Biomedical subjects
Publications and source records attributed to N Hiller.
Torsion of an accessory spleen is extremely rare. We report a case of an acute torsion of an accessory spleen in a young patient who presented with acute left abdominal pain and discuss the computed tomographic findings of this exceptional condition. Awareness of this entity and familiarity with typical imaging findings are mandatory for preoperative diagnosis.
BACKGROUND: Immature ovarian teratoma is the third most common germ cell tumor (GCT) following dysgerminoma and endodermal sinus tumor. The treatment of choice during childbearing age for immature teratoma composes of unilateral oophorectomy and in case of metastatic disease postoperative chemotherapy (BEP). Finding a solid mass in the peritoneal or chest cavity during routine follow up raises the suspicion of distance recurrence. DiSaia was the first to describe the appearance of benign distant metastasis during routine follow up. He termed this phenomenon "chemotherapeutic retroconversion". Latter, Logothetis described what seems to be a similar phenomenon in testicular non-seminomatous germ cell tumor (NSGCT) that he called the "growing teratoma syndrome". CASE: We present a case of a 12-year-old girl treated for growing teratoma syndrome after primary ovarian GCT. CONCLUSION: Review of the literature shows that this syndrome and the "chemotherapeutic retroconversion" are probably the same phenomenon.
Coarctation of the thoracic aorta is not often diagnosed after childhood. The combination of subclavian artery aneurysm in association with coarctation of the aorta is even less frequent. A review of the literature elicited only seven previously reported cases of such an association. Presented herein is a case of a young adult with coarctation of the aorta and secondary left subclavian artery aneurysm, diagnosed incidentally. We discuss the incidence of these rare conditions and possible causes for their co-existence.
BACKGROUND: The chest radiograph is considered one of the most complex imaging modalities to interpret. Several studies have evaluated radiograph interpretation in the emergency department, and considerable disagreement among clinical physicians and expert radiologists has been observed in the reading of chest films. The interpretation of chest radiographs by emergency department physicians was compared with senior radiologists in discharged patients, and misinterpretations assessed in relation to the physician's level of training. METHODS: Radiological descriptions of 509 chest radiographs of 507 patients, aged 16-98 years who were discharged from the emergency department, were prospectively reviewed. Missed findings were recorded with regard to the physician's level of training and experience. The effects of misinterpretations on discharge recommendations were also investigated. Statistical assessment was conducted using the chi(2) test. Interobserver agreement was also tested by the kappa coefficient. RESULTS: The sensitivity for detecting different abnormalities in the radiographs ranged from 20% to 64.9% and specificity from 94.9% to 98.7%. Despite the low sensitivities found, there were relatively few clinical implications of the "missed" findings since they were either of a minor nature or appropriate follow up was prescribed. The overall interobserver reliability, assessed by the kappa coefficient, was 0.40 (95% confidence interval 0.35 to 0.46). These findings did not change significantly by emergency department physician's level of training. CONCLUSIONS: Emergency department physicians frequently miss specific radiographic abnormalities and there is considerable discrepancy between their interpretations and those of trained radiologists. These findings highlight the importance of routine evaluation of chest radiographs by a well trained radiologist and emphasise the need for improving interpretive skills among emergency department physicians.
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Defining the specific cause of pain in patients with cancer often has substantial therapeutic and prognostic implications. This process often requires the use of specific diagnostic investigations. Here we critically review the diagnostic investigations used in the evaluation of common pain problems in patients with cancer. Familiarity with this information facilitates the development of efficient and rational diagnostic strategies.
BACKGROUND: Echinococcal disease, although known to occur in most organs and body areas, is extremely rare in the female reproductive system. A literature search revealed only three anecdotal non-English language case reports of ovarian echinococcosis. CASE: A 20-year-old woman presented with epigastric pain. Abdominal ultrasonography and computed tomography showed three multicystic masses, one intrahepatic, one intraperitoneal and the third situated in the left ovary. Serologic examination confirmed the diagnosis of echinococcal disease. Marked regression of all the cysts occurred following a short course of albendazole. CONCLUSION: Echinococcal cysts should be included in the differential diagnosis of multicystic ovarian lesions if the patient has cysts elsewhere and is from an endemic area.
BACKGROUND: Primary epiploic appendagitis is a relatively rare condition in which torsion and inflammation of an epiploic appendix result in localized abdominal pain. This is a non-surgical situation that clinically mimics other conditions requiring surgery such as acute diverticulitis or appendicitis. OBJECTIVE: To investigate the clinical, laboratory and radiological findings of the disease. METHODS: During the years 1995-88 five patients with primary epiploic appendigitis were diagnosed at our institution. The clinical, laboratory and imaging results were summarized and compared to previously reported series. Emphasis was placed on the computed tomography findings, which are the gold standard for diagnosis. RESULTS: All our patients (two males and three females, mean age 47 years) presented with left lower quadrant abdominal pain. CT proved to be the imaging modality of choice in all patients by showing a pericolic fatty mass with an increased attenuation as compared to normal abdominal fat. In all cases the mass was surrounded by a high attenuation rim, and focal stranding of the fat was observed. In no case was there thickening of the adjacent bowel wall. This serves as an important, and previously unreported, clue for diagnosis. CONCLUSION: Primary epiploic appendagitis is a relatively rare condition that may be clinically misdiagnosed, resulting in unnecessary surgical intervention. Judicious interpretation of CT may lead to early diagnosis and ensure proper conservative treatment.
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Spontaneous intramural hematoma of the esophagus (SIHE) is a rare condition, usually presenting with severe acute chest pain. Vomiting, dysphagia, odynophagia, and hematemesis may appear later. We herein report a case of this disease in a patient treated with low doses of aspirin, and review the literature for possible etiologies for this condition. In addition, we compare the utility of the various diagnostic modalities in this uncommon condition.
Gastric duplication cysts are uncommon congenital anomalies and are rarely diagnosed in adults. We present a unique case of a communicating type gastric duplication in a young woman with the multimodality imaging findings including barium examination, CT, and endoscopy. The morphological criteria for diagnosis of duplication cyst suggested pathogenetic mechanisms for its formation as well as clinical presentation. Associated pathologies are reviewed.
Thrombosis of the ovarian vein is a remarkable process occuring within a few days of labor in 1:500-1:2000 women. Its presentation is characterized by fever, abdominal pain and occasionally by a palpable abdominal mass that in earlier years sometimes lead to explorative laparotomy. With the advent of modern imaging techniques the diagnosis can be made relatively easily. The pathogenesis has been attributed to an infectious process expanding from the uterus to the right ovarian vein and stasis. A predisposition towards thrombosis has not been so far explored. In this study we retrospectively analysed the clinical features, diagnosis and treatment of 22 patients with objective documentation of post partum ovarian vein thrombosis (POVT) and assessed potential risk factors. In 11 of the 22 patients (50%) inherited prothrombotic risk factors were detected as follows: 4 were heterozygous for factor V G1691A, 2 had protein S deficiency, one had protein S deficiency and was heterozygous for factor V G1691A, and 4 were homozygous for MTHFR C677T. Eight of the 11 patients who bore a prothrombotic predisposition underwent cesarean section. Taken together, the data suggest that POVT may result from the combined effect of an infection, cesarean section and a prothrombotic tendency.
Acute megakaryocytic leukemia (AMKL) is a rare subtype of acute myeloid leukemia which is more common in children. Although the bone changes in leukemia are well documented, there are only a few reports of the AMKL subtype. We present an exceptional case of a young girl with very aggressive AMKL, who demonstrated symmetrical destructive lesions of the long bones characteristic of this disease. Lytic lesions of the skull and jaws were also present, and these have not been previously described in AMKL.
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Acute pancreatitis is a multifaceted disease as expressed by its multiple etiologies, varying clinical presentations, radiological appearances and pathological changes. This variability has lead to a confusing range in terminology that has complicated the precise classification of this entity. A uniform interdisciplinary classification is necessary to facilitate assessment of acute pancreatitis. An international symposium held in 1992, attended by experts in fields including surgery, radiology, and pathology, formulated a nomenclature to describe acute pancreatitis. We retrospectively studied 96 cases of acute pancreatitis to test the efficacy of this classification as regards severity of the disease process and its complications. The initial severity of the pancreatitis was assessed, complications and their treatment noted and the various imaging modalities and their indications reviewed. The most efficacious investigation was computed tomography with intravenous contrast injection. Good correlation with the newer classification was noted in assessing the severity of the illness and its complications, as well as aiding in interdisciplinary communication. Particular difficulty was noted differentiating infected necrosis, pancreatic abscess and infected psuedocysts. Our results correlate well with the current literature, with the exception of a higher relative incidence of pancreatitis among females. This probably reflects the lower incidence of alcoholism in Israel among men, with biliary lithiasis among females primary in the etiology of the disease.
OBJECTIVE: To assess the utility of MR in detecting surgically induced Stener lesions (displaced thumb ulnar collateral ligaments) in cadaveric models. DESIGN: Six cadaver thumbs had ulnar collateral ligament (UCL) tears created surgically. MR examinations (2D STIR and 3D GRASS) were performed identically on all specimens both before displacement (non-Stener) and after displacement (Stener lesion) of the UCL. The MR images were then randomly numbered. Each image was evaluated separately in blinded fashion by four musculoskeletal radiologists for the presence or absence of a Stener lesion. Each radiologist reinterpreted the images after an interval of several days. The interpretation was based on previously published criteria for Stener lesion diagnosis by MR. RESULTS: The sensitivity of GRASS ranged from 0.17 to 0.67 with the most experienced reader scoring the lowest. The specificity of GRASS ranged from 0.33 to 1.0 (most experienced reader 0.67, 0.83). STIR had a sensitivity of 0.00-0.17 and a specificity of 0.53-0.83. The kappa values for inter- and intraobserver agreement were measured. The intraobserver kappa for GRASS was 0.27-0.75 (most experienced reader 0.75). CONCLUSIONS: 2D imaging is probably inadequate for the evaluation of Stener lesions. The most likely reason is that the STIR slice thickness of 3 mm limits resolution of small UCLs. The poor sensitivity and specificity of GRASS as well as poor interobserver agreement suggest that MR may not be sufficiently accurate for Stener lesion evaluation.
Oxalosis of bone is caused by a combination of crystalline calcium oxalate deposition in bone and renal osteodystrophy in patients with chronic renal failure. The present paper presents the radiographic findings of oxalosis of bone in four patients who have been followed over a period of from 4 to 16 years. Four successive characteristic stages can be recognized in the development of the skeletal changes.
A 5-year-old girl with chronic granulomatous disease (CGD) and esophageal narrowing is described. To date, only two cases of esophageal involvement in CGD have been reported. We present a third, well-documented case and a brief review of the literature.