Thrombus in transit in a patient with ischaemic stroke

Stroke or cerebrovascular accident is common and is most commonly embolic or haemorrhagic. A common source of embolism is the heart and as such echocardiogram is an essential investigation. However, clinicians need to be aware of rare sources of embolism. We report a rare and interesting case of a 61-year-old Caucasian man who presented with stroke and on evaluation was found to have a large thrombus coiled striding over a patent foreman ovale into the right and left atrium consistent with a 'thrombus in transit'. The origin of the thrombus was later confirmed to be from the left saphenous vein. This case highlights an interesting case of 'thrombus in transit'.

Right atrial myxoma: An unusual cause of clinical right heart failure

Myxomas are the most common type of primary cardiac tumour with 86% occurring in the left atrium. Right atrial myxomas is far less common. Patients usually present with progressive dyspnoea, fever, weight loss, right-sided heart failure, or pulmonary embolisation. We report the case of a 55-year-old man who presented with progressive dyspnoea and signs of right heart failure secondary to a large right atrial myxoma, which was diagnosed with a bedside transthoracic echocardiogram. This was successfully removed surgically.

Gliosis of the cervix

Cervical glial polyps or gliosis of uterine cervix are rare. These are rare polypoidal mesenchymal tumours and usually manifest with vaginal bleeding, post-coital bleeding or cervical discharge. Microscopically these polyps show heterotopic glial tissue with varying degree of gliosis. Immunoperoxidase staining with Glial fibrillary acidic protein (GFAP) confirms the glial nature of the polyp. Controversies remain regarding the origin. Some consider them to be foetal implants following termination of pregnancy whilst others consider them to be metaplastic in nature. We report a rare case of cervical gliosis that was diagnosed after histological examination of the resected specimen in a 32-year-old lady who presented with irregular per vagina bleeding.

A holiday bug - Answers

(Refer to page 164) Answer: Giardiasis. The slide shows duodenal biopsy with pear shaped protozoa of Giardia lamblia on the luminal surface of the villi. Giardia lamblia is a pear-shaped, flagellated protozoan that causes a wide variety of gastro-intestinal complaints. Giardia is possibly the most common parasite of humans worldwide and the second most common in the United States after pinworm.

A holiday bug

A 35-middle-aged female with history of recent travel to the Indian Subcontinent, presented with features of malabsorption. Blood chemistry revealed low serum albumin and low serum Vitamin B12 levels. Upper gastrointestinal endoscopy was done and was reported as normal. The duodenal biopsy sent for histopathologic examination and is shown (Panel). What is the diagnosis? Answer: refer to page 186

Lymphangioma of the ovary

Lymphangioma of the ovary is an extremely rare lesion. There are only 19 cases reported in the literature. Lymphangioma is usually unilateral and asymptomatic, presenting as an incidental finding during routine gynaecologic procedures. It is composed of aggregates of lymphatic spaces in ovarian stroma and the endothelial cells lining these spaces stain positively with CD-31 and CD-34 on immunostaining. The main differential diagnosis is an adenomatoid tumour which can be differentiated from the lymphangioma by immunohistochemical studies. We report this rare lesion in a 42-year-old Malay lady diagnosed after total abdominal hysterectomy and right salpingo-oophrectomy. A literature review is presented and the histological and immunohistological findings along with differential diagnosis are discussed.

Cystic carcinoma of the neck

Malignant cystic lesions of the lateral side of the neck are usually due to metastasis and are rarely primary carcinoma. The most common is metastatic cystic squamous cell carcinoma arising from a primary site at the Waldeyer's ring. However, they can arise from papillary carcinoma of thyroid, lung and mediastinum but very rarely from the abdominal and pelvic organs without regional lymph node involvement. Therefore, accurate diagnosis is very important for appropriate management. We report two cases of cystic squamous cell carcinoma of the lateral neck; cystic metastasis from an occult squamous cell carcinoma of the tongue and a primary branchiogenic carcinoma. We emphasize the importance of meticulous search for the primary malignant lesions in cases of cystic carcinoma of the neck.

Development of subcutaneous abscesses due to mycobacterium bovis following hepatitis and bacillus Calmette-Guerin vaccination

Vaccination to prevent hepatitis B and tuberculosis [TB] forms a part of the national immunization program in the Kingdom of Saudi Arabia. The hepatitis B vaccination was introduced in the Makkah region in January 1991G. Since then, 25 children have developed post vaccination subcutaneous abscesses at the site of vaccination. Microbiological studies proved these to be of bacillus Calmette-Guerin vaccine [BCG] origin. Ten patients were treated successfully with isoniazid [INH] and rifampicin and 15 with INH alone. Four patients required incision and drainage. Possible reasons for this complication in our patients are discussed