Hérnia muscular: relato de caso diagnosticado pela ultrassonográfico / Muscular herniation: case report diagnosed by ultrasonography / Herniación muscular: reporte de caso diagnosticado por ultrasonografía

A hérnia muscular em extremidades é uma condição incomum e subdiagnosticada. A maioria das massas é indolor e assintomática. No entanto, em alguns casos, podem se tornar dolorosas após exercícios físicos prolongados. Neste relato de caso temos um paciente de 18 anos, queixando-se de abaulamento na perna esquerda após atividade física, com suspeita inicial de lipoma de extremidade A ultrassonografia identificou uma hernia muscular, destacando a importância de uma detecção precoce para que haja um tratamento adequado sem complicações, gastos desnecessários e diagnósticos equivocados.

Muscular hernia in extremities is an uncommon and underdiagnosed condition. Most masses are painless and asymptomatic. However, in some cases, muscle hernia can become painful after prolonged physical exercise. In this case report, we present an 18-year-old patient complaining of bulging in the left leg after physical activity, with initial suspicion of lipoma of the extremity. Ultrasonography identified a muscle hernia, highlighting the importance of early detection and leading adequate treatment without complications, unnecessary expenses, and misdiagnoses.

La hernia muscular en extremidades es una patología poco frecuente e infradiagnosticada. La mayoría de las masas son indoloras y asintomáticas. Sin embargo, en algunos casos, la hernia muscular puede volverse dolorosa después de un ejercicio físico prolongado. En este reporte de caso, presentamos a un paciente de 18 años que consulta por abultamiento en la pierna izquierda después de la actividad física, con sospecha inicial de lipoma de la extremidad. La ecografía identificó una hernia muscular, destacando la importancia de la detección temprana y conducir un tratamiento adecuado sin complicaciones, gastos innecesarios y diagnósticos erróneos.

Displasia ósea esclerosante en paciente adulto sin diagnóstico previo: presentación de un caso / Bone sclerosing dysplasia in an adult patient without previous diagnosis: a case report

La displasia ósea esclerosante es una afectación en el desarrollo intrínseco del esqueleto, por alteración en la formación y modelado del hueso, que lleva a una excesiva acumulación ósea con un aumento de la densidad (esclero-sis). Existen varios tipos y todos ellos son de origen genético. Presentamos el caso de una paciente de 37 años que llega a la consulta sin diagnóstico previo, por dolor en miembros inferiores de larga evolución con reagudizaciones, asociado a deformidad e impotencia funcional, que cedía parcialmente con analgésicos comunes. (AU)

Bone sclerosing dysplasia is an affectation of the intrinsic development of the skeleton by an alteration in bone formation and modeling. It causes excessive bone accumulation with an increase in density (sclerosis). There are several types of bone sclerosing dysplasia. They are of genetic origin. We report here a 37 year-old patient without a previous diagnosis of sclerosing bone dysplasia who was seen in the clinic for pain in the lower limbs associated with bone deformity with only partial response to analgesics. (AU)

Flegmasia cerúlea dolens posquirúrgica inmediata en el tratamiento de una fractura de pelvis: Reporte de un caso / Immediate phlegmasia cerulea dolens in the postoperative treatment of pelvic fracture. Case report

La flegmasia cerúlea dolens es una presentación poco habitual y grave de una trombosis venosa profunda producida por una obstrucción al flujo venoso de salida de la extremidad inferior, que conlleva un alto grado de morbilidad. Este cuadro no ha sido comunicado como complicación del tratamiento definitivo de una fractura de pelvis. Consideramos que una breve descripción del tema y la presentación de un caso pueden ser útiles para el cirujano ortopédico ante una situación similar. Nivel de Evidencia: IV

Phlegmasia cerulea dolens (PCD) is an unusual and serious presentation of deep venous thrombosis (DVT) caused by an obstruction to the venous outflow of the lower limb, which is associated with significant morbidity. To our knowledge, this complication has not yet been reported as a complication of the definitive treatment of a pelvic fracture. We believe that a brief description of the subject matter and the description of the case may be useful to Orthopedic surgeons in similar situations. Level of Evidence: IV

Tradução, adaptação cultural e validação do questionário de avaliação sintomática do lipedema (QuASiL) / Translation, cultural adaptation, and validation of a lipedema symptoms questionnaire

Resumo Contexto O lipedema é caracterizado como uma deposição anormal de gordura em glúteos e pernas bilateralmente, que pode ser acompanhada por edema ortostático em mulheres. Foi publicado questionário de avaliação sintomática em lipedema em alemão e inglês para avaliação de evolução de tratamento. Objetivos Tradução, adaptação cultural e validação do questionário de avaliação sintomática de lipedema para português brasileiro. Métodos O processo consistiu em três traduções e duas retrotraduções realizadas por tradutores independentes, seguida da elaboração de versão consensual e adaptação conforme compreensão das pacientes. O questionário foi convertido em versão digital, aplicado em 56 voluntárias e em 154 pacientes de consultório vascular e correlacionado com volumetria por bioimpedância segmentar. Resultados As 20 pacientes do pré-teste eram do sexo feminino e as questões foram compreendidas por pelo menos 90% das entrevistadas na fase final. Voluntárias mostraram compreensão de 96,4%, com tempo médio de resposta de 4 minutos. Em 154 pacientes, o volume dos membros mostrou correlação positiva com a intensidade dos sintomas avaliada pelo questionário traduzido e correlação fraca e moderada em apenas 3 perguntas, num total de 15 com nível de escolaridade. Conclusões A versão traduzida e adaptada culturalmente para o português do Brasil do questionário de avaliação sintomática do lipedema (QuASiL) é um instrumento prático, de fácil e rápida aplicação, que pode ser utilizado em nossa população. Ainda são necessários estudos adicionais para avaliar a sensibilidade do instrumento para o auxílio no diagnóstico do lipedema.

Abstract Background Lipedema is characterized as abnormal bilateral deposition of fat in the buttocks and legs that may be accompanied by orthostatic edema in women. A questionnaire for assessment of lipedema symptoms has previously been published in German and English to assess treatment progress. Objectives To translate, culturally adapt, and validate the lipedema symptoms assessment questionnaire for Brazilian Portuguese. Methods The process involved three translations and two back-translations performed by independent translators, followed by construction of a consensus version and adaptation according patients' comprehension. The questionnaire was converted into a digital version and administered to 56 volunteers and then administered to 154 patients from a vascular clinic and correlated with volume determined by segmental bioimpedance. Results The 20 pre-test patients were female and at least 90% of the interviewees were able to understand the questions in the final phase. Volunteers had a 96.4% rate of comprehension of the digital online version and a mean completion time of 4 minutes. In 154 patients, limb volume was positively correlated with intensity of symptoms, as assessed by the translated questionnaire, and 3 out of 15 questions were weakly correlated with educational level. Conclusions The translated and culturally adapted Brazilian Portuguese version of the lipedema symptoms assessment questionnaire (QuASiL) is a practical tool that is easy and quick to administer and can be used in our population. Additional studies are still needed to assess the instrument's sensitivity as an aid for diagnosis of lipedema.

Acrometástasis óseas, serie de casos y revisión de la literatura / Bone acrometástasis, case series and literature review

Resumen: Las acrometástasis se definen como metástasis óseas localizadas distales al codo y la rodilla. Su prevalencia es muy baja, aproximadamente el 0,1% de todas las metástasis óseas y se presentan en pacientes con enfermedad avanzada y son indicador de mal pronóstico. Hasta en el 10% de los casos se presentan como el primer signo de neoplasia oculta. Su forma de presentación clínica y radiológica es inespecífica, lo que genera retraso en su diagnóstico y tratamiento. La resonancia magnética es la imagen de elección para el diagnóstico. El tratamiento en la mayoría de los casos es paliativo. Presentamos cuatro pacientes con acrometástasis y una revisión de la literatura.

Abtract: Acrometastasis are defined as localized bone metastases distal to the elbow and knee. Its prevalence is very low, approximately 0.1% of all bone metastases and they present in patients with advanced disease and are considered indicators of poor prognosis. In up to 10% of cases are the first sign of undiagnosed neoplasia. Its clinical and radiological presentation is non-specific which generates delays in its diagnosis and treatment. Magnetic resonance is the image of choice for diagnosis. The treatment in most cases is palliative. We present four patients with acrometastasis and a review of the literature.

Severo edema inducido por la terapia dopaminérgica en la enfermedad de Parkinson. Caso clínico / Severe leg edema associated with the use of dopaminergic drugs in Parkinson's disease. Report of one case

The main adverse effects of dopaminergic drugs used in Parkinson's disease are hypotension, somnolence, hallucinations and impulse control disorder. Less common is leg edema. We report on a 68-year-old male receiving levodopa and pramipexole consulting for severe leg edema lasting two years, whose etiology was not ascertained with multiple lab tests. This edema subsided substantially when pramipexole was discontinued and the dose of levodopa was increased to treat motor symptoms.

Cutaneous angiosarcoma: report of three different and typical cases admitted in a unique dermatology clinic

Abstract: Angiosarcoma is a rare and aggressive tumor with high rates of metastasis and relapse. It shows a particular predilection for the skin and superficial soft tissues. We report three distinct and typical cases of angiosarcoma that were diagnosed in a single dermatology clinic over the course of less than a year: i) Angiosarcoma in lower limb affected by chronic lymphedema, featuring Stewart-Treves syndrome; ii) a case of the most common type of angiosarcoma loated in the scalp and face of elderly man and; iii) a skin Angiosarcoma in previously irradiated breast. All lesions presented characteristic histopathological findings: irregular vascular proliferation that dissects the collagen bundles with atypical endothelial nuclei projection toward the lumen.

Isolated plexiform neurofibroma mimicking a vascular lesion

Abstract Plexiform neurofibromas are benign tumors originating from peripheral nerve sheaths, generally associated with Neurofibromatosis Type 1 (NF1). They are diffuse, painful and sometimes locally invasive, generating cosmetic problems. This report discusses an adolescent patient who presented with an isolated, giant plexiform neurofibroma on her leg that was confused with a vascular lesion due to its clinical aspects. Once the diagnosis was confirmed by surgical biopsy, excision of the lesion was performed with improvement of the symptoms.

Sweet's syndrome associated with cellulitis - a challenging diagnosis

Abstract Sweet's syndrome is a neutrophilic dermatosis with worldwide distribution that has been associated with inflammatory autoimmune diseases, infections, malignancies, drugs, and pregnancy. The disease is idiopathic in up to 50% of patients. A 64-year-old woman, diagnosed with right limb cellulitis (4 days of evolution), was seen at our department, due to persistent cellulitis and progressive appearance of painful nodules and plaques in both shins and the right forearm (2 days of evolution). Taken together, clinical, laboratory and pathological data suggested the diagnosis of Sweet's syndrome, probably secondary to cellulitis of the right inferior limb. We suggest that cellulitis may be associated with Sweet's syndrome, a rare association in the literature.

Membranous lipodystrophy: case report and review of the literature

Membranous lipodystrophy is a distinct type of membranocystic fat necrosis. It is associated with many local and systemic diseases, including vascular disorders. The histopathological changes which characterize this phenomenon are variably sized cysts in the fat lobules of the subcutaneous tissue, which are surrounded by eosinophilic membranes projecting into the cystic space. We report a case of secondary membranous lipodystrophy associated with both hypertension and venous insufficiency.

Epidermolysis bullosa pruriginosa: A case with a novel mutation and co-existent lichen amyloidosus.

Epidermolysis bullosa pruriginosa is a rare variant of dystrophic epidermolysis bullosa characterized by severely pruritic and cicatricial lesions localized to the extensor extremities. We report a Singaporean Chinese male with epidermolysis bullosa pruriginosa with an underlying novel mutation in the COL7A1 gene. A heterozygous acceptor splice site mutation IVS67‑1G>T probably led to in‑frame skipping of exon 68 (36‑basepairs), resulting in a loss of 12 amino acids. Among his three children, only the youngest son, who had bilateral big toenail thickening, possessed the same mutation. His skin biopsy one decade ago revealed association of focal amyloidosis; a recent skin biopsy showed more established features of lichen amyloidosis. It is debatable whether the cutaneous amyloidosis was a secondary or primary phenomenon. Our report highlights that the diagnosis of epidermolysis bullosa pruriginosa may be obscured when cutaneous amyloidosis is coexistent.

Tratamento das áreas cruentas de perna com retalhos locais / Treatment of open wounds of the leg by using local flaps

INTRODUÇÃO: Até os anos 70, a reparação de perdas de substância na perna representava, quase sempre, um problema de solução muito difícil ou, até, insolúvel. Atualmente, embora ainda constitua um campo para os mais experientes, as áreas cruentas na perna já contam com várias técnicas confiáveis e algumas relativamente simples para sua reparação. Este trabalho visa equacionar condutas reparadoras de feridas de perna, utilizando tecidos locais. MÉTODO: Estudo retrospectivo pela análise de casos de reconstrução de perna com retalhos locais realizados pelos autores. Foram incluídos os retalhos dermoadiposos, fasciocutâneos, fasciossubcutâneos e musculares. RESULTADOS: Foram operados 70 pacientes que possuíam áreas cruentas na perna, em consequência de fratura de tíbia, osteomielite, perda tecidual isquêmica, úlcera crônica e tumoração de pele. Os resultados foram avaliados segundo etiologia, tipo de procedimento cirúrgico e complicações. CONCLUSÕES: A opção do tratamento de áreas cruentas de membros inferiores com retalhos locais é bastante válida. A escolha do retalho vai depender de condições locais da perna e da região anatômica afetada. No terço superior da perna, utilizamos retalhos fasciocutâneos baseados na rede vascular do joelho ou retalho de gastrocnêmio. Já no médio, os principais retalhos foram o solear e o fasciossubcutâneo de panturrilha. E, por fim, no inferior, o principal retalho usado foi o fasciossubcutâneo de panturrilha.

INTRODUCTION: Until the 70s, repairing loss of tissue in the leg was almost always difficult, or even impossible. Currently, only the most experienced surgeons are able to repair open wounds of the leg. Nevertheless, several reliable and simple techniques are currently available. This work aimed to evaluate repair techniques for leg wounds by using local tissues. METHOD: The authors performed a retrospective study of cases of leg reconstruction using local flaps. Dermoadipose, fasciocutaneous, fasciosubcutaneous, and muscle flaps were used. RESULTS: Seventy patients who had open areas in the leg due to tibial fractures, osteomyelitis, ischemic tissue loss, chronic ulcer, or skin tumor underwent surgery. Results were evaluated according to etiology, type of surgical procedure, and complications. CONCLUSIONS: The option of treating open wounds of the lower limbs by using local flaps is very valid. Selection of the flap type depended on local conditions in the leg, and the anatomical region affected. In the upper third of the leg, we used fasciocutaneous flaps, based on the vascular network of the knee, or gastrocnemius flaps. In the middle third of the leg, we used the soleus muscle as the primary flap, and fasciosubcutaneous flaps in the calf region. In the lower third of the leg, a fasciosubcutaneous flap of the calf was primarily used.

Acute Compartment Syndrome after Non-Contact Peroneus Longus Muscle Rupture

This case demonstrates a rare variation in the pattern of injury and the presentation of acute lateral compartment syndrome of the leg. Although uncommon, lateral compartment syndrome of the leg after an ankle inversion leading to peroneus longus muscle rupture has been previously documented. This case was unusual because there was no overt ankle injury and the patient was able to continue physical activity, in spite of a significant rupture of the peroneus longus muscle that was determined later. This case highlights the necessary vigilance clinicians must maintain when assessing non-contact injuries in patients with possible compartment syndrome.

A case of extensive chromoblastomycosis from North India

A case of extensive chromoblastomycosis of the right leg and thigh with verruciform to nodular lesions evolving rapidly over five years duration is reported. The diagnosis was confirmed by visualizing pathognomonic pigmented muriform bodies with unique septate hyphae and mycological culture yielding Fonsecaea pedrosoi.

Incidence of Nocturnal Leg Cramps in Patients with Lumbar Spinal Stenosis before and after Conservative and Surgical Treatment

PURPOSE: To examine the effects of conservative and surgical treatments for nocturnal leg cramps in patients with lumbar spinal stenosis (LSS). Nocturnal leg cramps is frequently observed in patients with peripheral neuropathy. However, there have been few reports on the relationship between nocturnal leg cramps and LSS, and it remains unknown whether conservative or surgical intervention has an impact on leg cramps in patients with LSS. MATERIALS AND METHODS: The subjects were 130 LSS patients with low back and leg pain. Conservative treatment such as exercise, medication, and epidural block was used in 66 patients and surgical treatment such as decompression or decompression and fusion was performed in 64 patients. Pain scores and frequency of nocturnal leg cramps were evaluated based on self-reported questionnaires completed before and 3 months after treatment. RESULTS: The severity of low back and leg pain was higher and the incidence of nocturnal leg cramps was significantly higher before treatment in the surgically treated group compared with the conservatively treated group. Pain scores improved in both groups after the intervention. The incidence of nocturnal leg cramps was significantly improved by surgical treatment (p=0.027), but not by conservative treatment (p=0.122). CONCLUSION: The findings of this prospective study indicate that the prevalence of nocturnal leg cramps is associated with LSS and severity of symptoms. Pain symptoms were improved by conservative or surgical treatment, but only surgery improved nocturnal leg cramps in patients with LSS. Thus, these results indicate that the prevalence of nocturnal leg cramps is associated with spinal nerve compression by LSS.

Presentación inusual de morfea en placas en un niño / Unusual presentation of morphea in plates in child

La morfea de presentación infantil se caracteriza por manifestarse como lesiones lineares, localizadas con mayor frecuencia en uno de los miembros o en la región facial. La morfea tiene mayor prevalencia en el sexo femenino. Se presenta el caso de un niño de once años sin morbilidad adicional, con lesiones planas, hiperpigmentadas y atróficas, localizadas en la parte medialy lateral del tercio inferior de ambas piernas. Las lesiones fueron confirmadas histopatologicamente como morfea superficial.

Child onset morphea is usually characterized by linear lesions, more frequently located in one limb or in the facial region, more prevalent in white female children. We report the case of a 11year-old male child without additional morbidity, with atrophic and hyperpigmented flat plaque lesions, located in the inner and outer side of the lower third part of both legs. The lesions were pathologically confirmed as superficial morphea.

Lymphangioleiomyomatosis - Retroperitoneum.

Lymphangioleiomyomatosis (LAM) is a progressive disease affecting women of childbearing age. It is microscopically characterized by abnormal smooth muscle proliferation in the walls of lymphatics and lymph nodes. A 52-year old female presented with pain in left leg and bilateral pedal oedema. USG and CT abdomen revealed a retroperitoneal cystic mass suspicious of malignancy. Retroperitoneal exploration was done and the mass was excised which revealed milky contents within. On gross examination of the specimen, a spongy mass was noted . Histopathological examination led to a diagnosis of lymphangioleiomyomatosis. LAM is a rare disease unfamiliar to many physicians and may pose a diagnostic dilemma to the physician, possibly resulting in delayed or missed diagnosis . Many treatment modalities including corticosteroids, cytotoxic drugs, chemotherapy, radiation and hormonal therapy are suggested. The prognosis of LAM varies with the individual, but many patients respond well to intramuscular medroxyprogesterone injections.

Loxoscelismo cutáneo. A propósito de un caso clínico / Skin loxoscelism. A clinical case report

Loxosceles laeta es una araña de distribución mundial y la necrosis cutánea caracteriza a su mordedura. Las formas sistémicas son de baja frecuencia pero alta mortalidad. El diagnóstico es de sospecha ante una lesión intensamente dolorosa o por la identificación del arácnido. La recomendación para la utilización de suero antiloxosceles no es uniforme. En este artículo reportamos un caso de loxoscelismo a forma cutáneo necrótica que requirió cirugía de debridamiento temprano y con buena evolución. El objetivo es concientizar a los pediatras de la existencia de esta entidad que sólo será diagnosticada tempranamente si pensamos en ella, lo que permitirá el oportuno y adecuado abordaje del paciente.