Streptococcus pneumoniae primary peritonitis mimicking acute appendicitis in an immunocompetent patient: a case report and review of the literature.

INTRODUCTION: Primary peritonitis without an identifiable intra-abdominal source is extremely rare in healthy individuals; it is commonly seen in cases of nephrotic syndrome, cirrhosis and end-stage liver disease, ascites, immunosuppression, and inflamed peritoneum due to pre-existing autoimmune and oncological conditions. CASE PRESENTATION: We present the case of a 68-year-old Caucasian woman operated on due to acute abdomen with a provisional diagnosis of acute appendicitis. During the operation a small amount of free intra-abdominal fluid was found. Her uterus, ovaries, and fallopian tubes were macroscopically normal. Therefore, with the suspicion of appendicitis, appendectomy was performed. Her blood cultures were negative while peritoneal fluid was positive for capsulated form of Streptococcus pneumoniae. A 30-day follow-up was performed and she was asymptomatic without any sign of infection. DISCUSSION: Streptococcus pneumoniae commonly causes upper respiratory tract infection and cutaneous infections. It very rarely causes gastrointestinal infection and it is very rarely responsible for primary peritonitis and septic shock syndrome. CONCLUSION: Pneumococcal peritonitis has a rare occurrence and represents a clinical challenge because of its subtle and non-specific clinical findings. The interest in our case lays in the relatively rare diagnosis of primary peritonitis mimicking acute appendicitis.

Emergency presentation of cystic lymphangioma of the colon: A case report and literature review.

INTRODUCTION: Colonic lymphangioma is an unusual benign malformation. The clinical presentation of lymphangiomas vary from incidental discovery on imaging to presenting with acute abdomen. PRESENTATION OF CASE: We present the case of a 73-year-old male, undergoing surgery due to acute abdomen associated with severe anemia, in whose case a lymphangioma of the cecum was recognised only in the postoperative histopathological examination. DISCUSSION: The management of colonic lymphangioma depends on the individual situation; close surveillance or endoscopic therapy may be appropriate for asymptomatic lesions smaller than 2.5cm in diameter. Surgical intervention can be considered for larger lesions or in patients who develop complications. CONCLUSION: The interest in our case lies in the relatively rare diagnosis of colon lymphangioma and how the cardinal sign was anemia, which may be due to the serosanguineous cystic contents of lymphangiomatosis from the internal bleeding and can cause fatal complications that require emergency surgery.

External Quality Assessment (EQA) program for the preanalytical and analytical immunohistochemical determination of HER2 in breast cancer: an experience on a regional scale.

BACKGROUND: An External Quality Assessment (EQA) program was developed to investigate the state of the art of HER2 immunohistochemical determination in breast cancer (BC) in 16 Pathology Departments in the Lazio Region (Italy). This program was implemented through two specific steps to evaluate HER2 staining (step 1) and interpretation (step 2) reproducibility among participants. METHODS: The management activities of this EQA program were assigned to the Coordinating Center (CC), the Revising Centers (RCs) and the Participating Centers (PCs). In step 1, 4 BC sections, selected by RCs, were stained by each PC using their own procedures. In step 2, each PC interpreted HER2 score in 10 BC sections stained by the CC. The concordance pattern was evaluated by using the kappa category-specific statistic and/or the weighted kappa statistic with the corresponding 95% Jackknife confidence interval. RESULTS: In step 1, a substantial/almost perfect agreement was reached between the PCs for scores 0 and 3+ whereas a moderate and fair agreement was observed for scores 1+ and 2+, respectively.In step 2, a fully satisfactory agreement was observed for 6 out of the 16 PCs and a quite satisfactory agreement was obtained for the remaining 10 PCs. CONCLUSIONS: Our findings highlight that in the whole HER2 evaluation process the two intermediate categories, scores 1+ and 2+, are less reproducible than scores 0 and 3+. These findings are relevant in clinical practice where the choice of treatment is based on HER2 positivity, suggesting the need to share evaluation procedures within laboratories and implement educational programs.

A case of mistaken identity of arrhythmogenic right ventricular dysplasia in a 75-year-old patient.

We present an uncommon case of a 75-year-old woman who was admitted to our department for the evaluation of her double valvular disease that hid a diagnosis of arrhythmogenic right ventricular dysplasia (ARVD). In the course of preoperative workup, a mass of tissue substituting the right ventricular free wall was identified and documented with transthoracic echocardiography, computed tomography scanning, and nuclear magnetic resonance imaging. This pathology was not identified as ARVD. Before and after surgery (double valve replacement), malignant arrhythmias were observed and treated with an implantable cardioverter-defibrillator. The patient underwent reoperation 24 days later for endocarditis and died in the immediate postoperative period from untreatable ventricular arrhythmias. At autopsy the histological characteristics of ARVD were detected. This report highlights the difficulty in diagnosing ARVD in patients who do not fulfil the McKenna criteria.