A man with foot ulcer - Answers

(Refer to page 210) Answer: Eumycetoma (Madurella mycetoma or Maduramycosis) Mycetoma is an uncommon localised chronic infection of the skin and subcutaneous tissue that can be due to fungus (eumycetoma) or bacteria (actinomycetoma). It is characterised by a triad of tumefaction, draining sinuses (usually in late stage) and presence of the exudates containing colonial grains. Mycetoma infection is classified based on the aetiological agents and colour of the grains (Refer to supplementary text).

A man with foot ulcer

A 59-year-old Malay man presented with a keratinising lesion over the dorsum of right toe. The resected specimen was an ulcerated necrotic skin covered lesion that measured 5 x 2.5 x 2.5 cm. The cut surface showed blackish powdery granular material embedded in nonviable tissue (Panel A; Haematoxylin and Eosin stain, B; Grocott (Silver) stain and C; Periodic Acid Schiff [PAS] stain). What is the diagnosis? Answer: refer to page 238

Haemoperitoneum secondary to spontaneous rupture of liver tumour

Hepatocellular carcinoma (HCC) is the most common primary tumour of the liver. Cholangiohepatocellular carcinoma (CHC) is less common and is a variant of HCC. There are many similarities with HCC with the exception that CHC tend to be more aggressive. We report a case of a 50-year-old man who was diagnosed with CHC and suddenly deteriorated secondary to hepatic tumour rupture. Despite aggressive supportive care, his condition rapidly deteriorated and died. Autopsy showed ruptured CHC.

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

Eccrine Porocarcinoma

Eccrine porocarcinoma is an extremely rare malignant cutaneous neoplasm. This tumour has an indolent behavior and misleading clinical diagnosis often leading to a delay in definitive treatment. The definitive diagnosis is made by histopathology since clinical findings often vary. The tumour must be considered in the differential diagnosis of elderly patients presenting with long standing skin lesion with a recent history of accelerated growth rate. Because of its reported high rate of local recurrence, a wide excision of the tumour with clear resection margins is mandatory. Close long term follow up is required. We present herein two cases of eccrine porocarcinoma.

Colonic obstruction secondary to phytobezoar

Large bowel obstruction is common in clinical practice and colorectal malignancy is a common cause. Bezoars are a rare and uncommon cause of large bowel obstruction. It can mimic tumour resulting in unnecessary surgery. Imaging studies can help in diagnosis. Endoscopy can be both diagnostic and therapeutic. We report a case of a 59-year-old Malay lady who presented with three days history of constant lower abdominal pain and bowel obstruction secondary to colonic phytobezoar. She also had ischaemic colitis. The bowel obstruction was successfully managed without any surgical interventions. Our case highlights a rare but interesting cause of large bowel obstruction that was diagnosed with colonoscopy and successfully managed with bowel lavage and enema.

A glimpse at male infertility based on semen analyses in Brunei Darussalam

Introduction: Infertility is defined as the inability to conceive children and the causes are equally divided between males and females. Considerable advances have been made in treatment of infertility amongst women, especially with the introduction of in-vitro fertilisation. However there is very little progress made in treating the male infertility. Male causes of infertility can be categorised into pre-testicular, testicular and post-testicular. This study looked at the causes of infertility amongst the males, based on the semen analysis in our local setting. Materials and Methods: From 2006-2008, 1,242 semen specimens were received for analysis. Subjects were instructed on proper semen collection using the World Health Organisation criteria, where the specimen is collected following three days of abstinence and sent to the laboratory within one hour of collection. Semen samples were examined microscopically for morphology, motility and the concentration. Results: Interestingly, 109 subjects (8.8%) had normal spermatozoa (normal analyses) and this included 38 patients (34.2%) whose initial analyses were abnormal. 57 (4.6%) subjects were azoospermic. 730 (58.8%) men had more than two abnormalities in spermatozoa and a further 217 (17.5%) men had abnormal morphology alone. Among patients with two or more abnormalities, a majority had three abnormalities and this was consistently seen in all age groups. There was a trend towards less severe abnormalities from 2006 to 2008. Conclusions: Majority had more than two abnormalities and abnormal morphology and they may not be able to father a child normally. However they may be able to have an offspring by assisted reproductive methods. Only a minority was azoospermic and they will not be able to father any children even with assisted reproductive techniques. Interestingly, 8.8% had normal analyses suggesting other causes of infertility such their female partners or improper techniques.

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.

Methylene blue for sentinel lymph node localisation in breast cancer surgery: Experience of RIPAS Hospital

Introduction Axillary lymph node dissection (ALND) is a standard procedure in the management of breast cancer for diagnosis of axillary node metastasis and for local control. The aim of this study was to investigate the ease and the effectiveness of using methylene blue dye in the localisation of sentinel lymph node (SLN) and biopsy (SLNB) in patients undergoing surgery for breast cancer at RIPAS Hospital. Materials and Methods Twenty-five patients with confirmed fine needle aspiration cytological diagnosis of breast cancer, who were undergoing planned mastectomy and axillary node clearance, were included in the study. Four to five milliliters of methylene blue dye was injected into the peri-tumour area 20 to 30 minutes preoperatively before surgical incision was made. All SLNs were submitted for intra-operative frozen section analysis. All patients underwent mastectomy and Level II axillary clearance. Results Methylene blue dye staining and localisation of SLNs were positive in 22 (88%) patients, out of which 10 (45.45%) patients had SLN which were positive for metastasis. In three patients (12%), the dye failed to reach the axilla with one patient having micro-metastasis in the axillary lymph nodes. The mean duration to SLN harvesting was 20 min (range 15 to 25 min) after injection of the methylene blue. Complications included blue discolouration of urine (28%), post-operative fever (4%), tattooing near the scar (4%) and a small area of skin necrosis near the scar (4%). Conclusions In our setting, SLNB using methylene blue dye is also an effective method for accurately identifying SLNs in breast cancer patients and provide an accurate pathological staging without having to do a formal axillary clearance.

A patient evaluated for chronic iron deficiency anaemia - Answers

(Refer to page 49) Answer: Gastric antral vascular ectasia or Watermelon stomach The endoscopy showed several antral inflammatory folds with linear red stripes running at the crests of the folds or parallel to the folds. These erythematous stripes are vascular ectasia, dilated vascular channels located within the mucosa and submucosa. Histology typically show fibromuscular hyperplasia of the lamina propria and dilated vascular channels with clots (Panel a). Special staining for vascular endothelium will show increase density (Panel b).

A patient evaluated for chronic iron deficiency anaemia

A middle aged patient with end stage renal failure on regular dialysis was referred for evaluation of chronic iron deficiency anaemia. Previous faecal occult blood testing had been positive four out of five times. Previous two upper gastrointestinal endoscopies had been reported as moderate to severe antral gastritis. A colonoscopy only showed grade I haemorrhoids. He had also required regular blood transfusion. A repeat endoscopy was carried out and this finding is shown in the panel above. A biopsy was also taken for histological evaluation. What is the diagnosis? Answer: refer to page 70

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.

Evaluation of the RIPASA Score: a new appendicitis scoring system for the diagnosis of acute appendicitis

Introduction: We recently developed a scoring system for diagnosis of acute appendicitis. This study prospectively evaluates the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score for the diagnosis of acute appendicitis in patients presenting to the Accident & Emergency department or the Surgical wards with right iliac fossa pain. Materials and Methods: From November 2008 to April 2009, consecutive patients presenting to the Accident & Emergency department or the surgical wards with right iliac fossa pain were recruited for the study. The RIPASA score was applied but the decision for radiological investigations or emergency appendicectomy was made based on clinical judgement. Receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the new scoring system were derived. Ethical approval for the study was obtained from the Medical & Health Review Ethics Committee. Results: Within six months, 144 consecutive patients with a mean age of 29.5 ± 13.3 yrs were recruited to the study. Ninety-eight patients underwent emergency appendicectomy of which 79 were confirmed histologically for acute appendicitis. The observed negative appendicectomy rate was 19.4%. The optimal cut-off threshold score from the ROC was 7.5, with a sensitivity of 97.5%, specificity of 81.8%, PPV of 86.5%, NPV of 96.4% and a diagnostic accuracy of 91.8%. The predicted negative appendicectomy rate was 13.5%, which is a 5.9% reduction from the observed rate of 19.4% (p=0.3). Conclusion: The RIPASA score is a more suitable appendicitis scoring system developed for our local settings with a population that is reflective of our region in South-east Asia and has high sensitivity, specificity and diagnostic accuracy.