[From acute coronary syndrome to zoster : Differential diagnostics in segmental and somatic dysfunction of the thoracic spine and ribs]

Hintergrund

Segmentale und somatische Dysfunktionen im Thorakalbereich können zu unterschiedlichen klinischen Bildern führen. Es gilt, drei wesentliche Varianten zu unterscheiden.

Klinik

1. Lokale Schmerzen

Hierbei müssen auch potenziell lebensbedrohliche Differenzialdiagnosen bedacht und im Zweifel die Chest-Pain-Notfalldiagnostik initiiert werden.

2. Vertebro-viszeraler Reflex

Der sympathische Grenzstrang hat seine segmentalen Ursprünge im Wesentlichen in den thorakalen Segmenten, dies führt zu einer hochgradigen neuronalen Vernetzung mit den Thorax- und Oberbauchorganen. „Unspezifische“ Thorax- und Bauchbeschwerden können deswegen ihre Ursache in segmentalen und somatischen Dysfunktionen der thorakalen Segmente haben.

3. Viszero-vertebraler Reflex

Viszerale Noziafferenzen gelangen über die vegetative Vernetzung zu thorakalen Segmenten und können hier zu schmerzhaften thorakalen Dysfunktionen führen. Diese können erste Anzeichen einer ernsthaften strukturellen Erkrankung, z. B. Neoplasie oder Ulkus, der Thorax- und Oberbauchorgane darstellen.

Differenzialdiagnostik

Die Differenzialdiagnostik ist anspruchsvoll, die manuelle Medizin kann einen entscheidenden Beitrag leisten. Die biomechanischen und neurophysiologischen Besonderheiten am Thorax müssen dafür bekannt sein.

Combined expression of HOXA11 and CD10 identifies endometriosis versus normal tissue and tumors

The gold standard for diagnosing endometriosis is by laparoscopic visual demonstration of ectopic endometrial lesions outside the uterus, preferably verified by biopsy and microscopical examination. Molecular markers to facilitate the microscopical diagnosis of endometriosis and for distinguishing endometriosis from other benign and malignant lesions are lacking. Our aim was to test and validate an immunohistochemical antibody panel for improved diagnostic accuracy of endometriosis. Both CD10 and HOXA11 have been implicated in regulation of endometrial homeostasis. Here we have analyzed the expression pattern of these two proteins using immunohistochemistry on human tissues in a tissue microarray format. CD10 and HOXA11 expression in endometriosis lesions were compared to expression patterns in a range of normal tissues and in primary- and metastatic lesions of endometrial-, cervical- and ovarian cancer. HOXA11 and CD10 were expressed in 98% and 91% of endometriosis lesions and the combined double-positive expression profile of both HOXA11 and CD10 was highly sensitive for ectopic endometrial tissue (90%). The specificity and sensitivity for this double-positive signature in endometriosis was significantly different from all investigated tissues, cancers and metastases except normal, eutopic endometrial- and cervical mucosa. The combination of HOXA11 and CD10 expression profiles provides a useful tool to identify ectopic endometrial tissue and for distinguishing endometriosis from various types of gynecological malignancies and metastases.

Imaging features associated with idiopathic normal pressure hydrocephalus have high specificity even when comparing with vascular dementia and atypical parkinsonism

Background

Vascular dementia (VaD) and atypical parkinsonism often present with symptoms that can resemble idiopathic normal pressure hydrocephalus (iNPH) and enlarged cerebral ventricles, and can be challenging differential diagnoses. The aim was to investigate frequencies of imaging features usually associated with iNPH and their radiological diagnostic accuracy in a sample containing the relevant differential diagnoses VaD, progressive supranuclear palsy (PSP), multiple system atrophy parkinsonian type (MSA-P), and healthy controls.

Methods

Nine morphological imaging features usually associated with iNPH were retrospectively investigated in MR images of 55 patients with shunt-responsive iNPH, 32 patients with VaD, 30 patients with PSP, 27 patients with MSA-P, and 39 age-matched healthy controls. Logistic regression and receiver operating characteristic curves were used to assess diagnostic accuracy, sensitivity, and specificity for each imaging finding.

Results

In a logistic regression model using iNPH diagnosis as a dependent variable, the following imaging features contributed significantly to the model: callosal angle (OR = 0.95 (0.92–0.99), p = 0.012), Evans’ index * 100 (OR = 1.51 (1.23–1.86), p < 0.001), enlarged Sylvian fissures (OR = 6.01 (1.42–25.40), p = 0.015), and focally enlarged sulci (OR = 10.18 (1.89–55.02), p = 0.007). Imaging features with 95% specificity for iNPH were: callosal angle ≤ 71°, temporal horns ≥ 7 mm, Evans’ index ≥ 0.37, iNPH Radscale ≥ 9, and presence of DESH, bilateral ventricular roof bulgings or focally enlarged sulci. A simplified version of the iNPH Radscale with only four features resulted in equally high diagnostic accuracy as the original iNPH Radscale.

Conclusions

There is a notable overlap between some of the commonly used imaging markers regarding iNPH, VaD and atypical parkinsonism, such as PSP. However, this study shows that the specificity of imaging markers usually associated with iNPH was high even when comparing with these challenging differential diagnoses. The callosal angle was the single imaging feature with highest diagnostic accuracy to discriminate iNPH from its mimics. A simplified rating scale using only a few selected features could be used with retained specificity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12987-021-00270-3.

Luminescent Analysis of Blood Serum for Diagnostics of Pathological and Pre-Pathological States of Cancer Patients

This study is devoted to the development of a methodological approach to mathematical analysis and data interpretation of blood serum phosphorescence intensity in cancer patients for determining the pathological states and differential diagnostics of oncological process stages. The purpose of the study is blood serum phosphorescence research in patients with colorectal cancer (CRC) and stomach adenocarcinoma (SAC) and determination of the ultraweak luminescence role for diagnostics of the disease, determining its stages, control of pathogenetic therapy efficiency and forecast of recovery. The values of phosphorescence intensity of blood serum films in patients with CRC and SAC are significantly higher than the corresponding values for the control group. Contrary to the absolute intensity, the relative intensity increase compared to the control group is much more informative for oncoprocess diagnostics, since it exhibits three times increase even at the first stage of tumoral process. Serum phosphorescence intensity continues to increase with progressing of the disease. As the result of our study, the relative intensity increase compared to the first stage can be recommended as an informative indicator for differential diagnostics of oncological process stages. As a conclusion, determination of blood serum phosphorescence intensity can be considered as a sensitive and specific diagnostic method in oncology. With a correct methodological approach to data processing and interpretation, this method can be used in clinical practice for determining the oncopathological states, differential diagnostics of oncoprocess stages and diagnostics of precancer changes, which precede tumoral process development.

Morphological features useful in the differential diagnosis between undifferentiated carcinoma and gastrointestinal stromal tumor

Undifferentiated (sarcomatoid) carcinomas may closely mimic gastrointestinal stromal tumors (GISTs) due to possible histological and immunohistochemical overlap between these two entities. To avoid unnecessary employment of a wide spectrum of immunohistochemical stainings and molecular genetics and thus decrease costs, finding simple morphological features to target further investigation of such neoplasms of the gastrointestinal tract would be helpful. Five cases classified as undifferentiated (sarcomatoid) carcinomas with a definite proof of the diagnosis, i. e. the presence of a differentiated carcinomatous component, were retrieved from archives of several institutions. For comparison, 84 cases of GIST mutated in KIT or PDGFRA genes served as the control group. Hematoxylin and eosin stained slides were evaluated for the presence of patterns which might discriminate between sarcomatoid carcinoma and GIST. Lymphatic invasion and entrapment of fat tissue strongly favor the diagnosis of undifferentiated carcinoma, as it was found in all or almost all cases of undifferentiated carcinoma, but in no GIST. Alternation of low- and high- grade areas, formation of angiosarcomatous-like spaces, and the presence of yolk sac-like areas were also detected in all cases of undifferentiated carcinoma, but only in 1.2%, 2.4% and 7.2% of the GISTs, respectively. Furthermore, DOG1 was negative in all cases of undifferentiated carcinoma. According to this study, the presence of the histological findings listed above should prompt extensive tumor sampling in order to find a differentiated carcinomatous component. However, due to the small number of cases of undifferentiated carcinoma available for the study, a larger multi-institutional study is warranted.

[Fever in systemic lupus erythematosus: disease exacerbation or infection?]

The differential diagnosis of fever, especially in the context of autoimmune diseases is broad. Accordingly, the spectrum of diagnostic procedures is extensive and the therapeutic consequences are partly contradictory. Fever is basically the manifestation of an increased cell proliferation, such as classically seen in tumors, infections or autoimmune inflammation. Systemic lupus erythematosus (SLE) is one of the most multifaceted rheumatological diseases. Fever is one component of the new classification criteria which help to classify and possibly diagnose SLE. The differential work-up of fever is a special challenge for clinicians particularly in the context of the initial diagnosis of SLE or another autoimmune disease and also in the course of the disease in patients with autoimmune diseases. Based on a case report this article discusses differential diagnostic considerations and proposes a concrete differential diagnostic procedure. The patient's history is highlighted as an extremely important source of relevant information. Without claiming completeness various factors are listed, which help to differentiate fever as a consequence of SLE activity versus fever as a consequence of an infection.

[Revised S3 guidelines on schizophrenia : Developmental process and selected recommendations]

Schizophrenia is one of the most severe mental diseases and leads to significant personal and social impairments for affected persons. The illness is characterized by frequent relapses, results in increased mortality and is associated with the highest socioeconomic costs of all diseases. Moreover, patients with schizophrenia are often stigmatized in everyday life and also in most treatment settings. In 1998 the first German schizophrenia guidelines were published, followed by the first S3 guidelines for schizophrenia in 2006. The revision process started in 2012 coordinated by the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) and the revised guidelines were published in 2019. The target group for the revised S3 guidelines includes all persons involved in the care of patients with schizophrenia in all sectors of the German healthcare system, including decision makers and insurance funds. Starting with an introduction of the biological, clinical and epidemiological basis of the disorder, recommendations for the diagnostics of schizophrenia, the detection of comorbidities, the use of antipsychotic medication and other somatic procedures, for psychotherapy, psychosocial interventions, handling of special treatment conditions and rehabilitation are made. Finally, recommendations for an evidence-based and optimal coordination within the healthcare system are made, followed by a discussion of the cost-effectiveness of treatment and presentation of strategies for improved quality management. The most important aspect of the revised S3 guidelines on schizophrenia is the multiprofessional cooperation in all phases of the disorder and an empathic and respectful therapeutic alliance.

[Rheumatoid arthritis-mimics : When appearances are deceptive]

Rheumatology represents a discipline full of differential diagnoses. Even for classical diseases, such as rheumatoid arthritis as the most frequent chronic inflammatory joint disease and described so clearly in many textbooks, it is not uncommon that it can be a diagnostic challenge in daily practice. This applies to arthritic joint involvement and also to frequently associated extra-articular manifestations. The patient history and results of the clinical examination are essential; however, laboratory and imaging findings often make a significant contribution to confirming the diagnosis, especially in early phases of the disease. This article, which makes no claims to completeness, focuses on diseases that in the opinion of the authors can imitate rheumatoid arthritis due to similar joint and other organ manifestations. These include metabolic, inflammatory infective and non-infective as well as tumorous diseases. A misinterpretation as rheumatoid arthritis as a rule leads to long-term and severe consequences for affected patients. Thus, the diagnosis of rheumatoid arthritis should be questioned and re-evaluated in cases of unusual accompanying symptoms, atypical course of disease and a lack of response to standard treatment approaches.

Heterogeneity of childhood acute leukemia with mature B-cell immunophenotype

BACKGROUND

Flow cytometry (FCM) plays a crucial role in the differential diagnosis of Burkitt lymphoma/leukemia (BL) and B-cell precursor acute lymphoblastic leukemia (BCP-ALL). The presence of surface IgM (sIgM) alone or with light chain restriction indicates a mature blast phenotype (BIV by EGIL) and is usually observed in BL. However, sIgM expression could also be detected in transitional BCP-ALL cases. These similarities in immunophenotype and ambiguous correspondence with other laboratory findings may challenge the correct BL diagnostics.

METHODS

We retrospectively reviewed the available data from immunophenotypic, morphological, cytogenetic, and molecular genetic studies of 146 children (85 boys and 61 girls) with a median age of 10 years (range 0-18 years) who were diagnosed with BL and BCP-ALL. The blasts' immunophenotype was studied by multicolor FCM. The conventional cytogenetic analysis included G-banded karyotyping and fluorescence in situ hybridization (FISH).

RESULTS

In 54 children classified as BIV-ALL according to the EGIL, it was demonstrated that sIgM in a minority of cases can be associated with various types of BCP-ALL. Analysis of the antigen expression profile of 105 patients with verified BL (n = 21) and BCP-ALL (n = 84) showed significant differences in BL and the sIgM(+) vs BCP-ALL immunophenotype. Thus, even in cases of ambiguous sIgM expression, these two diseases could be reliably discriminated by complex immunophenotyping. Moreover, 10 patients (7 boys and 3 girls) with BL leukemic cells did not express sIgM, and they were diagnosed with BL on the basis of other laboratory and clinical signs.

CONCLUSIONS

In conclusion, our study shows that BIV subtype is heterogeneous group of leukemia including not only the BL, but also BCP-ALL. In ambiguous cases, only a combination of multiple immunophenotypic, cytomorphologic, and genetic diagnostic technologies can allow the precise discrimination of BL and BCP-ALL and selection of the appropriate treatment scheme.

[Genetics of movement disorders-rare but important]

Rare genetic movement disorders are a heterogeneous group of diseases. The causes of many of these rare movement disorders could be resolved due to the progress in molecular genetic diagnostics. This led to a better pathophysiological characterization of rare movement disorders and also to the fact that many phenotypical overlaps could be found between different diseases. The classification of genetic results requires a close cooperation between neurologists and geneticists. Therefore, modern diagnostic procedures cannot replace the clinical classification of genetic movement disorders and the exact patient history. This article provides the reader with an overview of the most important groups of genetic movement disorders. Genetic Parkinson syndromes, dystonia, essential tremor, genetic chorea, cerebellar ataxia and hereditary spastic paraplegia are dealt with in detail. For a better understanding individual genetic terms are explained and differences in molecular genetic diagnostics are presented.

[Expression of cancer testis (CT) antigens in pediatric and adolescent melanomas]

BACKGROUND

One of the main problems in the diagnostics of pediatric melanomas is the differentiation from benign dermal lesions typical for this age group, such as Spitz nevus. The biological behavior of pediatric melanomas differs considerably from that of melanomas in adults.

MATERIAL AND METHODS

Cancer testis (CT) antigens are named after their typical expression pattern since they are present in various types of malignant tumors but in normal adult tissues are solely expressed in testicular germ cells. Because of this tumor-associated expression pattern, CT antigens are regarded as potential targets for vaccine-based immunotherapy of cancer and might be used as diagnostic tools in surgical pathology. In adults, melanoma is among the tumors showing a high incidence of CT antigen expression; however, while there is ample knowledge about adult melanomas, little is known about the presence of CT antigens in pediatric melanomas. Consequently, the expression of CT antigens MAGE-A1, MAGE-A4, CT7/MAGE-C1, NY-ESO-1, and GAGE was analyzed in a series of pediatric melanomas. The study was restricted to cases of metastatic disease and/or fatal outcome. A total of 12 cases were available and immunohistochemically analyzed with monoclonal antibodies (mAb).

RESULTS

The expression of CT antigens was generally low and present in only 4 of 12 cases. This is in stark contrast to the expression of these antigens in adult melanomas. Moreover, the extent of expression was very limited with most cases showing only a focal CT antigen expression and only marked in very small tumor areas (<5%).

CONCLUSION

Despite the low case numbers this study indicates that CT antigens are most likely not useful as diagnostic markers in pediatric melanomas or as targets for vaccine-based immunotherapy. It supports the notion that pediatric melanomas show a different biological behavior than their adult counterparts.

[Early undifferentiated arthritis]

Early recognition and treatment of inflammatory arthritis is imperative for the further course of the disease. Patients with inflammatory arthritis should be referred as early as possible to a rheumatologist for further management. A combination of anamnesis, clinical examination, imaging and laboratory measurements enable a differential diagnosis. If a specific diagnosis is not possible, the disease is called early undifferentiated arthritis. Early effective treatment should be instituted for those at risk of developing persistent and/or erosive arthritis. Treatment includes both pharmacological and non-pharmacological options. In the management of early arthritis a combination of regular monitoring and optimal treatment interventions are paramount to achieve remission and improve outcome of the disease (treat-to-target).

[Endometritis : Rare disease with clinical importance?]

Endometritis is nowadays rare in developed countries and typically shows a subclinical or mild course; therefore, there are probably more cases of endometritis than diagnosed but they lack clinical relevance. In the fertile period of life it can be the reason for vaginal bleeding and infertility. The most common causes for non-specific endometritis are residual placental tissue after abortion or childbirth, intrauterine interventions, lesions within the uterine cavity, such as endometrial polyps, endometrial hyperplasia and neoplasms, intrauterine devices (IUD) and cervical stenosis. The histological detection of plasma cells in the endometrial stroma is required for the diagnosis of chronic endometritis. These can be detected immunohistochemically using anti-CD138 antibodies, which should be carried out particularly in cases of infertility with only slight inflammatory symptoms and few plasma cells. The use of an IUD containing progestin is frequently associated with an asymptomatic lymphoplasmacytic infiltration. After curettage or endometrial biopsy, an eosinophilic xanthogranulomatous or granulomatous endometritis and also a foreign body granuloma reaction can occur. Specific forms of endometritis, such as caused by tuberculosis, sarcoidosis, mycoplasma and herpes are very rare. Cytomegalovirus endometritis is associated with immunosuppression. Endometritis caused by infections with Chlamydia trachomatis is characterized by an extensive lymphoplasmacytic infiltration. The differential diagnoses of chronic endometritis include the very rare malignant lymphoma, which is usually characterized by a relatively monotonous cell infiltration.

Crystal arthritides - gout and calcium pyrophosphate arthritis : Part 2: clinical features, diagnosis and differential diagnostics

Gout develops in four stages beginning with an asymptomatic increase in blood levels of uric acid. An acute gout attack is an expression of an underlying inflammatory process, which in the course of time is self-limiting. Without therapy monosodium urate crystals remain in the synovial fluid and synovial membrane and trigger more acute attacks. In the course of the disease monosodium urate crystals form deposits (tophi) leading in severe forms to irreversible joint deformities with loss of functionality. In 20% of cases gout leads to involvement of the kidneys. Overproduction of uric acid can cause nephrolithiasis. These stones can be composed of uric acid or calcium phosphate. Another form of kidney disease caused by gout is uric acid nephropathy. This is a form of abacterial chronic inflammatory response with deposition of sodium urate crystals in the medullary interstitium. Acute obstructive nephropathy is relatively rare and characterized by renal failure due to uric acid precipitation in the tubules because of rapid cell lysis that occurs, for example, with chemotherapy. There is a causal interdependence between the occurrence of hyperuricemia and hypertension. Uric acid activates the renin-angiotensin-aldosterone (RAA) system and inhibits nitric oxide (NO) with the possible consequence of a rise in systemic vascular resistance or arteriolar vasculopathy; however, uric acid is also an apparently independent risk factor for atherosclerosis. In contrast to young patients, the diagnosis of an acute gout attack in the elderly can be a challenge for the physician. Polyarticular manifestations and obscure symptoms can make it difficult to differentiate it from rheumatoid arthritis and calcium pyrophosphate deposition disease (CPPD). Aspiration of synovial fluid with visualization of urate crystals using compensated polarized light microscopy is the gold standard for diagnosis of acute gout. Moreover, analysis of synovial fluid enables a distinction from septic arthritis by Gram staining and bacterial culture. Soft tissue ultrasonography is useful to detect affected synovial tissue and monosodium urate crystals within the synovial fluid. Involvement of bone occurs relatively late in the disease so that x‑ray images are not useful in the early stages but might be helpful in differential diagnostics. Dual energy computed tomography (CT) and magnetic resonance imaging (MRI) can be used for certain indications.

Angiomatosis of soft tissue as an important differential diagnosis for intramuscular venous malformations

Background We aimed to improve management of extremity low-flow vascular malformations by analyzing the histology and imaging of venous malformations (VMs) not responsive to sclerotherapy. Method We reviewed patient records of 102 consecutive patients treated with sclerotherapy for extremity VM in our institution to identify patients who had undergone surgery due to insufficient response. We semi-quantitatively analysed the tissue specimens and compared histological findings to those in preoperative imaging. Result The number of patients operated on was 19 (18.6%); 15 of them had lower-extremity intramuscular lesions. The histological pattern of 13 of these 15 lesions corresponded to angiomatosis of soft tissue (AST). All other lesions treated surgically were VMs. The histology of AST was distinctive but magnetic resonance imaging findings often overlapped with those of VM. Conclusion AST is easily mixed with intramuscular VM. The differentiation of these two entities has therapeutic importance. We emphasize the role of histology in the differential diagnostics of intramuscular slow-flow vascular malformations.

[Malformations of hand and forearm : Conspicuous postpartum]

Many congenital malformations of the hand and forearm, e. g. polydactyly, thumb duplication, syndactyly and radial aplasia, are already evident at birth and newborns are promptly referred to specialized departments. In contrast, orthopedic surgeons are often confronted with malformations of the hand and forearm, which gradually become clinically conspicuous during growth. This review article focuses on these specific malformations, which regularly upset the patients in practice and in most cases the parents even more so. In addition to the diagnostics and differential diagnostics, the conservative and surgical treatment options are presented.