Transtracheal endoscopic-assisted resection of a rare inflammatory myofibroblastic tumour in adult trachea: a case report

SUMMARY

Inflammatory myofibroblastic tumours (IMTs) are rare and clinically benign in childhood, and malignant in adults. The aetiology of IMTs is not clear, and recent studies report it as true neoplasm rather than a reactive or inflammatory lesion. IMTs can involve any part of the body, but are usually common in lungs. These are rarely seen in adults and tracheal involvement is also rare in both adults and children. We describe an 18-year-old woman who presented with respiratory difficulty to the emergency department. On clinical examination, the patient had complete absence of breath sounds on the right side of the chest. CT of the chest and virtual bronchoscopy revealed a polypoidal soft tissue mass lesion involving the carina with occlusion of right main bronchus. Endoscopic-assisted resection was performed under general anaesthesia and the final pathological diagnosis was tracheal IMT.

Brunner's gland hamartoma of the duodenum

Brunner's gland hamartoma (BGH) is a rare benign tumour of the duodenum. We present a case of duodenal obstruction caused by a BGH, which required surgical resection after a failed attempt at endoscopic removal.

Angiosarcoma of the spleen presenting as spontaneous splenic rupture: A rare case report and review of the literature

INTRODUCTION

Angiosarcoma of the spleen is a rare malignancy of vascular origin with a high rate of metastasis and poor prognosis. We report one such rare case of spontaneous splenic rupture, along with a review of current literature.

PRESENTATION OF CASE

A 30 year old man presented to our emergency services with severe abdominal pain, distension, hypotension and splenomegaly. Investigations revealed a marked anaemia, coagulopathy, severe lactic acidosis, and acute kidney injury. Imaging demonstrated splenomegaly with acute haemorrhage and lymphadenopathy. Laparotomy and splenectomy revealed piecemeal spleen and nodular omentum. The patient suffered an intra-operative cardiorespiratory arrest, and despite successful resuscitation, fatally arrested postoperatively in ICU. Histology revealed a primary splenic angiosarcoma with omental metastases.

DISCUSSION

Primary splenic angiosarcoma was first reported in 1879, with only 200 cases reported to date, largely as isolated case reports, with an annual incidence of 0.14-0.25 per million. With variable symptomatology and a potential to present with life-threatening complications, early diagnosis is paramount. CT scanning shows distinctive changes and is invaluable in disease assessment. Tissue diagnosis is often possible only after splenectomy. Spontaneous rupture carries the worst prognosis.

CONCLUSION

Primary splenic angiosarcoma is a rare and aggressive malignancy that often presents with metastatic disease, and largely carries a dismal prognosis. Definitive diagnosis is challenging, but imaging with CT scanning can show characteristic changes and establish any metastatic disease. With no established adjuvant therapy long term outlook remains poor even if treated successfully by surgery.

Bilateral anomaly of rectus capitis posterior muscles in the suboccipital triangle and its clinical implication

Rectus capitis posterior muscles are located in the suboccipital triangle and function in extension and lateral rotation of the head and neck. There are two of these muscles on each side: the rectus capitis posterior major and the rectus capitis posterior minor. In the present case we observed bilateral double rectus capitis posterior major muscle and bilateral absence of rectus capitis posterior minor muscle. The additional rectus capitis posterior major may put more strain to the spine of the axis and mean time the bilateral absence of rectus capitis posterior minor muscles will result in muscular in coordination in the suboccipital region while balancing the head. The present variation should be considered in the aetiology of cervicogenic headache.

Serial evaluation of serum neopterin in HIV seronegative patients treated for tuberculosis

OBJECTIVE

To delineate the course of serum neopterin (s-neo) concentrations in patients with pulmonary tuberculosis who are on anti-tuberculosis therapy.

DESIGN

S-neo concentrations were measured by high performance liquid chromatography (HPLC) in 39 patients treated for pulmonary tuberculosis at pretreatment, at one month and at end of treatment. It was also measured in 11 relapse cases and their matched controls at the above time points and at the time of relapse. The results were correlated with bacteriological and radiological findings.

RESULTS

All patients had elevated levels of s-neo at pretreatment which had declined at 1 month and were near normal at the end of treatment. The decline was more significant in patients with moderate lesions, suggesting that immune activation is maximum in this group of patients. The mean decrease was 37% at one month and 66% at the end of treatment. The corresponding decreases were 11% and 56% in patients with limited lesions and 11% and 45% in those with extensive lesions. It continued to fall after completion of therapy in patients who did not relapse, whereas an increase after completion of therapy was associated with bacteriologically proven relapse.

CONCLUSIONS

The measurement of s-neo concentration could be of help in evaluating response to therapy. This study provides a rational basis for the association between s-neo concentration and relapse.

Neopterin as a marker for cell-mediated immunity in patients with pulmonary tuberculosis

SETTING

Cell-mediated immunity (CMI) involves macrophage activation and T cell proliferation. These two parameters are compared in this study.

OBJECTIVE

To ascertain the role of neopterin as a biochemical marker for CMI in patients with pulmonary tuberculosis.

DESIGN

We measured neopterin levels in serum and the culture supernatants of peripheral blood mononuclear cells (MNC) after stimulation with purified protein derivative (PPD) in 11 patients with pulmonary tuberculosis and 10 healthy individuals. Lymphocyte proliferative response to PPD was carried out in these two groups.

RESULTS

The mean concentration of serum neopterin was significantly higher in patients than in controls (P < 0.01). The spontaneous release of neopterin was significantly higher in culture supernatants of MNC from patients when compared with those of healthy controls (P < 0.05). Release of neopterin from MNC stimulated with PPD, however, was similar in both groups. The neopterin release and the stimulation index (SI) in lymphocyte proliferation assay were not comparable, suggesting that these two parameters do not run in parallel for measuring the status of CMI. However, serum concentration of neopterin was inversely related to the SI in a large proportion of subjects (66%).

CONCLUSION

Measurement of neopterin, a soluble product of immune cells (macrophage), may provide information on the state of CMI.

Monocyte antimycobacterial activity before and after Mycobacterium bovis BCG vaccination in Chingleput, India, and London, United Kingdom

Monocytes from purified protein derivative S Mantoux-negative children and young adults inhibited intracellular growth of Mycobacterium microti more in Chingleput than in London. Mycobacterium bovis BCG vaccination did not enhance bacteriostasis with the Indians but did so with the Londoners. No evidence was found for involvement of cytokines such as macrophage-activating factor and granulocyte macrophage colony-stimulating factor in the differences.