ABSTRACT
Introduction: Mucinous adenocarcinomas of the appendix are defined as epithelial neoplasms often causing cystic dilation of the appendix due to accumulation of gelatinous material. Pseudomyxoma peritonei is an extremely rare complication of appendiceal mucinous adenocarcinomas with an estimated incidence rate of one to 2 people per million per year. Here-in we present a unique case of enterocutaneous fistula formation secondary to percutaneous biopsy of an enlarging omental mass in the setting of pseudomyxoma peritonei. Case Description/Methods: A 50-year-old male with a past medical history of metastatic appendiceal mucinous adenocarcinoma presented to the ED with abdominal pain, nausea, and vomiting. The patient had previously undergone 2 debulking surgeries over the past 2 years prior to admission and has since been on FOLFOX therapy. Due to the COVID pandemic, the patient did not follow-up in the 2 years period from previous admission. A CT scan was now notable for a new enlarging omental mass despite the recent debulking surgery. Given the enlarging mass, a decision was made to pursue a percutaneous biopsy of the mass due to concern for potential new malignancy. Two weeks after the biopsy, the patient presented to our facility due to worsening erythema and drainage from the biopsy site. The patient met SIRS criteria, thus broad-spectrum antibiotics were initiated. A CT of the abdomen and pelvis with oral and IV contrast was obtained, which demonstrated a 9 cm abscess or continuation of intra-abdominal multilocular cystic lesion/ pseudomyxoma peritonei. The surgical team was consulted. Patient had 100 cc of purulent and mucinous drainage expressed from biopsy site. The patient was then placed for transfer to a hospital capable of advanced surgical management for evaluation and potential resection of fistula formation. The patient had a successful reductive surgery and intraoperative chemotherapy (Figure). Discussion(s): Given the rarity of pseudomyxoma peritonei, appropriate management is not always straightforward. A literature review yielded no previous reports of enterocutaneous fistula as a complication of percutaneous drainage in the setting of pseudomyxoma peritonei. We recommend that percutaneous drainage not be sought in individuals with this diagnosis due to potential for fistula formation.
ABSTRACT
Introduction: Tuberculosis (TB) is an airborne infectious disease caused by the Mycobacterium tuberculosis (MTB) complex. It attacks the lungs and other extra-pulmonary sites. It remains a major public health concern in Malaysia with incidence of 79/100,000 in 2015. Case Description: We report a case of a 29-year-old lady, presented with a complain of generalised abdominal pain for 2 months. Patient had Covid-19 infection in pregnancy 8 months ago and underwent lower segment caesarean section at term for fetal distress. In 2018 she had TB screening for contact tracing which turned out to be negative. In this current presentation, a Computerized-Tomography (CT) Abdomen-Pelvis scan reported a left ovarian lesion with pseudomyxoma peritonei and omental caking. Diagnostic laparoscopy showed dense adhesions between peritoneal wall and surrounding organs with multiple pockets and fluid collections seen. Whitish friable lesion seen over the peritoneum. Samples sent for histopathology, culture and sensitivity and MTB PCR. Histopathology sample returned as caseating granuloma;suggestive of extrapulmonary tuberculosis. Microscopically, acid fast bacilli seen in Ziehl-Neelsen staining. Peritoneal fluid was transudative in nature. The diagnosis of peritoneal tuberculosis was established, and patient was referred to Infectious Disease team for treatment of active TB. Discussion: Reactivation of latent TB may be explained by immune-suppressive state associated with Covid-19 may be implicated in the progression of latent to active TB in a similar manner to HIV. Very few cases post Covid-19 activation of latent TB have been reported. This is one such a case.