Tracheal Duplication Cyst Presenting as Chest Pain.

Tracheal duplication cysts (TDCs) are congenital malformations that are rarely diagnosed in adulthood. The authors present a case of a 43-year-old female with no known comorbidities with a two-year history of chest and upper abdominal pain. Her previous imaging on an outpatient basis was suggestive of an esophageal duplication cyst, and she was lost to follow-up until the current admission. She gave a past surgical history of video-assisted thoracoscopic surgery for a "cyst" excision, with the relevant details unavailable. On examination, the findings were unremarkable. Repeat imaging was suggestive of an esophageal duplication cyst with no change in dimensions. She underwent a right-sided elective thoracotomy and cyst excision. Intraoperatively, a smooth globular mass was visualized next to the esophagus below the level of the carina. The biopsy revealed a TDC. The patient had an uneventful postoperative period and was asymptomatic on follow-up after three months. TDCs pose a diagnostic challenge as they can only be diagnosed by imaging and histopathology. However, when the imaging is atypical, histopathology clinches the diagnosis. Complete surgical excision is recommended for symptomatic patients after ruling out malignancy. Recurrence of the lesion must be considered in patients such as ours. Our case emphasizes the consideration of TDCs in the differential diagnosis and advocates the importance of complete surgical resection to prevent a recurrence.

Giant lung tumor in hereditary spherocytosis: inflammatory myofibroblastic tumor.

Inflammatory myofibroblastic tumors are a rare subset of lung lesions in the adult age group. They pose a diagnostic challenge as they present with non-specific findings. We report a 27-year-old female with an inflammatory myofibroblastic tumor on a background of hereditary spherocytosis.

Idiopathic Extremity Arteriovenous Fistula: A Rare Etiology of Cardiac Failure.

Idiopathic extremity arteriovenous fistulas are rare, abnormal connections between arteries and veins commonly occurring between iliac vessels. We present the case of a 42-year-old female who was referred to our center for a mitral valve replacement with a one-year history of breathlessness and a six-month history of progressive abdominal distension. Physical examination revealed a pansystolic murmur in the mitral area, basal crepitations, and a non-tender pulsatile swelling in the right iliac fossa. Imaging showed severe mitral regurgitation in heart failure along with a large arteriovenous fistula between the common femoral vessels which suggested that the arteriovenous fistula was the etiology of heart failure. Postoperatively, the patient showed significant improvement in symptoms with imaging. On follow-up, the patient reported no progression of symptoms. Our case demonstrated an idiopathic extremity arteriovenous fistula in an unusual location, unexpectedly causing heart failure despite a significant valvular disease. Therefore, arteriovenous fistulas warrant inclusion in the differential of heart failure despite a valvular lesion and absence of classical signs of high output heart failure, as in our case.

An uncommon aetiology for a common clinical problem: Primary pericardial mesothelioma.

Mesothelioma is a tumour arising from the mesothelial cells lining the pleura, pericardium, peritoneum, or the tunica vaginalis of testes. Primary pericardial mesothelioma is a rare tumour that can have varied manifestations and survival in patients with malignant pericardial tumours is generally dismal. The role of asbestos in pericardial mesotheliomas is less well established compared to that in pleural or peritoneal mesotheliomas. The prognosis is generally poor with the treatment options available. We present a middle-aged man with large pericardial effusion secondary to primary pericardial mesothelioma with no previous exposure to asbestos.

Absent Testis With a Mediastinal Germ Cell Tumor.

Primary mediastinal mixed germ cell tumors (PMMGCTs) are rare, aggressive tumors that, at diagnosis, are typically metastatic. A 22-year-old male with a three-month history of cough, chest pain, and fever presented to our outpatient department. Clinical examination showed reduced left-sided air entry in the left hemithorax, with a non-palpable left testis. Imaging suggested a large anterior mediastinal mass and an absent left testis. Multiple biopsies revealed only necrotic tissue, and laboratory investigations showed elevated alpha-fetoprotein levels. A provisional diagnosis of mediastinal germ tumor was made, and surgical excision was planned given absent nodal or distant metastasis. Intraoperatively, a densely adherent bosselated mass was found. A biopsy revealed a mixed germ cell tumor with a predominant seminoma component and chemotherapy with cisplatin and ifosfamide was advised. However, the patient was lost to follow-up after one cycle. PMMGCTs possibly occur due to reverse migration. These tumors warrant an early diagnosis due to their highly aggressive nature. A multimodal approach with chemotherapy with surgical resection is recommended. Our case sheds light on the possible mechanism and emphasizes the impact of early diagnosis.

Primary Malignant Synovial Tumor in the Mediastinum.

Primary mediastinal synovial sarcomas constitute a rare subset of mediastinal tumors. The diagnosis is often delayed at the time of presentation impacting the five-year survival rate due to its highly aggressive natural history. We report a 22-year old female with a monophasic variant of the primary mediastinal synovial sarcoma. A 22-year-old female, with a two-month history of productive cough, fever, breathlessness, was referred to our center in view of persistent right-sided hydropneumothorax despite multiple thoracocenteses. Examination revealed reduced right-sided air entry with a succussion splash. Imaging suggested a well-defined cystic lesion with fluid, air foci, and multiple septations. A provisional diagnosis of a ruptured hydatid cyst was made and exploratory thoracotomy was planned. Intraoperatively, a well-defined cystic lesion with 350 mL of hemorrhagic fluid, densely adherent to the lung and diaphragm, was found. The biopsy revealed a monophasic spindle cell variant of the primary synovial sarcoma. Follow-up positron emission tomography (PET) on postoperative day 20 showed no residual disease and evidence of metastasis. However, the patient was lost to follow up following one cycle of chemotherapy with ifosfamide. Primary mediastinal synovial sarcomas are aggressive tumors that warrant an early diagnosis for prompt treatment. They usually present with non-specific respiratory symptoms. The gold standard of diagnostic modalities is a molecular panel looking for the translocation - t(X;18)(p11;q11). However, in low-middle income countries, a biopsy may be more practical, as they are cost-effective. The treatment is surgical resection, with combined chemotherapy and radiotherapy if metastases are present. Our case emphasizes the early detection of this lesion, its mimicry with other lesions, and the impact of early diagnosis.

Chronic granulomatous 'Aspergillus lung mass'.

The diverse clinicopathological spectrum of pulmonary aspergillosis is a consequence of varying levels of invasiveness of this ubiquitous fungus, which largely depends on the host immune response and pre-existing lung disease. The clinical presentation of pulmonary aspergillosis spans a wide spectrum from hypersensitivity to life threatening angio-invasive and disseminated disease. We report the case of a young immunocompetent male with no underlying lung disease, who presented with an incidentally detected 'infective mass' lesion in the lung associated with minimal respiratory symptoms. The diagnostic challenges posed by the unusual clinical, radiological and histological picture as well as the therapeutic dilemmas faced are discussed in this report.

A simple technique for securing Gore-Tex neochordal height and knot slippage in mitral valve repair.

Polytetrafluoroethylene or Gore-Tex sutures are used for chordal replacement, and are durable but extremely slippery, a property which causes knot slippage and ineffective neochordal length. We report a modification that is simple and reproducible in preventing knot slippage and maintaining optimal neochordal length, without the use of devices or additional sutures.