The Role of MR Mammography in Differentiating Benign from Malignant in Suspicious Breast Masses.

INTRODUCTION: Magnetic Resonance (MR) Mammography is being increasingly used now-a-days for the evaluation of breast lesions. AIM: To find out the effectiveness and the exact role of MR mammography in differentiating benign lesions from malignant lesions in patients with palpable, suspicious breast masses found on routine conventional imaging techniques. MATERIALS AND METHODS: It was a prospective study wherein patients with suspicious breast lesions were subjected to MR mammography. The morphological feature (smooth vs irregular margin) and the enhancement patterns (Type Ia/Ib vs Type II vs Type III) of the lesions were assessed and finally the effectiveness of MR mammography in differentiating benign and malignant lesions was judged by taking the histopathological diagnosis as the gold standard. RESULTS: A total of 33 patients with 35 breast lesions were finally analysed. The sensitivity, specificity, Positive Predictive Value (PPV) and the Negative Predictive Value (NPV) in differentiating benign from malignant breast lesion for the type of margin on MR mammography was 95.45%, 84.6%, 91.3% and 91.7%, while for the type of enhancement curve it was 76.2%, 90.9%, 94.1% and 66.7% respectively. The sensitivity and negative predictive value for the type of margins was statistically better when compared to the type of enhancement curve in differentiating benign from malignant lesions but the specificity and PPV though better for the type of enhancement curve was not found to be statistically significant. CONCLUSION: MR mammography was found to be an effective tool in differentiating benign from malignant suspicious breast lesions. The type of margin and the enhancement patterns both individually and in combination provide the clinicians with ample information so as to decide on further management.

Assessment of Portal Venous and Hepatic Artery Haemodynamic Variation in Non-Alcoholic Fatty Liver Disease (NAFLD) Patients.

INTRODUCTION: Non-Alcoholic Fatty Liver Disease (NAFLD) has various spectrums of liver diseases like isolated fatty liver, steatohepatitis and cirrhosis usually progressing in a linear fashion. In this process they are known to cause certain haemodynamic changes in the portal flow and hepatic artery flow. AIM: The aim of the study was to study these haemodynamic changes in patients with NAFLD and to correlate it with the disease severity. MATERIALS AND METHODS: Ninety patients diagnosed to have NAFLD based on ultrasound abdomen (30 each in grade1, grade2 and grade3 NAFLD) and 30 controls (Normal liver on ultrasound abdomen) were subjected to portal vein and hepatic artery Doppler study. Peak maximum velocity (Vmax), Peak minimum velocity (Vmin), Mean flow velocity (MFV), and Vein pulsality index (VPI) of the portal vein and hepatic artery resistivity index (HARI) of the hepatic artery were the doppler parameters which were assessed. Liver span was also assessed both for the fatty liver and controls. RESULTS: The mean Vmax, Vmin, MFV and VPI of the portal vein in patients with NAFLD was 12.23±1.74cm/sec, 9.31±1.45cm/sec, 10.76±1.48cm/sec, and 0.24±0.04 as compared to 14.05±2.43cm/sec, 10.01±2.27cm/sec, 12.23±2.47cm/sec, 0.3±0.08 in controls respectively. All these differences were statistically significant except for Vmin. The Mean HARI in patients with fatty liver was 0.65±0.06 when compared to controls of 0.75±0.06 (p=0.001). HARI (r-value of -0.517) had a better negative correlation followed by VPI (r-value of -0.44) and Vmax (r-value of -0.293) with the severity of NAFLD. MFV had a very weak negative correlation (r-value of -0.182) with the severity of NAFLD. CONCLUSION: The Vmax, MFV, VPI and HARI were significantly less when compared to controls suggesting a reduced portal flow and an increased hepatic arterial flow in patients with NAFLD. Among the parameters, HARI correlated better with the severity of NAFLD followed by VPI.

Neglected partial denture in the lower oesophagus presenting after 7 days.

Accidental ingestion of a denture is an acute emergency, and the denture is usually removed on the same day it is discovered. We present a patient who had a seizure while asleep, during which his denture broke; he accidentally swallowed a major part of it, which had a clasp attached. He was unaware that he had ingested the denture, since he was asymptomatic, but he started developing symptoms after 5 days and presented to us on the eighth day of ingestion. With much difficulty, the impacted section of the denture in the distal oesophagus was removed with the combined effort of flexible endoscopy and a rigid oesophagoscopy. Post-procedure, the patient developed mediastinitis, which was managed conservatively; he is doing well on follow-up.

Transient renal medullary hyperechogenicity in a term neonate.

Although neonatal renal medullary hyperechogenicity can occur in a variety of pathological conditions, it has been reported to occur transiently with or without renal abnormalities in term as well as in preterm neonates. Variably described in the literature as Tamm-Horsfall nephropathy, or stasis nephropathy, the pathogenesis is unknown, but has an excellent prognosis. The authors describe a 3-day-old neonate with transient renal medullary hyperechogenicity, with no other abnormalities, which resolved within 2 weeks.

Hemophagocytic Lymphohistiocytosis: an Unusual Complication of Orientia tsutsugamushi Disease (Scrub Typhus).

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially fatal, hyperinflammatory syndrome that may rarely complicate the clinical course of Orientia tsutsugamushi disease (scrub typhus). METHODS: Here we describe the clinicopathological features, laboratory parameters, management, and outcome of three adult patients (1 female, 2 males) with scrub typhus associated HLH from a tertiary center. A brief and concise review of international literature on the topic was also added. RESULTS: All three patients satisfied the HLH-2004 diagnostic criteria; one had multi-organ dysfunction with very high ferritin level (>30,000 ng/ml), and all had a dramatic recovery following doxycyclin therapy. Literature review from January 1990 to March 2014 revealed that scrub typhus associated HLH were reported in 21 patients, mostly from the scrub endemic countries of the world. These included 11 females and 10 males with a mean age of 35 years (range; 8 months to 81 years). Fifteen of 17 patients (where data were available) had a favorable outcome following early serological diagnosis and initiation of definitive antibiotic therapy with (N=6) or without (N=9) immunosuppressive/immunomodulator therapy. Mutation analysis for primary HLH was performed in one patient only, and HLH-2004 protocol was used in two patients. CONCLUSION: We suggest that HLH should be considered in severe cases of scrub typhus especially if associated with cytopenia (s), liver dysfunction, and coagulation abnormalities. Further studies are required to understand whether an immunosuppressive and/or immunomodulator therapy could be beneficial in those patients who remain unresponsive to definitive antibiotic therapy.

Hemophagocytic lymphohistiocytosis in association with primary cutaneous anaplastic large cell lymphoma.

Hemophagocytic lymphohistiocytosis (HLH) has a well known association with lymphomas, especially of T cell origin. Prognosis of lymphoma associated HLH is very poor, especially in T cell lymphomas; and, therefore, early diagnosis might alter the outcome. Though association of HLH with systemic anaplastic large cell lymphoma (ALCL) is known, its occurrence in primary cutaneous ALCL (C-ALCL) is distinctly rare. We aim to describe a case of C-ALCL (anaplastic lymphoma kinase (ALK)-) in an elderly male who succumbed to the complication of associated HLH, which was possibly triggered by coexistent virus infection. We briefly present the literatures on lymphoma associated HLH and discuss the histopathological differentials of cutaneous CD30+ lymphoproliferative disorders. We do suggest that HLH may pose diagnostic challenges in the evaluation of an underlying lymphoma and hence warrants proper evaluation for the underlying etiologies and/or triggering factors.

Endoscopic (video) demonstration of hookworm infestation of the stomach.

Hookworm infestation is common in southern India. The adult worms normally reside in the duodenum, graze the intestinal mucosa with their large buccal cavities and ingest the intestinal epithelial cells and blood. Depending on the number of worms the infection may be either asymptomatic or can cause iron deficiency anaemia due to chronic blood loss. Adult worms live in the small intestine and are not usually seen in the stomach. There are only very few case reports in the literature reporting hookworm infestation of the stomach. In this case report we present an endoscopic (video) demonstration of hookworm infestation of the stomach in a woman who presented with chronic anaemia.

Amoeboma: resurfacing of a vanishing illness.

Amoeboma is a rare manifestation of intestinal amoebiasis. More than 90% of patients with intestinal amoebiasis have a history of diarrhoea. This report describes the case of a 60-year-old patient who presented with a right iliac fossa (RIF) mass with normal bowel habits and was eventually diagnosed with an amoeboma. In developing countries, a traditional differential diagnosis for an RIF mass is an amoeboma, but its incidence is declining. Hence this treatable condition is often overlooked in the differential diagnosis of an RIF mass. This case report emphasises that amoeboma still exists and should be considered in a patient with an RIF mass.

Typhoid fever with caecal ulcer bleed: managed conservatively.

Typhoid fever is caused by enteroinvasive Gram-negative organism Salmonella typhi. The well-known complications of typhoid fever are intestinal haemorrhage and perforation. In the pre-antibiotic era, these complications were quite common, but in the current antibiotic era the incidence of these complications is on the decline. We report a case of a patient with typhoid fever who developed haematochezia during the hospital stay and was found to have caecal ulcer with an adherent clot on colonoscopy. He was managed successfully with conservative measures without endotherapy and there was no rebleed.

Spontaneous fistulisation of infected walled-off necrosis (WON) into the duodenum in a patient following acute necrotising pancreatitis.

Infected walled-off necrosis (WON), previously referred to by various terminologies including pancreatic abscess, is one of the well-known local complications of acute necrotising pancreatitis. Very rarely they can spontaneously rupture or fistulise into adjacent structures, leading to either further complications or resolution. More often these events lead to complications rather than resolution of the condition. We report a case of an infected WON following an episode of acute necrotising pancreatitis with spontaneous fistulisation into the duodenum resulting in a complete resolution of the symptoms.