Published: Thu, 16 Mar 2017 00:00:00 GMT
Last Build Date: Thu, 16 Mar 2017 10:48:25 GMT
2017-01-15A 28-year-old man with unremarkable past history presented with a 2-month history of low back pain and 3-day history of fever. Physical examination revealed limited range of motion while bending. His routine blood investigations showed a white blood cell count of 35 × 103/μl; platlet count of 653 × 103/μl; Hgb of 11.6 g/dl and ESR of 78 mm/1 h,CRP of 23.90 U/l, LDH of 260 U/l, ALP of 86 U/l. MRI of S-spine showed bony destruction over S1 surrounded by inflammatory process from S4 to S2 with epidural invasion. Figure 1a. The patient underwent empiric antibiotic treatment with vancomycin and ceftriaxone due to suspected underlying osteomeylitis. Given the known compression on MR image, urgent surgical decompression and fusion was elected to prevent progressive neurological decline. Histological specimen analysis was consistent with highly aggressive anaplastic large cell lymphoma composed of moderate to large sized lymphoid cells with hyperchromatic nuclei and moderate amount of eosinophilic cytoplasma. The tumor was CD2(+), CD4(+), CD30(+), CD45(+) and negative for other markers, suggestive of a T-cell phenotype. Immunochemistry was positive for Epithelial Membrane Antigen (EMA), ALK, CD45, CD30, CD2, CD4, and vimentin(+); and negative for CK, CD34, CD138 (Figure 1b)The patient underwent further chemotherapy with CHOP regime and led an uneventful hospital course. Figure 1(a) Median sagittal T1-weighted fat suppressed MRI showed a hyperintensity mass over S1 with epidural invasion. (b) CT-guided needle biopsy demonstrated highly aggressive anaplastic large cell lymphoma.
2017-01-15Diffuse large B cell lymphoma (DLBCL) is the most common histologic subtype of non-Hodgkin lymphoma (NHL) accounting for 25% of NHL cases with an incidence of 7 cases per 100 000 persons per year.1 We report a case of lacrimal gland DLBCL diagnosed by the imaging and histology. The lacrimal gland lymphomas are rare; however, 37% of all malignant tumors of the lacrimal gland are lymphomas.2
2016-12-30An 82-year-old man with a history of pulmonary tuberculosis (TB) treated with Plombage, hypertension and hyperlipidemia was admitted to hospital for severe community-acquired pneumonia. He was admitted to medical intensive care unit, treated with intravenous hydration, antibiotics and mechanical ventilator support. The patient’s subsequent course was uneventful and was discharged home. Patient’s anteroposterior x-ray of the chest and computed tomography of the chest showed the right upper lobe filled with Lucite balls (Figure 1A and B). Figure 1(A) Anteroposterior X-ray of the chest showing the right upper lobe filled with Lucite balls (black arrows). (B) Computed tomography of the chest showing the right upper lobe filled with Lucite balls (black arrows).
2016-11-15A 37-year-old woman presented with several hours of intermittent chest pressure at rest associated with nausea. She had no significant past medical history but reported a recent flu-like illness about 1–2 weeks prior, associated with mild fever, headache and a runny-nose. Physical examination was unremarkable with no abnormal cardiovascular findings. Her ECG showed sinus-rhythm with significant inferior ST-segment elevations (Figure 1A), and serum troponin-T levels were elevated at 2.5 ng/ml. Urgent cardiac-catheterization revealed angiographically normal coronary arteries. Cardiac magnetic resonance (CMR) cine-imaging showed normal left-ventricular function without valvular or pericardial abnormalities. CMR late gadolinium enhancement (LGE) imaging demonstrated patchy mid-myocardial and epicardial hyperenhancement in the inferior wall (Figure 1B, arrows), indicative of injury from myocarditis. Figure 1(A) ECG showed sinus-rhythm with significant inferior ST-segment elevation and reciprocal depressions. (B) Cardiovascular magnetic resonance imaging with LGE in the 2-chamber view demonstrated patchy mid-myocardial and epicardial hyperenhancement in the inferior wall (arrows) of the left ventricle.
2016-11-15Our patient is a 31-year-old lady who delivered her third child 3 months prior to the current admission. The delivery was uneventful but she continued to have per vaginal spotting occasionally. She presented with cough and breathlessness for 2 months associated with significant weight and appetite loss. On examination she was pale and tachycardic. She had fine tremor but no goiter or Grave’s opthalmopathy. Breath sounds were reduced bilaterally. Endocrine team was consulted as her thyroid function test showed freeT4 of 50 pmol/l with suppressed thyroid stimulating hormone (TSH) of <0.01 mIU/L. There were multiple canon ball lesions bilaterally in her chest x-ray (Figure 1). Beta human chorionic gonadotrophin (HCG) was markedly elevated (>200 000 mIU/ml). Trans-abdominal ultrasound revealed uterine mass with snowstorm appearance. 250 cc vesicle-like tissue was removed during evacuation. Histopathology examination of endometrial tissue was consistent with choriocarcinoma. Hyperthyroidism was treated with Lugol’s iodine, Carbimazole and propanolol. Chemotherapy (Methotrexate, Actinomycin and Etoposide) was initiated post surgery. Her thyroid function test improved dramatically with reduction of Beta HCG. Figure 1Chest X-ray showing multiple canon ball lesions.
2016-11-15A 29-year-old female had a history of hypopigmented skin lesions over the left cheek, back and thighs for over 3 years. These lesions were not associated with itching or any altered sensation but were progressively increasing in size and number. She took indigenous medications for 3 years with no response. Finally, she visited our hospital for her complaints and a skin biopsy confirmed a diagnosis of leprosy. She was started on multi drug therapy. No new lesions developed following therapy and her existing lesions also reduced in size. On follow-up, after about 6 months, she started developing progressive anemia. Nutritional causes were excluded and drugs were stopped; however, the anemia persisted. The patient started experiencing intermittent and high-grade fever as well. On examination, she had pallor, was febrile (103°F) and had multiple skin lesions (Figure 1A). Complete blood counts revealed anemia (Hemoglobin - 80 g/L, Total leukocyte count-8.6 × 109/L and platelet count –201 × 109/L). Her blood and urine cultures were sterile and other infective work-up was negative. Finally, a bone marrow examination was performed to evaluate the cause of anemia and persistent fever. Bone marrow aspirate smears showed adequate representation and maturation of all hematopoietic lineage elements, however, had many foamy macrophages (Figure 1B). Fite stain demonstrated single and occasional bunches of acid fast bacilli in some of these macrophages (Figure 1B, inset). Ziehl Neelson stain for mycobacterium tuberculosis was negative. Trephine biopsy revealed multiple interstitial well formed granulomas composed of foamy macrophages (Virchow cells) (Figure 1C). The bone marrow involvement by leprosy was confirmed explaining the cause of persistent fever and anemia. Figure 1(A) Thick and shiny skin of face with hyperpigmented macular and papular lesions typical of leprosy. (B) Bone marrow aspirate smear showing foamy macrophages (May Grunwald Giemsa, ×100). (Inset) Fite acid fast stain shows single and clumps of acid fast bacilli in the macrophages. (C) Trephine biopsy section shows granulomas (Haematoxylin and eosin, ×20).
2016-11-01We all recognize that today’s healthcare megatrends are challenging to people, practitioners, scientists, healthcare systems, governments and life science companies. This is particularly true for the increasingly frequent chronic conditions in which these trends coalesce.1 How do we handle the complexity of delivering personalized medicine that reflects individual preferences while taking advantage of the evidence base?2 What is the answer for the rising cost of both the proliferation of treatments effective for chronic conditions3 and those of conducting clinical research?4 Finally, how do we address the new business challenge for healthcare providers to move away from paying for volumes of services in favor of paying for the value of health outcomes achieved by the patients they serve who have lifelong chronic health problems?5