Spontaneous Haemoperitoneum in Pregnancy with Placenta Percreta in Bicornuate Uterus with Successful Pregnancy Outcome: A case study.

Intraperitoneal haemorrhage during pregnancy or postpartum without any history of trauma (spontaneous haemoperitoneum in pregnancy [SHiP]) is a rare condition, causing significant morbidity and mortality for the mother and the neonate. We report a 27-year-old female patient with SHiP at 31 weeks of gestation who was referred to a tertiary care hospital in Muscat, Oman, in 2019, with right iliac fossa pain, pallor and tachycardia. Radiological investigations revealed intraperitoneal bleeding and a right adnexal haematoma. She was managed conservatively with blood transfusion and supportive care. At 36 weeks of gestation, lower segment caesarean section was done and a live baby with good Apgar score was delivered. Pre-operatively, she was found to have a bicornuate uterus, placenta percreta at the junction of the horns and a right adnexal haematoma. This case highlights the significance of thorough evaluation of acute abdominal pain in pregnancy in avoiding unnecessary surgical intervention and iatrogenic prematurity.

COVID-2019 Pneumonia: Severity and distribution of lung changes observed on the initial chest X-ray as an indicator of final outcomes.

Objectives: This study aimed to assess the correlation between the severity of the initial chest x-ray (CXR) abnormalities in patients with a confirmed diagnosis of COVID-19 and the final outcomes. Methods: This retrospective study was conducted at the Royal Hospital, Oman between mid-March and May 2020 and included patients who had been admitted with a confirmed diagnosis of COVID-19 and had a final outcome. Serial CXRs were identified and examined for presence, extent, distribution and progression pattern of radiological abnormalities. Each lung field was divided into three zones on each CXR and a score was allocated for each zone (0 is normal and 1-4 is mild-severe). The scores for all six zones per CXR examination were summed to provide a cumulative chest radiographic score (range: 0-24). Results: A total of 64 patients were included; the majority were male (89.1%) and the mean age was 50.22 ± 14.86 years. The initial CXR was abnormal in 60 patients (93.8%). The most common finding was ground glass opacity (n = 58, 96.7%) followed by consolidation (n = 50, 83.3%). Most patients had bilateral (n = 51, 85.0%), multifocal (n = 57, 95.0%) and mixed central and peripheral (n = 36, 60.0%) lung abnormalities. The median score of initial CXR for deceased patients was significantly higher than recovered patients (17 versus 11; P = 0.009). Five CXR evolution patterns were identified: type I (initial radiograph deteriorates then improves), type II (fluctuate), type III (static), type IV (progressive deterioration) and type V (progressive improvement). Conclusion: A higher baseline CXR score is associated with higher mortality rate and poor prognosis in those with COVID-19 pneumonia.

COVID-19 Associated Pneumonia: A review of chest radiograph and computed tomography findings.

Medical imaging, including chest radiography and computed tomography, plays a major role in the diagnosis and follow-up of patients with COVID-19 associated pneumonia. This review aims to summarise current information on this topic based on the existing literature. A search of the Google Scholar (Google LLC, Mountain View, California, USA) and MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA) databases was conducted for articles published until April 2020. A total of 30 articles involving 4,002 patients were identified. The most frequently reported imaging findings were bilateral ground glass and consolidative pulmonary opacities with a predominant lower lobe and peripheral subpleural distribution.

Hereditary Paraganglioma in an Omani Family.

Pheochromocytomas are tumors derived from chromaffin cells within the medulla of adrenal glands, whereas paragangliomas are tumors derived from extra-adrenal chromaffin cells of the sympathetic prevertebral and paravertebral ganglia. The growing deployment of genetic testing has shown that approximately 30% of pheochromocytoma and paraganglioma (PPGL) patients carry familial pathogenic germline mutations in known PPGL-susceptibility genes. This prompts genetic screening of their family members and leads to an increase in the detection of asymptomatic PPGLs or non-secreting tumors reported in familial cases discovered after the index patient work-up. Here, we present three case reports of affected members of a single Omani family with a history of paraganglioma and highly variable clinical presentations among the affected members. Eight out of the 16 siblings (50.0%) in the second generation of the reported family pedigree were carriers of the succinate dehydrogenase B:c.574T>C mutation, reflecting the autosomal dominant inheritance risk of paraganglioma and other associated tumors. This report highlights the complexity of managing such families and encourages further discussion regarding the management of asymptomatic PPGL-associated mutation carriers. Genetic screening has enabled the early detection of PPGLs, for which early surgical intervention can significantly impact prognosis and treatment strategies to reduce morbidity and mortality. Although PPGLs are similar tumors, they warrant distinction from each other with respect to their differences in locations, manifestations, secretory functions, genetic syndromes, and propensity to metastasize. While current guidelines are clear concerning symptomatic PPGL cases, the management of asymptomatic mutation carriers requires further elucidation.

Renal Epithelioid Angiomyolipoma: A Case Report and Review of Literature.

Epithelioid angiomyolipoma (EAML) is an uncommon renal neoplasm with malignant potential. It is classified under the group of perivascular epithelioid cell tumors and can be sporadic or as part of the tuberous sclerosis complex. On imaging, unlike classical AML that contains fat, EAML has a very low percentage of fat which can mimic the imaging findings of renal cell carcinoma. We reported a 31-year-old female who had a history of renal failure and bilateral renal masses. Magnetic resonance imaging of the abdomen revealed bilateral large renal masses replacing renal parenchyma with features suggestive of bilateral renal AML. The patient underwent left nephrectomy, and histopathology examination findings were consistent with the diagnosis of EAML.

Pulmonary Alveolar Microlithiasis: A Case Report.

Pulmonary alveolar microlithiasis (PAM) is a rare disease caused by a mutation in the SLC34A2 gene encoding the type IIb sodium phosphate cotransporter in alveolar type II cells. This results in the formation and accumulation of calcium phosphates crystals in the alveoli. Early in the disease, most patients are asymptomatic or might experience mild symptoms. However, in some patients, PAM can progress resulting in pulmonary fibrosis, cor pulmonale, and respiratory failure. We report the case of a 33-year-old Omani male who was referred to our institute with a history of fever and shortness of breath. A chest radiograph revealed bilateral dense consolidation. Chest computed tomography showed bilateral dense interlobular thickening and extensive consolidations with a lower lung predominance. Our findings were highly suggestive of PAM. The diagnosis was confirmed by bronchoalveolar lavage.

Eosinophilic Fasciitis Responds Well to Steroids and Methotrexate.

Eosinophilic fasciitis (EF) is a rare systemic inflammatory disease with an unknown etiology. Making a diagnosis in such a case is always a challenge as it is a rare disease and mimics scleroderma and scleroderma-like syndrome but should be kept in mind as it carries a high mortality. Furthermore, it is a treatable disease. Here, we report a 41-year-old woman who presented to the rheumatology clinic at the Royal Hospital, Muscat, Oman, with a one-month history of bilateral swelling of the forearms along with skin tightness and fingers contraction. Her history and physical examination along with histopathological examination and magnetic resonance imaging findings were consistent with EF. She showed an excellent response to steroids and methotrexate which is not a combination therapy that has been tried or mentioned previously.

Pulmonary Hyalinising Granuloma: A report of two cases.

Pulmonary hyalinising granuloma (PHG) is a rare fibrosclerosing inflammatory lung condition of unknown aetiology. It is characterised by solitary or multiple pulmonary nodules that are usually found incidentally while imaging the chest for other reasons. We report two cases of histologically proven PHG diagnosed at the Royal Hospital, Muscat, Oman. The first case was a 71-year-old male patient who presented in 2010 with a dry cough, weight loss and bilateral pulmonary nodules. The second case was a 58-year-old male patient who presented in 2012 and was found to have incidental bilateral pulmonary nodules on chest X-ray. Both patients were started on prednisolone and on follow-up the PHG nodules remained stable. Although there is no definitive treatment, PHG generally has an excellent prognosis.

Tuberculosis (TB) of the Porta Hepatis Presenting with Obstructive Jaundice Mimicking a Malignant Biliary Tumor: A Case Report and Review of the Literature.

Localized hepatobiliary tuberculosis (TB) is a rare disorder which can present with an obstructive jaundice mimicking other noninfectious causes such as cholangiocarcinoma. Here, we report a case of porta hepatis tuberculosis in 19-year-old female who presented with an obstructive jaundice, and her computed tomography (CT) of the abdomen revealed a hepatic hilar mass with radiological features mimicking a malignant biliary tumor. We also review the literature related to this disorder.

Aggressive Angiomyxoma of the Pelvis and Perineum: A Case Report and Literature Review.

Aggressive angiomyxoma (AA) is a rare mesenchymal tumor that usually occurs in the pelvis and perineum of young females. AA can simulate Bartholin's gland cyst, abscess, lipoma, simple labial cyst, or other pelvic soft tissue tumors. Cross-sectional imaging, particularly magnetic resonance imaging (MRI), plays an essential role in the diagnosis and management of AA. We report a case of AA in a 38-year-old woman with typical MRI features. We also present the findings of a literature review on the radiological features of this disease.

Solid Pseudopapillary Tumor in a Pregnant Woman: Imaging Findings and Literature Review.

A solid pseudopapillary neoplasm is a rare pancreatic tumor accounting for 1-2% of exocrine pancreatic neoplasms. It is usually asymptomatic and discovered incidentally. It is mainly seen in young women between the second and third decades of life. Although it usually has a large size at the time of diagnosis, it is considered to have low malignant potential. Solid pseudopapillary tumors (SPTs) have characteristic magnetic resonance imaging (MRI) features that enable it to be differentiated from other more common pancreatic tumors. Here, we report the case of a 34-year-old pregnant woman who was admitted to The Royal Hospital, Oman, with a large mass in her pancreas, which was incidentally discovered during abdominal ultrasonography. The mass was investigated further with MRI. The MRI revealed a well-defined mass related to the tail and body of the pancreas with solid and cystic components. It had a heterogeneous texture with fluid levels of different signal intensities due to the presence of blood of different ages. The cystic-solid appearance of an encapsulated lesion with characteristic signal intensity on MRI suggested the possibility of a SPT. Postoperative histopathology results confirmed the diagnosis of a SPT. In this case report, we highlight the MRI features of a SPT and discuss how to differentiate it from other cystic pancreatic tumors to increase the awareness of clinicians to this rare pancreatic tumor.

Synchronous bilateral ureteric metastasis from gastric cancer.

Distant metastasis to the ureters is uncommon. Moreover, isolated ureteric metastasis from gastric cancer is extremely rare and only sporadically reported. It indicates an advanced stage and carrier a very poor prognosis. We describe a case of synchronous bilateral ureteric metastasis from stomach adenocarcinoma after gastrectomy and chemoradiation. To our knowledge, it is the first case published in the literature with such presentation.

Aromatase inhibitors--a viable option for recurrent granulosa cell tumour of ovary: overview and case report.

Granulosa cell tumour of the ovary in adults is a rare tumour of low malignant potential affecting middle aged peri or post menopausal patients. These tumours are often diagnosed at an early stage, due to their hormonally active nature. They, however, have unique distinguishing histologic features and behaviour of frequent and late local or systemic relapses. The diagnosis can be challenging with unusual presentations. There is high association of endometrial carcinoma. Surgery is the mainstay of management in early low risk disease, while radiotherapy and systemic platinum based chemotherapy are employed in higher stage with poor prognostic indices. Survival is good in early stage disease. Recurrent, progressive, and treatment refractory disease is not infrequent and poses management challenge. Endocrine manipulation and hormone treatment are employed in few cases with equivocal results, as reported in literature. We present a case of recurrent and treatment refractory GCT in a postmenopausal patient, managed by aromatase inhibitor Anastrozole with reasonable efficacy.

Resolution of extensive leptomeningeal metastasis and clinical spinal cord compression from breast cancer using weekly docetaxel chemotherapy.

Metastatic breast cancer to the leptomeninges is a late event in the disease course and is associated with significant morbidity and a grave prognosis. Treatment typically involves direct intrathecal injection of chemotherapy into the cerebrospinal fluid compartment since systemic chemotherapy penetrates poorly to the central nervous system. Here we report an interesting clinical observation involving a patient presenting with leptomeningeal spread of breast cancer causing extensive spinal cord compression with obliteration of the subarachnoid space, thus precluding the use of direct intrathecal chemotherapy. We administered systemic chemotherapy using weekly docetaxel with complete radiographic resolution of her disease and recovery from clinical spinal cord compression. While this is a single clinical observation, weekly administration of docetaxel in this circumstance may have been associated with improved drug "escape" into the central nervous system and better antitumor effect. Because leptomeningeal disease is typically a late event in metastatic breast cancer, resistance to therapeutic intervention may reflect intrinsically resistant disease in the setting of extensive prior therapy rather than a routine problem with systemic drug delivery to the CNS. Studying patterns of disease relapse in patients who had received adjuvant weekly taxanes may provide insights into this hypothesis.

Puerperal ovarian vein thrombosis presenting as rt loin pain and hydronephrosis: report of 2 cases.

Post-partum ovarian vein thrombosis is an uncommon clinical presentation. 90% of cases present as right loin and right iliac fossa pain, within 10 days of the puerperal period. Two such cases that were referred to the Imaging department as suspected appendicitis/ureteric colic are reported. The findings seen on imaging illustrate the difficulty in the clinical and radiological diagnosis of post-partum ovarian vein thrombosis and highlight the need to include it as a differential diagnosis in cases of post partum acute abdomen. Post-partum ovarian vein thrombosis can be accurately diagnosed by appropriate non-invasive investigations to enable early therapy with anti-coagulants and intravenous antibiotics which are the mainstay of treatment. Surgery can be avoided if diagnosis is made early.

Pediatric Burkitt's lymphoma: CT findings.

PURPOSE: To review and analyze all CT scans of the cases of Burkitt's lymphoma (BL) in children diagnosed in our institution. MATERIALS AND METHODS: A retrospective analysis of 33 children with BL between the years 2003 and 2005 seen in our institution was undertaken. Twenty-nine male and four female patients from age 3 to 16 years (with a mean age 5.9 years) were reviewed. RESULTS: The gastrointestinal tract was involved in 19 patients (57.5%), kidneys in 9 (27.2%), peritoneum in 8 (24.2%), liver in 4 (12.1%), spleen in 3 (9%), adrenals in 3 (9%), and pancreas in 1 patient (3%). Extra-nodal head and neck involvement was seen in eight patients (24.2%). Bone involvement in four (12.1%), lung in three (9%), heart in two (6%), skin in two (6%), and testis in one (3%) of these patients. Abdominal lymph nodes were enlarged in 21 children (63.6%), while cervical lymph nodes were enlarged in 8 (24.2%). CONCLUSION: CT proved to be an invaluable tool in the characterization of the disease processes in these children. In addition, it provided us with useful information about the anatomical distribution, patterns of involvement, as well as complications of BL.