 cases (25.7%) had mixed intra- and extracardiac anomalies.

Conclusion:

Given the frequency, it is clear that CHDs is a complex health problem in Afghan paediatric population. MDCT angiography can be considered as a non-invasive, readily available diagnostic tool in evaluation of complex cardiac anomalies after initial evaluation.

Advances in knowledge:

MDCT evaluation of CHD as an alternative to echo/angiography has become more important in a country where there is severe shortage of interventional cardiologists.

CT features of lung agenesis - a case series (6 cases)

Back ground

Lung agenesis is a rare congenital anomaly. The main etiology of the disease is unknown whereas genetic, iatrogenic and viral factors as well as vitamin A deficiency during early pregnancy may result in developmental failure of primitive lung bud causing unilateral pulmonary agenesis. Affected patients usually present with variable respiratory symptoms and recurrent chest infection at any age. Plain film demonstrates opaque unilateral lung while chest CT scan can definitely diagnosis the disease. The anomaly has three types. Type I is pulmonary agenesis, type II is called pulmonary aplasia and type III is pulmonary hypoplasia.

Cases’ presentation

Six patients with main complaint of dyspnea underwent contrast enhanced chest CT in radiology department of French Medical Institute for Mothers and children, Kabul and were diagnosed lung agenesis.

Three patients were categorized as type II pulmonary agenesis (aplasia). Two patients, three months old boy and a seven year- old girl demonstrated right lung aplasia. Another patient boy of eighteen years old presented with left lung aplasia.

Two boys of four and seven months of age were classified as type I pulmonary agenesis (agenesis).

A boy of one year old was diagnosed pulmonary agenesis type III, right lung hypoplasia.

Conclusion

Six patients were diagnosed with pulmonary agenesis by Chest CT scan. The clinicians should consider possibility of congenital pulmonary agenesis in dyspneic patients with opaque unilateral hemithorax in plain film.

Late presentation, MR imaging features and surgical treatment of Herlyn-Werner-Wunderlich syndrome (classification 2.2); a case report

Background

Herlyn-Werner-Wunderlich syndrome is a very rare congenital genitourinary anomaly characterized by uterus didelphys, blind hemivagina and ipsilateral renal agenesis.

Case presentation

Authors present a case of Herlyn-Werner-Wunderlich syndrome in a 19-year-old unmarried woman who presented with pelvic pain and pelvic mass. MR imaging revealed the typical features of didelphys uterus, obstructed right hemivagina and ipsilateral renal agenesis. The patient subsequently underwent surgery.

Conclusions

Herlyn-Werner-Wunderlich syndrome would be suspected in patients with unilateral absent kidney and pelvic mass. Ultrasonography and MR imaging can well depict the disease entity and surgery is the treatment of choice for obstructed hemivagina.

Incidental finding of cardiac hydatid cysts, report of two cases

Background

Hydatid is a parasitic infection which can affect any organ of body. In some organs like liver and lung; it can be found regularly while in other organs like heart, it is seen very rarely. Cardiac hydatid cysts comprise less than of 2% of hydatid infection cases and may be detected incidentally.

Case presentation

Authors report two cases of cardiac hydatid cysts in young adult patients living in rural areas of the country with positive animal contact. Both patients were complained from shortness of breath and cough. Contrast enhanced chest computed tomography (CT) revealed left ventricular wall hydatid cysts in addition to lung and liver hydatid cysts.

Conclusion

Cardiac hydatid cyst is a rare finding with wide range of signs and symptoms. These may be suspected in patients coming from endemic areas. Echocardiographic follow up of patients with liver or lung hydatid cysts can be helpful.

Radiographic features of Ollier's disease - two case reports

Background

Ollier’s disease is a non-hereditary, benign bone tumor which is usually characterized by presence of multiple radiolucent lesions (enchondromas) in the metaphysis of long bones with unilateral predominance. The disease is a rare clinical entity with 1/100000 occurrence in early childhood. Patients mostly present with multiple hard swellings and deformity of the tubular bones specially hands and feet with leg discrepancy and pathologic fractures.

Case presentation

We present two cases of Ollier’s disease in a 13 years old female and 8 years old boy which had no specific symptoms. The girl had multiple hard swellings and deformity in the fingers of both hands and left toes with left leg deformity and discrepancy. Her plain radiographs demonstrated multiple expansile enchondromas in the phalanges of hands, left toes and metaphyses of upper humeri as well as left leg bones. The enchondromas were also noted in the left iliac bone and anterior end of ribs. The boy had bowing deformity and shortage of left leg with multiple enchondromas in the metaphyses of left femur, left tibia and fibula as well as left iliac bone in his radiographic images.

Conclusion

Ollier’s disease is usually diagnosed by clinical signs and typical location of enchondromas across skeleton in conventional radiography. It usually does not need specific treatment. Well understanding of the clinical manifestation and radiographic features can prevent unnecessary application of other imaging modalities; while other diagnostic imaging modalities like MRI, ultrasound and scintigraphy can be used in complicated and painful conditions.

A rare clinic entity: Huge trichobezoar

INTRODUCTION

Trichobezoar is a rare clinical entity in which a ball of hair amasses within the alimentary tract. It can either be found as isolated mass in the stomach or may extend into the intestine. Trichobezoars mostly occur in young females with psychiatric disorders such as trichophagia and trichotillomania.

CASE REPORT

Authors present a giant trichobezoar in an 18year old female presented with complaints of upper abdominal mass, epigastric area pain, anorexia and weight loss. The patient underwent trans-abdominal ultrasonography (USG), Computed tomography (CT), upper gastrointestinal endoscopy and subsequently laparotomy. USG was inconclusive due to non-specific findings. It revealed a thick echogenic layer with posterior dirty shadowing extending from the left sub-diaphragmatic area to the right sub hepatic region obscuring the adjacent structures. Abdominal CT images revealed a huge, well defined, multi-layered, heterogeneous, solid appearing, non-enhancing mass lesion in the gastric lumen extending from the gastric fundus to the pyloric canal. An endoscopic attempt was performed for removal of this intraluminal mass, but due to its large size, and hard nature, the endoscopic removal was unsuccessful. Finally the large trichobezoar was removed with open laparotomy.

CONCLUSION

Trichobezoars should be suspected in young females with long standing upper abdominal masses; as the possibility of malignancy is not very common in this age group. While USG is inconclusive, trichobezoar can be accurately diagnosed with CT. In patient with huge trichobezoar, laparotomy can be performed firstly because of big size and location of mass, and psychiatric recommendation should be made to prevent relapse of this entity.

Visual and otologic manifestation of Camurati-Engelmann's disease: a case report

Camurati–Engelmann’s disease (CED) is a rare disorder worldwide with just over 200 cases reported. No case of CED has been reported in Afghanistan till date. Most patients of CED (also known as progressive diaphyseal dysplasia and oeteopathica hyperostotica multiplex infantalis) present with extremity pain, muscle weakness, and waddling gait. It tends to be bilateral and symmetrical and can affect any bone but has greater affinity for long bones e.g., humerus, femur, tibia, ulna, and radius. Other common sites include skull and pelvis. Symptomatology relating to cranial nerve impingement is secondary to amorphous increase in the density of skull bones resulting in stenosis of various foramina/spaces within skull.

Elevated CDCP1 predicts poor patient outcome and mediates ovarian clear cell carcinoma by promoting tumor spheroid formation, cell migration and chemoresistance

Hematogenous metastases are rarely present at diagnosis of ovarian clear cell carcinoma (OCC). Instead dissemination of these tumors is characteristically via direct extension of the primary tumor into nearby organs and the spread of exfoliated tumor cells throughout the peritoneum, initially via the peritoneal fluid, and later via ascites that accumulates as a result of disruption of the lymphatic system. The molecular mechanisms orchestrating these processes are uncertain. In particular, the signaling pathways used by malignant cells to survive the stresses of anchorage-free growth in peritoneal fluid and ascites, and to colonize remote sites, are poorly defined. We demonstrate that the transmembrane glycoprotein CUB-domain-containing protein 1 (CDCP1) has important and inhibitable roles in these processes. In vitro assays indicate that CDCP1 mediates formation and survival of OCC spheroids, as well as cell migration and chemoresistance. Disruption of CDCP1 via silencing and antibody-mediated inhibition markedly reduce the ability of TOV21G OCC cells to form intraperitoneal tumors and induce accumulation of ascites in mice. Mechanistically our data suggest that CDCP1 effects are mediated via a novel mechanism of protein kinase B (Akt) activation. Immunohistochemical analysis also suggested that CDCP1 is functionally important in OCC, with its expression elevated in 90% of 198 OCC tumors and increased CDCP1 expression correlating with poor patient disease-free and overall survival. This analysis also showed that CDCP1 is largely restricted to the surface of malignant cells where it is accessible to therapeutic antibodies. Importantly, antibody-mediated blockade of CDCP1 in vivo significantly increased the anti-tumor efficacy of carboplatin, the chemotherapy most commonly used to treat OCC. In summary, our data indicate that CDCP1 is important in the progression of OCC and that targeting pathways mediated by this protein may be useful for the management of OCC, potentially in combination with chemotherapies and agents targeting the Akt pathway.

Clinical characteristics of ovarian cancer classified by BRCA1, BRCA2, and RAD51C status

We evaluated homologous recombination deficient (HRD) phenotypes in epithelial ovarian cancer (EOC) considering BRCA1, BRCA2, and RAD51C in a large well-annotated patient set. We evaluated EOC patients for germline deleterious mutations (n = 899), somatic mutations (n = 279) and epigenetic alterations (n = 482) in these genes using NGS and genome-wide methylation arrays. Deleterious germline mutations were identified in 32 (3.6%) patients for BRCA1, in 28 (3.1%) for BRCA2 and in 26 (2.9%) for RAD51C. Ten somatically sequenced patients had deleterious alterations, six (2.1%) in BRCA1 and four (1.4%) in BRCA2. Fifty two patients (10.8%) had methylated BRCA1 or RAD51C. HRD patients with germline or somatic alterations in any gene were more likely to be high grade serous, have an earlier diagnosis age and have ovarian and/or breast cancer family history. The HRD phenotype was most common in high grade serous EOC. Identification of EOC patients with an HRD phenotype may help tailor specific therapies.

Dietary betaine affect duodenal histology of broilers challenged with a mixed coccidial infection

The purpose of this research was to investigate effect of dietary betaine on intestinal morphology after an experimental coccidiosis. Hence a total of 189 male and female broiler chicks were randomly assigned to 9 floor cages. Chicks were fed a basal diet supplemented with 0, 0.6 or 1.2 g kg(-1) betaine. All birds were inoculated orally with Eimeria oocysts on day 28. Duodenal morphology parameters and lesions were scored by microscopic observation on intestine samples which were taken at day 42 of age. Adding 1.2 g kg(-1) betaine to diet diminished intestinal lesions (p < 0.05). Dietary supplementation with 0.6 or 1.2 g kg(-1) betaine significantly (p < 0.01) increased intraepithelial lymphocytes as well. Level of additive betaine had no effect on the ratio of villus height/crypt depth or villus surface area. Lamina propria of duodenum became thicker in the intestine of chickens which received more supplemental betaine via their diet. In conclusion, since the number of intraepithelial lymphocytes and thickness of lamina propria represent the condition of gut immune response, it seems that dietary betaine may immunomodulate the gastrointestinal tract of broilers. In addition, betaine effect on villus morphology measured later in life differed from what had been measured already earlier in life of the chicks.