Appendiceal endometriosis invading the sigmoid colon: a rare entity.

PURPOSE: We report an unusual case of endometriosis of the appendix with simultaneous invasion of the sigmoid colon. METHODS: Clinical, radiological, surgical, and histological data of the patient were reviewed, as well as the current literature on gastrointestinal endometriosis. RESULTS: A 41-year-old woman presented to the emergency department of our hospital with acute right lower quadrant pain, pronounced tenderness elevated white blood cell count, and increased C-reactive protein. Abdominal CT scan suggested a mucocele of the appendix. The patient was first treated with antibiotics, followed by en bloc resection of the appendix and of the sigmoid colon 2 months later. Histological examination revealed an endometriotic nodule of the appendix filling the appendiceal lumen and resulting in a mucocele which invaded the sigmoid colon wall. CONCLUSIONS: The diagnosis of gastrointestinal endometriosis can be challenging due to the variety of symptoms it can produce. Although extremely rare, a concomitant double gastrointestinal location of endometriosis may be possible and should be considered in women of reproductive age.

What every radiologist should know about adnexal torsion.

Adnexal torsion is the fifth most common gynecologic surgical emergency, requiring clinician and radiologist awareness. It involves the rotation of the ovarian tissue on its vascular pedicle leading to stromal edema, hemorrhagic infarction, and necrosis of the adnexal structures with the subsequent sequelae. Expedient diagnosis poses a difficult challenge because the clinical presentation is variable and often misleading. Adnexal torsion can mimic malignancy as it can take a subacute, intermittent, or chronic course, and thereby can be complicated to diagnose. The torsion may occur in the normal ovary but is usually secondary to a preexisting adnexal mass. Early surgery is necessary to avoid irreversible adnexal damage and to preserve ovarian function especially in children and young women. Pelvic ultrasound forms the foundation of diagnostic evaluation due to its ability to directly and rapidly evaluate both ovarian anatomy and perfusion. Moreover, it is a noninvasive and accessible technique. However, the color Doppler appearance of the ovary should not be relied upon to rule out torsion because a torsed ovary or adnexa may still have preserved arterial flow due to the dual blood supply. MR and CT may be used as problem-solving tools needed after the ultrasound examination but should not be the first-line imaging modalities in this setting due to ionizing radiation and potential time delay in diagnosis. The goal of this article is to review the adnexal anatomy, to familiarize radiologists with the main imaging features, and to discuss the main mimickers and the most common pitfalls of adnexal torsion. Main points Adnexal torsion is an uncommon gynecological disorder caused by partial or complete rotation of the ovary and/or the Fallopian tube about the infundibulopelvic ligament. The ovaries receive a dual blood supply from the ovarian artery and uterine artery. The lack of pathognomonic symptoms and specific findings on physical examination makes this entity difficult to diagnose. Since the right adnexa are most commonly involved, symptoms may mimic acute appendicitis. Persistence of adnexal vascularization does not exclude torsion. In the pediatric age group, gray-scale ultrasound is the best modality of choice. Obtaining CT and/or MR images should not delay treatment in order to preserve ovarian viability.

The parasite Entamoeba histolytica exploits the activities of human matrix metalloproteinases to invade colonic tissue.

Intestinal invasion by the protozoan parasite Entamoeba histolytica is characterized by remodelling of the extracellular matrix (ECM). The parasite cysteine proteinase A5 (CP-A5) is thought to cooperate with human matrix metalloproteinases (MMPs) involved in ECM degradation. Here, we investigate the role CP-A5 plays in the regulation of MMPs upon mucosal invasion. We use human colon explants to determine whether CP-A5 activates human MMPs. Inhibition of the MMPs' proteolytic activities abolishes remodelling of the fibrillar collagen structure and prevents trophozoite invasion of the mucosa. In the presence of trophozoites, MMPs-1 and -3 are overexpressed and are associated with fibrillar collagen remodelling. In vitro, CP-A5 performs the catalytic cleavage needed to activate pro-MMP-3, which in turn activates pro-MMP-1. Ex vivo, incubation with recombinant CP-A5 was enough to rescue CP-A5-defective trophozoites. Our results suggest that MMP-3 and/or CP-A5 inhibitors may be of value in further studies aiming to treat intestinal amoebiasis.

Development of hairy cell leukemia in a patient treated with cytoreductive agents for essential thrombocythemia.

The association of second malignancies in hairy cell leukemia (HCL) is well recognized. Most of these malignancies are either solid tumors or lymphoproliferative disorders rather than myeloproliferative disorders. But these malignancies are usually related to a complication of the drug treatment for HCL. The chronological sequence of HCL occurring after a hematological disorder is very rarely described. This report describes the first case, to our knowledge, of a patient who developed HCL five years after essential thrombocythemia that was treated with oral cytoreductive agents. Pathogenesis of the coexistence of both diseases is discussed.