Medical Image Database

SPONTANEOUS PNEUMOTHORAX AFTER FLIGHT

CLAUDIU EDUARD NISTOR, BOGDAN STEFAN CRETU, ANCA PATI CUCU — Wed, 31 Jan 2024 14:26:54 -0800

A 42-year-old patient with a history of extrauterine pregnancy and interadnexal hysterectomy for persistent cervical HPV infection was referred to the Thoracic Surgery Clinic for increased shortness of breath. The patient was diagnosed with a spontaneous pneumothorax following a flight. She underwent pleural drainage at another hospital and was transferred for specialist surgical management. A CT scan was performed and showed a pneumothorax and collapsed lung. Video-assisted thoracic surgery (VATS) thoracoscopy was performed with evidence of apical emphysema bullae, which were resected. As this was the first episode of spontaneous pneumothorax and considering the young age of the patient, no pleurodesis was performed. The patient was discharged five days after surgery after suppression of pleural drainage.

Primary spontaneous pneumothorax is usually caused by the rupture of subpleural blebs or bullae. In the first episode of spontaneous pneumothorax, pleurodesis is not performed except in well-selected cases - single lung, professions with a risk of pneumothorax recurrence [pilot/diver]. However, in the presence of a persistent air leak on the chest tube, the decision for chemical pleurodesis should be considered.

Fig. 1- CT scan performed upon admission showed a partially collapsed lung and right pneumothorax.

Fig. 2- Intraoperative aspect of apical blebs.

ENLARGED BRONCHIAL ARTERY IN A PATIENT WITH LUNG TUMOR AND HEMOPTYSIS

ANCA PATI CUCU, BOGDAN STEFAN CRETU, CLAUDIU EDUARD NISTOR — Sat, 03 Feb 2024 02:38:49 -0800

A 57-year-old male patient, heavy smoker with no significant past medical history, was admitted for hemoptysis, dyspnea and weight loss. Laboratory results showed mild anemia (hemoglobin 10.2 g/dL) and elevated CRP 10.2 g/dL. Computed tomography showed a right upper lobe lung tumor with negative fiberoptic bronchoscopy. A right upper lobectomy was performed and during dissection of the right upper bronchus an enlarged right bronchial artery was found. The bronchial artery was dissected, ligated, and transected without injury.

Bronchial artery injury is the second most common vascular injury in lung surgery. As it originates from the aorta, the amount of blood loss can reduce visibility in the surgical field. Enlargement of the bronchial artery is less common and may be a risk factor for hemoptysis in this patient, especially if its caliber exceeds 2 mm and becomes more tortuous (1).

In addition to lung cancer, other underlying causes of bronchial artery anomalies include bronchiectasis, aspergilloma, lung abscess and cystic fibrosis. In such cases, bronchial artery embolization is often performed in the presence of varying degrees of hemoptysis that cannot be controlled by conservative measures (2).

A peculiar clinical presentation of DRESS syndrome

Alexandra Maria Roman, Corina Ionescu, Florica Sandru — Sat, 17 Feb 2024 14:52:32 -0800

Drug-induced exanthemas, the most prevalent cutaneous adverse drug reactions, pose diagnostic challenges due to their diverse manifestations and variable onset.

We describe a case involving a 40-year-old man who exhibited erythematous macules, papules, plaques, and rare target-like lesions symmetrically distributed on his upper and lower extremities. He experienced myalgia, arthralgia, headaches, fever, and flu-like symptoms. Notably, his high serum IgE levels and eosinophilia persisted despite initiating hydrocortisone hemisuccinate treatment two days prior. To establish a diagnosis, we conducted various tests, including screening for viral infections, a skin biopsy, and a peripheral blood smear. We also employed the RegiSCAR DRESS validation scoring system and the EAACI form to identify trigger medications (2,3). Although viral infections could not be identified, uncertainty remained regarding potential influenza exposure while self-administering a combination of metamizole and paracetamol a week before admission. The patient had also been taking pantoprazole, metoclopramide, and sucralfate for six weeks before the exanthema. In our clinic, decreasing systemic corticotherapy led to an increased eosinophil count, which, together with the peripheral blood smear and the biopsy, confirmed DRESS syndrome (1).

The peculiarity of the case presented consists of the patient’s delayed presentation in our clinic, after having received treatment that may have affected all the clinical and paraclinical findings, making diagnosing on purely cutaneous findings and blood tests less reliable, as well as the convoluted history that may indicate triggers for different forms of cutaneous drug reactions (4).

Clinical Conundrum: Navigating Erythematous Facial Rash in a middle-aged woman

Alexandra Maria Roman, Florica Sandru, Aifer Cherim — Tue, 20 Feb 2024 06:50:38 -0800

We present a clinical case involving a 62-year-old female patient with a prior diagnosis of hypothyroidism and psoriasis vulgaris. The patient sought emergency medical care due centrofacial and periocular edema, erythema, and pain. The onset of the current episode occurred less than 24 hours before admission, commencing as a right-sided malar rash that rapidly disseminated. Notably, the patient's medical history revealed a recent periorificial (nasal) psoriasis lesion treated with clobetasol ointment, identified subsequently as the likely point of bacterial entry.

In the differential diagnosis, prominent considerations included dermatomyositis and systemic lupus erythematosus, owing to the similarity in erythema distribution in both conditions, as well as the patient's age and gender. Systemic lupus erythematosus is characterized by a malar rash, also termed a butterfly rash, presenting as an erythematous flat or raised rash across the nose and cheeks, typically sparing nasolabial folds. Dermatomyositis is marked by the heliotrope rash, manifesting on the upper eyelid, across the cheeks, and the nasal bridge in a "butterfly" distribution.

Considering serological evidence of infection (neutrophilia and elevated C-reactive protein and erythrocyte sedimentation rate), the rapid onset of symptoms, and the observable skin manifestations (erythema, edema, and warmth), a diagnosis of facial erysipelas was established. The patient underwent a 10-day intravenous course of Ceftriaxone for antibiotic therapy and received prophylactic doses of enoxaparin to address the risk of cavernous sinus thrombosis. The patient exhibited favorable progress, ultimately experiencing complete recovery.

Superficial Spreading Melanoma: Clinical Case, Histological Analysis, and Management

Florica Sandru, Bianca Maria Petrescu, Adelina Popa — Tue, 20 Feb 2024 07:00:48 -0800

Skin cancer, particularly melanoma, is a serious health concern that demands timely diagnosis and treatment. We present the case of a 36-year-old woman who carries a family medical history of cancer. Her journey to diagnosis commenced with a routine dermatoscopic examination, revealing an atypical nevus in an unexpected location - a solitary tumor, approximately 1.5 cm in diameter, in the left internal supramalleolar region (Fig.1), that exhibited several distinctive dermoscopic features, including irregular margins, chromatic polymorphism, an atypical pigment network, blue-white veil with a central regression area, uneven dots and globules (Fig. 2). Recognizing the need for thorough evaluation, a surgical excision was promptly performed, maintaining a 0.5 cm safety margin. The histopathological examination (Fig. 3) unveiled primary cutaneous melanoma, classified as unulcerated, with a Breslow thickness of 1.2 mm (pT2a) and Clark Level III invasion. The histological subtype revealed superficial spreading melanoma, with a low dermic mitotic index (1 mitosis per square millimeter), with no lymphovascular invasion or neurotropism. The melanoma exhibited partial regression. Immunohistochemistry revealed Melan A's diffuse positivity, SOX10's nuclear-positive tumor cells without emboli or microsatellites, PRAME's nuclear-positivity, and p16's abnormal expression in tumor cells but positivity in the hyperplastic epidermis.

This case highlights melanoma's diverse characteristics, demonstrating its ability to appear in unexpected areas with distinctive clinical and pathological attributes. Regular dermatoscopic monitoring is a valuable tool for tracking the patient's progress and detecting any potential issues at an early stage. Histological analysis and immunohistochemistry are crucial for precise diagnosis and should not be undervalued.

Disseminated cryptococcosis due to Cryptococcus deneoformans in an immunosuppressed patient

Daniel Nunes, Dinah Carvalho, José Melo Cristino — Tue, 27 Feb 2024 01:18:39 -0800

The prevalence of cryptococcosis in Haematopoietic Stem Cell Transplantation (HSCT) recipients is very low [1]. However, these patients are at a high risk of life-threatening complications due to immunosuppressive therapy. The coexistence of Graft-versus-Host Disease (GvHD) further complicates management [2]. Skin involvement in cryptococcosis is rare and an early marker for disseminated disease. Cryptococcus deneoformans rarely causes disease [1].
A 71-year-old male patient was admitted to the Emergency Department with a 15-day history of inflammatory signs on his left forearm, without improvement on oral flucloxacillin and piperacillin-tazobactam. His past medical history was significant for T-cell lymphoma, in remission after Allo-HSCT in 2014, and coexistent chronic GvHD under ruxolitinib. On hospitalization day 4, the soft tissue infection worsened, characterized by drainage of purulent exudate. This was collected and sent for bacteriological and mycological studies.
In the laboratory, direct microscopic examination of the exudate revealed small, round yeast forms (Figure 1), surrounded by a clear halo which did not stain with the Gram method, raising suspicion for Cryptococcus spp. When the exudate was prepared with India ink, it highlighted the encapsulated yeast. This finding was consistent with a diagnosis of cryptococcosis and liposomal amphotericin B was initiated. Cultures grown from the sample showed white, smooth colonies within 18-24 hours of incubation. These colonies were identified as Cryptococcus deneoformans by MALDI-TOF mass spectrometry. Subsequent blood cultures were also positive for C. deneoformans, confirming the diagnosis of disseminated cryptococcosis. The patient underwent 45 days of liposomal amphotericin B, with gradually improving clinical condition.

Ocular Toxoplasmosis

Suher Abduraman, Ali Riza Cenk Celebi — Mon, 20 May 2024 03:22:54 -0700

A 25-year-old male presented to our clinic with blurry vision in the left eye, for about 1 month. He had a history of ocular toxoplasmosis for which he was under care, but he stopped using his medication one week later. His best corrected visual acuity was 6/48 in the right eye and 6/24 in the left eye, on the Snellen chart. The anterior segment of both eyes was unremarkable. Fundus examination was normal in the right eye, while the left eye had vitritis and two active lesions of focal retinochoroiditis outside the temporal vascular arcade (Figure 1). OCT of the left eye showed increased thickness in the superficial layers of the retina with hyper-reflective particles in the vitreous adjacent to the retina (Figure 2). Serology was positive for Toxoplasma gondii, with detectable IgG antibodies. After 1 month of follow-up under treatment, the patient’s visual acuity was increased, the fundus examination showed clear vitreous and white inactive retinal choroiditis scars (Figure 3), and the OCT scan showed decreased thickness of the retina (Figure 4).

Ocular toxoplasmosis is one of the most common causes of infectious chorioretinitis. Depending on the retinal location, this condition may cause substantial vision impairment [1]. The treatment includes antimicrobial drugs and corticosteroids and is maintained for 4–6 weeks [2]. Recent studies revealed that the mean visual acuity significantly improves after treatment and lesion size decreases during the initial months with limited change after that [3, 4].

Onset IgA-Type Multiple Myeloma with Flame cells

Bruno Carvalho, Francys Llanos, Sara Ismail — Fri, 20 Sep 2024 02:46:36 -0700

Multiple myeloma (MM) represents 1% of all neoplasms and 10% of all malignant hematological diseases. The monoclonal immunoglobulin (M protein) is predominantly IgG (50%), with IgA (20%) or free chains (20%) being less frequent. The prevalence of IgA biclonality is 2%.

The flame cells have a characteristic bright purple-red cytoplasm (Wright-Giemsa staining), related to the high carbohydrate content of IgA molecules, present at their endoplasmic reticulum and cytoplasmic projections. Although usually associated with IgA MM, this polymorphic cells with eosinophilic cytoplasm can also be present in non-IgA MM, MGUS and reactive plasmacytosis.

A 68-year-old male consults his physician, due to unrelated symptoms. The analytical evaluation revealed normochromic normocytic anemia (hemoglobin 113g/L) and acute kidney injury (AKI) KDIGO stage I (sCr 150μmol/L). Follow-up reevaluation, after 1 month, showed increased IgA (22.3g/dL), protein electrophoresis with 2 Beta region peaks (0.3 and 0.7g/dL), and Lambda Bence-Jones protein, with the patient being referred to Hematology.

At the hospital, an in-depth analytical study showed worsening of anemia (hemoglobin 76g/L), AKI KDIGO stage 3 (sCr 645µmol/L), increased lambda free light chains (3550mg/dL) and ratio (0.006). Immunofixation identified biclonal IgA Lambda. Bone marrow aspirate revealed 92% plasma cell infiltration (flame cells). Flow cytometry shown 63.8% plasma cells with CD138+|CD38+|CD56+|CD81+|CD19-|CD45-|β2-microglobulin+|CD27-|CD28-|CD117-|Lambda cytoplasmic chains. Cytogenetic analysis revealed 1q+ in 35% nuclei and a CT scan identified multiple lytic lesions in the spine and pelvis. The patient was diagnosed with MM, initiated bortezomib, cyclophosphamide plus dexamethasone, and due to a good clinical response after 5 cycles underwent autologous stem cell transplant.

Unexpected Inclusions – Howell-Jolly body-like Inclusions in Neutrophils Mimicking Basophils in Scatter Plot

Ana Catarina Marques, Ana Venâncio de Barros, Filipa Fernandes — Fri, 20 Sep 2024 03:42:32 -0700

A 34-year-old woman with chronic kidney disease underwent a kidney transplant, currently on immunosuppressive therapy, presented to the emergency department with left flank abdominal pain and fever with 3 days of evolution.

On admission, blood tests showed hemoglobin 10.2 g/dL, leucocytes 8.100x10⁹/L, platelets 203x10⁹/L; the scatter plot showed a cluster in the basophil region (Fig. 1), with a corresponding total basophil count of 1.88x10⁹/L (23.3%). The complete blood count was repeated using the same equipment, Beckman Coulter DxH 900 Hematology Analyzer, revealing similar results. The peripheral blood smear showed neutrophils with Howell-Jolly body-like inclusions – HJBL - (1.215x10⁹/L, 15%) and also Barr Bodies (0.486x10⁹/L, 6%) (Fig. 2 and 3), but no basophils.

HJBL are detached pycnotic nuclear fragments in the cytoplasm of neutrophils and occur as a consequence of dysplastic granulopoiesis, resembling the Howell–Jolly bodies present in erythrocytes [1,2,3].

HJBL are linked to immunosuppression, viral infections and chemotherapy [1,3], with studies showing a correlation to myelodysplastic syndrome [2].

The Barr body, typically seen in females, appears as a drumstick-shaped appendage of a nuclear lobe [1].

No published data was found about neutrophils with inclusions being counted as basophils by fully automated blood cell analyzers. Once Beckman Coulter DxH 900 separates and counts the leukocytes according with their volume and cellular complexity using Volume, Conductivity and Scatter (VCS) technology, we believe that HJBL, being such densely basophilic, alter neutrophil’s complexity, so they are identified as basophils by the equipment, showing a cell cluster on the basophilic region on a scatter plot.