Medical thoracoscopy with cryobiopsy as diagnostic tool for pleural metastatic in cutaneous squamous cell carcinoma: a rare case report.

Introduction: Distance metastasis of cutaneous squamous cell carcinoma (cSCC) to pleural is rarely reported, and meets difficulties in diagnosing due to quality of pleural biopsy sample. This case presented a novel technique by using cryobiopsy to obtain adequate sample and was first conducted in our hospital. Case presentation: A 62-years-old man admitted to hospital with dyspnoea due to massive right pleural effusion. Lung multi-sliced computed tomography showed right lung pleural effusion with compression atelectasis as well as collapse of medial lobe and upper lobe, multiple solitary nodules on mediastinal, costal antero-posterior and right diaphragm pleural part. Medical thoracoscopy was performed to obtain pleural samples by using cryobiopsy and forceps biopsy. Pathological analysis with Immunohistochemistry (IHC) revealed metastatic squamous cell carcinoma. Discussion: Recurrence rate of cSCC remains high even after treatment, with worse prognosis. Distant metastasis to pleural is rarely reported. Clinical approach for malignant pleural effusion by using medical thoracoscopy has 80% sensitivity with minimal complication. Pleural cryobiopsy is a novel technique used for obtaining sample from pleural biopsy with significant larger size of the specimen, less crush artefacts, fragmented and better tissue integrity, although the diagnostic yield and bleeding severity between cryobiopsy and conventional forceps biopsy are not significant. Conclusion: Medical thoracoscopy with cryobiopsy should be considered as a preferrable diagnostic tool for obtaining better sample specimen, especially for pleural metastatic.

Acute acalculous cholecystitis in a pediatric dengue hemorrhagic fever patient: A case report, lesson learned from limited resource setting.

Introduction: Dengue fever (DF) is endemic in numerous regions of Indonesia with primary clinical features such as high fever as well as pullout of intravascular fluid and albumin leakage, which provokes pleural effusion, hypoproteinemia, and blood hemoconcentration. However, the incidence of abdominal pain as a clinical manifestation of DF, which refers to acalculous cholecystitis, is rare. Case presentation: An 11-year-old female was admitted to the to hospital with fever, headache, and myalgia. Blood examination resulted in low platelet coua nt and positive IgM Dengue antibody test. On the third day, the patient felt sharp abdominal pain. Abdominal ultrasound showed cholecystitis, cholestasis, pleural effusion, ascites, and laboratory finding showed increased C-reactive protein. The management was conservative and discharged at the 7th day. Discussion: The acalculous cholecystitis in Dengue Fever/Dengue Hemorrhagic fever (DF/DHF) is challenging in diagnose due to atypical presentations. Several proposed mechanisms are critical illness, including direct invasion of the gallbladder epithelial cells, vasculitis, stasis of biliary flow, obstruction of the biliary tree, ischemia, and sequestration. The actual mechanism of the dengue virus has been proposed that direct viral incursion of the gallbladder may yield edema and exudation. Abdominal ultrasonography is considered to diagnose acute acalculous cholecystitis (AAC) in children. Conclusion: Understanding pathophysiology of the acalculous cholecystitis in DF/DHF patients and atypical presentation of sharp abdominal pain help physicians for early diagnosis and management both in monitoring and patient care management. Abdominal ultrasonography can help physicians to diagnose AAC.

Invisible incarcerated umbilical hernia: A case report.

INTRODUCTION: Umbilical hernia usually manifests as a bulging of umbilicus. Invisible incarcerated umbilical hernia has never been reported. CASE PRESENTATION: A 53-years-old obese woman admitted to hospital with abdominal pain and vomitus one day after discharged from other hospital, was managed conservatively as an adhesion small bowel obstruction (ASBO) for seven days. There was history of caesarean section 20 years ago. Abdomen was bloated, there was transverse scar wound in hypogastric region and no signs of external abdominal hernia. Plain abdominal x-ray showed dilated small bowel located in the central part of the abdomen. Abdominal CT scan was done to determine the other cause besides adhesion, it showed incarcerated umbilical hernia and gallbladder stone. Herniorrhaphy and laparoscopic cholecystectomy were performed. During surgery, there was a loop of vital small bowel, trapped in the umbilical defect. Mayo method was performed to close the defect. DISCUSSION: The other causes of small bowel obstruction should be determined besides adhesion, infectious disease and trauma. Umbilical hernia should be considered in obese women even without bulging in the umbilicus. Abdominal CT scan with oral water-soluble contrast is preferred as diagnostic tool to identify the cause of small bowel obstruction. CONCLUSION: Invisible incarcerated umbilical hernia is possible in obese patients. Routine palpation on potential sites of developing hernia and abdominal CT Scan are necessary to be done in obese patients with small bowel obstruction.

Giant duodenal diverticulum with mucinous carcinoma of distal bile duct, mimmicking Lemmel syndrome: A rare case report.

INTRODUCTION: Giant duodenal diverticulum is a very rare case. There are only few cases reported. We reported a case of giant duodenal diverticulum with biliary obstruction caused by mucinous carcinoma of distal common bile duct (CBD), that mimicking Lemmel syndrome. CASE PRESENTATION: A 68-years-old man admitted to hospital with recurrent epigastric pain, jaundice and fever. Magnetic resonance cholangiopancreatography showed dilated intrahepatic and extrahepatic biliary tree, dilated gallbladder and cystic mass in pancreatic head that pushed the pancreatic duct ventrally. Emergency laparotomy was performed. Distended edematous gallbladder with necrotic spot, dilated of CBD and compressible bulging of the pancreatic head were found. Duodenotomy in 2nd-3rd part was made and found a giant duodenal diverticulum filled with food and mucus. Tight adhesion to the ampula of Vater, common bile duct, and pancreas due to fibrosis, met difficulties in dissection with a lot of bleeding, hence the diverticulum was not removed. Gastrojejunostomy, cholecystectomy and choledocho-duodenostomy were also done. Pathologic examination of CBD mucus was accordance with mucinous carcinoma. DISCUSSION: Periampullary duodenal diverticulum can cause obstructive jaundice, known as Lemmel syndrome. This case was different as the giant duodenal diverticulum located in the 3rd part filled with food and mucin that compressed both distal CBD and pancreatic duct. The cause of obstructive jaundice could be fibrotic tissue in distal CBD and mucinous carcinoma. CONCLUSION: Giant duodenal diverticulum with bile obstruction is very rare and challenging in diagnosis and treatment. The other cause of obstruction should be considered such as mucinous carcinoma of distal CBD.

Unilateral duplicated collecting system and ureter with severe hydroureteronephrosis and ectopic ureter insertion of upper pole moiety: A case report.

INTRODUCTION: Incidence of duplicated urinary system is 0.7-4% of population, mostly are females and often diagnosed in childhood. Various symptoms meet difficulties to be diagnosed. CASE PRESENTATION: A 20-years-old woman admitted to hospital with fever, fatigue, nausea, loss of appetite, colic epigastric pain and right flank pain since 5 days before admission, normal pattern of urination with dribbling and recurrent urinary tract infection. Abdominal ultrasonography showed complicated cystic tumor upper pole of right kidney. Abdominal computed tomography with contrast showed enlargement right kidney with duplicated collecting system and duplicated ureter obstruction (severe hydroureteronephrosis right upper pole moiety) right kidney and ectopic ureter insertion of upper pole moiety between urethra and anterior vagina, no insertion to bladder, seemed to be dead end. DISCUSSION: Various symptoms of duplicated collecting system are asymptomatic, flank pain, abdominal pain, urinary incontinence, and recurrent UTI, often accompanied by abnormality of upper pole or lower pole or both. Abnormality of upper renal moiety usually has ectopic ureter as in Weigert-Meyer principle. Insertion into infrasphincter usually manifests as urinary dribbling or urinary incontinence or normal urination with few volume leakage or spotting incontinence, whereas suprasphincter usually manifests as recurrent UTI without incontinence. There are imaging modalities for diagnosing these anomalies, including USG and abdominal CT with contrast. CONCLUSION: Understanding embryology, symptoms, imaging modality, and complications are necessary to consider this diagnosis for early detection. Ultrasonography and abdominal CT with contrast can be used to diagnose the urinary tract anomalies, especially duplicated urinary systems with ectopic ureter insertion.

Liver abscess with necrosis in post COVID-19: A case report.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is an acute respiratory tract infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2). Recent evidences mentioned the possibility of COVID-19 as a systemic infectious and inflammatory disease. Signs and symptoms of liver and gastrointestinal system are often found in post-acute COVID-19 patients. However, there are only few data found about liver abscess and necrosis in post COVID-19 patients. CASE PRESENTATION: A 49-year-old man admitted to the hospital with dyspnea, nausea, loss of appetite and epigastric pain, post confirmed SARS CoV-2 severe pneumonia 1 month ago in ICU with noninvasive ventilator (NIV), enoxaparin, tocilizumab, azithromycin, levofloxacin, hydroxychloroquine, and no preexisting liver condition. Swab PCR result was negative. The result of abdominal computed tomography (CT) scan with contrast was liver abscess formation with hemorrhages measuring about 16 × 12 × 11 cm & 10 × 9x9 cm occupying most of the right lobe liver. The patient underwent exploratory laparotomy, there were multiple liver abscesses in segment 8 with parenchymal liver necrosis and abscesses in segment 7 of liver. Necrosectomy and liver abscess drainage was performed. CLINICAL DISCUSSION: Pathophysiology of liver damage in post COVID-19 are direct cytotoxicity of SARS-CoV2, immune-mediated due to severe systemic inflammatory response syndrome (SIRS) in COVID-19, hypoxemia, vascular changes due to coagulopathy, endothelitis or congestion from right heart failure, and drug-induced liver injury (DILI). CONCLUSION: The possible pathophysiology of liver abscess and necrosis in post COVID-19 should be considered in monitoring and management for both COVID-19 patients and post COVID-19 patients.