Osteolytic lesions (brown tumors) of primary hyperparathyroidism misdiagnosed as multifocal giant cell tumor of the distal ulna and radius: a case report.

BACKGROUND: Brown tumors represent a rare clinical manifestation reported in approximately 3% of patients with primary hyperparathyroidism and correspond to radiologically osteolytic lesions with well-defined borders in different parts of the skeleton. CASE PRESENTATION: We report the case of a 53-year-old white man who presented to our hospital with osteolytic lesions of his distal ulna and radius, causing pain and swelling of 2-month duration. A subsequent biopsy revealed histological features consistent with giant cell tumor and a complete resection of his distal ulna was followed, along with curettage and cementoplasty of the distal radial metaphysis. Two weeks later, he was re-admitted with diffuse musculoskeletal soreness, anorexia, constipation, nausea, and localized abdominal pain and multiple osteolytic lesions on plain radiographs. A histopathological examination of the ulna and radius specimens showed similar findings and, given the multifocality, brown tumors related to primary or secondary hyperparathyroidism was included in the differential diagnosis. A laboratory examination showed high total serum calcium (14.5 mg/dl) and low serum phosphorus and 25-hydroxyvitamin D levels. Primary hyperparathyroidism was suspected and confirmed by the elevated parathyroid hormone levels of 1453 pg/mL. At radiological work-up, using computed tomography, ultrasonography, and parathyroid subtraction technetium-99m sestamibi scintigraphy, a 4.5 × 2.5 × 3.2 cm mass emanating from the right lobe of his thyroid gland was detected, displaying extensive uptake in the right lower parathyroid gland. After appropriate medical support including hyperhydration and high doses of diuretics and diphosphonates, his laboratory profile normalized and he underwent total thyroidectomy with removal of the parathyroid glands. Our patient is now recovering 12 months after surgery, with normal values of serum parathyroid hormone and calcium levels. The lytic bone lesions have almost disappeared and no other additional orthopedic intervention was necessary. CONCLUSIONS: The present case report emphasizes the need of inclusion of brown tumors in the differential diagnosis of multifocal osteolytic bone lesions, in order to avoid harmful surgical interventions. Laboratory testing of serum phosphate, calcium levels, and parathyroid hormone levels should always be included in the routine survey of patients with multifocal osteolytic lesions.

Revisiting reliability of quantified perineal ultrasound: Bland and Altman analysis of a new protocol for the rectangular coordinate method.

AIMS: This study tested the reliability of a new protocol for the rectangular coordinate method of quantifying perineal ultrasound. METHODS: Representative scans of healthy primiparous females were quantified by positioning a pubic bone template, drawn onto an acetate sheet containing x-y axes, over scans, by aligning the x-axis with the pubic bone central axis. Values for x (D(x)) and y (D(y)) located the urethrovesical junction (UVJ) at Rest, and at maximal Valsalva and Kegel. Range of motion (V-K) was calculated. Bland and Altman analysis, correlations, and t-tests determined intra- and inter-rater reliability, and variance due to designation of the pubic bone central axis (template control). RESULTS: Correlations averaged 0.72, 0.70, and 0.92 for intra-rater, inter-rater, and template control experiments. D(x) Rest, D(x) Kegel, and V-K were reliable in all experiments. First and second measures for inter-rater D(y) Rest and D(y) Kegel, and template control D(y) Valsalva were significantly different. Bland and Altman analysis showed D(y) Rest, D(y) Kegel, and D(x) and D(y) Valsalva for both reliability experiments to have limits of agreement (LOA's) large enough to explain >or=50% of the actual value ranges. Template control LOA's explained

Gastrografin administration in the treatment of postoperative delayed gastric emptying.

Five cases of delayed gastric emptying (DGE) are reported. Three patients had pancreatic head carcinoma and underwent a Whipple operation during which truncal vagotomy and gastrectomy were performed. The remaining two patients underwent vagotomy and gastrectomy because of benign peptic ulcer. In one of the pancreatectomy cases, the pylorus was at first preserved, but after DGE developed, a gastrectomy was carried out, which did not result in any improvement. The duration of DGE was 16-72 days, during which time the patients were under total parenteral or enteral nutrition. There were no other major complications. The patients received prokinetic agents (metoclopramide, erythromycin) but without any improvement. Finally, all patients were treated with Gastrografin, 40 ml every two hours, via a nasogastric tube. In all cases, gastric motility was restored within 20-36 hours.

Activity of 5-formyl tetrahydrofolate cyclodehydrase and 5,10-methenyl tetrahydrofolate cyclohydrolase in primary brain tumors in children.

The activity of the enzymes 5-formyl tetrahydrofolate cyclodehydrase and 5,10-methenyl tetrahydrofolate cyclohydrolase has been studied cytochemically in children's primary brain tumors. These enzymes play a significant role in purine biosynthesis. Thirty children, aged 1-12 years, were studied, 12 with medulloblastoma, 14 with glioma grade I-IV, and 4 with ependymoma. The activity of the enzymes was apparent as cytoplasmic granules that sometimes overlie the nucleus of the tumor cells. This coincidence showed that different types of brain tumors exhibit different degrees of enzymic activity, which in some cases correlated positively with the malignant potential of the tumor. Approximately one third of the cases were negative for any activity of these enzymes. The intensity of the staining of 5,10-methenyl tetrahydrofolate cyclohydrolase activity was actually higher than that of 5-formyl tetrahydrofolate cyctodehydrase. The clinical or prognostic significance of these findings remains to be clarified, but we believe that cylochemistry provides a sensitive technique for the detection, localization, and description of these enzymes in brain tumor cells. A clear understanding of the mode of action of these enzymes may contribute to devising novel therapeutic strategies.

Value of the facial nerve latency test in the prognosis of childhood Bell's palsy.

In the present study we evaluated the facial nerve latency test (FNLT) as a prognostic tool in cases of childhood Bell's palsy. Twenty-five children aged 4-14 years were studied. We divided our subjects into three groups according to duration of latency time (LT). Group A patients had an LT within the normal range, with average of 3.27 ms, group B a slightly prolonged LT averaging 5.7 ms, and group C a markedly prolonged LT averaging 10.5 ms. Analysis of the recovery index by group showed that group A patients experienced complete and quick recovery, while in group B 50% had complete but delayed recovery and 50% slightly impaired facial nerve function, and in group C 50% had slightly impaired function and 50% incomplete recovery. The more prolonged the LT, the worse the clinical results. The FNLT is thus a valuable prognostic tool in cases of Bell's palsy in childhood.

Effect of glutamine on intestinal mucosal integrity and bacterial translocation after abdominal radiation.

This study evaluates the effect of oral glutamine on intestinal mucosal integrity and bacterial translocation in rats. 80 animals were randomised into four groups: group 1 (chow diet and water), group 2 (chow diet and glutamine 3%), group 3 (radiation, chow diet and water), group 4 (radiation, chow diet and glutamine 3%). Groups 1 and 2 were fed for 5 days, then sacrificed. Groups 3 and 4 were fed for 12 days, irradiated on the 5th day and sacrificed on 1st, 3rd and 7th post-radiation days. Cultures from the mesenteric lymph nodes (MLN), portal vein (PV) and aorta (A) were taken and two tissue samples were also taken from the terminal ileum for light and electron microscopic examination. In non-radiated rats glutamine did not alter the histologic parameters of villous height (VH), mitoses per crypt (M/C) and muscle thickness (MT). Group 3 rats had severe mucosal damage associated with a significant decrease of VH (p < 0.0001) and M/C (p < 0.01) on 1st and 3rd post-radiation days respectively. In contrast, group 4 rats maintained their mucosal structure and had a significant increase of VH and M/C (p < 0.0001) on post-radiation days 1 and 3. Bacterial translocation in MLN was 87.5% (p < 0.002) and 75% (p < 0.04) on 1st and 3rd post-radiation days respectively in group 3, and fell significantly to 12.5% (p < 0.002) in group 4. The data demonstrate that glutamine helps maintain the integrity of the intestinal mucosa and thereby reduces the incidence of bacterial translocation following abdominal irradiation.

Treatment of enterocutaneous fistulas with TPN and somatostatin, compared with patients who received TPN only.

Eighteen patients with post-operative enterocutaneous fistulas were treated with total parenteral nutrition (TPN), skin care, infection control and intravenous somatostatin (SMS) 250 micrograms/h. This group was compared with 30 patients treated with standard medical treatment (total parenteral nutrition (TPN), skin care and infection control). In the SMS group the fistula output was reduced to 50% in three days and spontaneous closure was observed in 14 patients after a mean of 6.1 +/- 3.1 days of treatment with SMS, and in 18.2 +/- 6.3 days after the TPN administration. In the control group the fistula output was reduced by up to 50% after a week and spontaneous closure occurred in 20 patients in a mean of 27.4 +/- 8.7 days after the start of treatment. These results are statistically significant. There was one (5.5%) death in the SMS group compared with three (10%) deaths in the other, and glucose intolerance was observed in two (11%) patients in the SMS group. Somatostatin has been shown to be useful in the conservative treatment of enterocutaneous fistulas because of its ability to reduce output and accelerate closure.

Intracranial epidermoid tumors. A continuing diagnostic challenge.

Epidermoid tumors are benign, slowly growing intracranial masses that still present difficulty in preoperative diagnosis. This article reviews six cases of histologically proven epidermoid tumors. Computed tomography and magnetic resonance imaging were complementary in their evaluation. Computed tomography demonstrated a hypodense, smoothly contoured extra-axial paramedian mass with lower density than cerebrospinal fluid. Magnetic resonance imaging usually demonstrated an irregularly but sharply marginated mass with inhomogeneous density, variable enhancement with gadolinium, lack of edema in adjacent normal structures, extensive insinuation into cisternal and other cerebrospinal fluid spaces, and a high-signal intensity on proton-weighted images. Multiplanar magnetic resonance imaging was extremely helpful in displaying the full anatomic extent of the lesion and its relationship with other structures.

Transsphenoidal surgery for visual loss in patients with pituitary adenomas.

This paper presents the results of transsphenoidal surgery in 41 consecutive patients with visual loss from pituitary adenomas. The most common pattern of loss was bitemporal hemianopia. Transsphenoidal decompression resulted in visual improvement in 78% of patients. If patients with optic atrophy and pre-operative complete blindness were excluded, improvement extended to 94% of patients. Because of its efficacy and low morbidity, transsphenoidal resection of pituitary tumours is the procedure of choice for most adenomas with extrasellar extension and visual field loss.

Loss of distinct regions on the short arm of chromosome 17 associated with tumorigenesis of human astrocytomas.

Astrocytomas, including glioblastoma multiforme, represent the most frequent and deadly primary neoplasms of the human nervous system. Despite a number of previous cytogenetic and oncogene studies primarily focusing on malignant astrocytomas, the primary mechanism of tumor initiation has remained obscure. The loss or inactivation of "tumor suppressor" genes are thought to play a fundamental role in the development of many human cancers. Thus, we have analyzed astrocytomas of various histological malignancy grades with polymorphic DNA markers to search for specific chromosomal deletions potentially pointing to loci containing tumor suppressor genes. Loss of constitutional heterozygosity indicating chromosomal loss or deletions was most frequently seen for markers on the short arm of chromosome 17 in 50% of the informative tumors (5 of 10 informative cases) and, to a lesser extent, for markers on chromosomes 1 and 10. Deletions on chromosome 17p were seen in both low-grade and high-grade malignant astrocytomas, suggesting that this chromosome may contain a tumor suppressor gene associated with the early events in tumorigenesis. The common region of deletions on the short arm of chromosome 17 is, therefore, clearly distinct from the gene causing von Recklinghausen neurofibromatosis (NF1), a tumor syndrome associated with glial tumors that maps to the long arm of chromosome 17. The search for progressively smaller deletions on chromosome 17p in astrocytomas may be the way to clone and characterize this locus, thus leading to insights into normal and abnormal growth and differentiation of glial cells.

Mucinous cysts of the pituitary stalk. Report of two cases.

This report describes two cases of a mucinous cyst (Rathke's cleft cyst) in the pituitary stalk: the first was found in a 29-year-old woman 5 years following pregnancy and the second in a 30-year-old woman 6 years after pregnancy. The presenting symptoms are analyzed and the diagnosis is discussed, with emphasis on the role of magnetic resonance imaging.

Neurovascular decompression for cranial rhizopathies.

For some cranial rhizopathies, such as hemifacial spasm and glossopharyngeal neuralgia, treatment has been unsatisfactory. Neurovascular decompression now offers a cure in almost 90% of these cases. In spite of the availability of alternative minor surgical procedures for trigeminal neuralgia, neurovascular decompression, being non-destructive, is a superior method of treatment. Vascular compression may also play a role in atypical facial pain and decompression may offer relief in this intractable condition. Vascular compression was not observed on exploration for nervus intermedius neuralgia, spasmodic torticollis and Meniere's disease. However, microsurgical techniques for selective section of nerves have been beneficial in Meniere's disease and nervus intermedius neuralgia. Neurovascular decompression is a relatively major procedure and is associated with a complication rate of 15%, deafness being most significant. Surgical expertise, a familiar operating team and possibly intraoperative monitoring facilities can reduce these complications.