Urine retention as presenting manifestation of tuberculous meningitis complicated by lacunar infarction and transverse myelitis: Case report and literature review.

Early diagnosis and management of tuberculous meningitis will prevent lethal and fatal neurological complications such as acute infarction and permanent disability.

Groove Pancreatitis Associated with Transient Liver Injury Mimicking Ampullary Neoplasm.

Groove pancreatitis is an unusual form of pancreatitis characterized by fibrous inflammation and pseudo-tumor in the area around the head of the pancreas. The underlying etiology is unknown but is strongly linked to alcohol abuse. We report a 52-year-old male smoker with hypertension, asthma, and alcohol abuse who was admitted with severe epigastric pain radiating to the back. He was found to have acute pancreatitis. A computed tomography scan of the abdomen showed a mass lesion in the peri-ampullary region. MRI of the abdomen revealed dilated common bile duct and duodenal mass and features suggestive of groove pancreatitis. During the hospital stay, bilirubin and liver enzymes started to rise and then decreased gradually to the previous normal range. The secondary workup for liver disease was unremarkable. The patient improved and was discharged. Six-month follow-up showed regression of the duodenal lesion and reduction in the common bile duct dilatation. Excluding malignancy remains the main challenge in managing groove pancreatitis, and a conservative approach is more reasonable in cases with a typical profile.

Tuberculoid Leprosy with External Jugular Vein Thrombosis: A Case Report and Literature Review.

Thrombotic disease represents a rare manifestation of leprosy. In this study, we report the case of an external jugular vein thrombosis associated with tuberculoid leprosy in a 23-year-old male patient. The patient presented with a 3-month history of painful cord-like swelling on the left side of the neck and a nearly 3-week history of skin lesions on the left cheek and right leg. Physical examination revealed cord-like, tender swelling on the left lateral aspect of the neck overlying the sternocleidomastoid muscle, and a hypopigmented, hypoaesthetic 6×7 cm lesion with an irregular margin on the left cheek. A Doppler ultrasound examination of the jugular vein showed thrombosis of the left external jugular vein. Three-dimensional reconstruction of the computed tomography scan showed the enlarged and enhanced left external jugular vein, as well as 1 of its tributaries, and the thickened skin patch. A skin punch biopsy from the left cheek lesion revealed granulomatous inflammation with occasional peri-adnexal granulomas, consistent with the clinical impression of tuberculoid leprosy. A diagnosis of leprosy with external jugular vein thrombosis was established. Anticoagulation therapy was initiated, and the patient was referred to an infectious disease clinic for treatment with anti-leprosy medications. LEARNING POINTS: Thickened cord-like neck swelling in leprosy can be vein thrombosis rather than a thickened nerve.Leprosy should be considered if a skin lesion is associated with thrombosis.The common causes of upper extremity DVT.

Diffuse Hepatic Accumulation of 99mTc-Macroaggregated Albumin Suggesting Synchronous Superior and Inferior Vena Cava Obstruction.

We report a rare case of incidental diffuse hot liver on 99mTc-macroaggregated albumin lung perfusion scanning done to exclude pulmonary embolism. This scintigraphic finding suggested synchronous obstruction of the superior and inferior venae cavae, later confirmed on CT angiography. Although many cases of focal hepatic uptake have been reported, reports of diffuse uptake because of vena cava obstruction are scarce in the literature.

True left-sided gallbladder: A case report and comparison with the literature for the different techniques of laparoscopic cholecystectomy for such anomalies.

INTRODUCTION: True left-sided gallbladder (LSG) is a rare finding that may present with symptoms similar to those of a normally positioned gallbladder. Moreover, it may be missed by preoperative imaging studies such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), or endoscopic ultrasound. True left-sided gallbladder is a surgical challenge and surgical technique may need to be modified for the completion of laparoscopic cholecystectomy. PRESENTATION OF CASE: In this case report, we present a case of true left-sided gallbladder that produced right-sided abdominal symptoms. Ultrasound of the abdomen failed to show the left-sided position of the gallbladder. MRI showed the gallbladder located to the left of the ligamentum teres underneath segment III of the liver. Intraoperatively, the gallbladder was grasped and retracted to the right under the falciform ligament and it was removed using classical right-sided ports with no modification to the technique. No complications were encountered intraoperatively or postoperatively. DISCUSSION: True LSG is a rare anomaly that may present with right-sided symptoms like normally positioned gallbladder. It may be missed in preoperative imaging studies and can be discovered only intraoperatively. Modification of laparoscopic ports, change in patient's position and/or surgeon's position, or conversion to open cholecystectomy may be needed for safe removal of the gallbladder. CONCLUSION: Classical technique of laparoscopic cholecystectomy is feasible for left-sided gallbladder. However, if the anatomy is not clear, modifications of the surgical technique may be necessary for the safe dissection of the gallbladder.

Surgical management of complicated intra-mural duodenal hematoma: A case-report and review of literature.

INTRODUCTION: Intramural duodenal hematoma (IDH) is a rare pathological entity that occurs as a complication of trauma, pancreatitis, peptic ulcer disease or endoscopic biopsy procedures. In this report, we present a case of IDH related to a duodenal diverticulum that was complicated by intra-abdominal bleeding and peritonitis. PRESENTATION OF CASE: We report a 31-year old male who presented with pancreatitis that was complicated with IDH, as diagnosed using endoscopy and CT scan of the abdomen. The condition was related to a duodenal diverticulum as appears on imaging. The patient was treated conservatively over a course of 1 week when he started to have intra-abdominal bleeding and developed peritonitis. The patient was successfully treated with laparotomy, drainage of intra-abdominal abscess, evacuation of IDH and repair of duodenal perforation. We discuss this case in the context of the current indications of surgery in cases of IDH. CONCLUSION: Despite shift towards conservative management of IDH cases over last few decades, these cases should be handled carefully as they might develop life-threatening complications.

What is changing in indications and treatment of hepatic hemangiomas. A review.

Hepatic cavernous hemangioma accounts for 73% of all benign liver tumors with a frequency of 0.4-7.3% at autopsy and is the second most common tumor seen in the liver after metastases. Patients affected by hemangioma usually have their tumor diagnosed by ultrasound abdominal examination for a not well defined pain, but pain persist after treatment of the hemangioma. The causes of pain can be various gastrointestinal pathologies including cholelithiasis and peptic ulcer disease.The malignant trasformation is practically inexistent. Different imaging modalities are used to diagnosis liver hemangioma including ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging, and less frequently scintigraphy, positronemission tomography combined with CT (PET/CT) and angiography. Imaging-guided biopsy of hemangioma is usually not resorted to except in extremely atypical cases. The right indications for surgery remain rupture, intratumoral bleeding, Kasabach-Merritt syndrome and organ or vessels compression (gastric outlet obstruction, Budd-Chiari syndrome, etc.) represents the valid indication for surgery and at the same time they are all complications of the tumor itself. The size of the tumor do not represent a valid indication for treatment. Liver hemangiomas, when indication exist, have to be treated firstly by surgery (hepatic resection or enucleation, open, laproscopic or robotic), but in the recent years other therapies like liver transplantation, radiofrequency ablation, radiotherapy, trans-arterial embolization, and chemotherapy have been applied.

Epidural fat interposition between dura mater and spinous process: a new sign for the diagnosis of spondylolysis on MR imaging of the lumbar spine.

The purpose of this study was to assess the diagnostic value of epidural fat interposition between the dura mater and spinous process of L5 as an indirect sign of spondylolysis on mid-sagittal MR imaging of the lumbar spine. Mid-sagittal T1-weighted MR images of the lumbar spine of 85 patients with spondylolysis and 93 patients without pars interarticularis fractures were randomized and evaluated by a masked reader. After a training sample of five cases, the reader was asked to note the presence or absence of epidural fat interposition between the dura mater and spinous process of L5 on the randomized images. The epidural fat interposition between the dura mater and spinous process of L5 was noted in 67 out of the 85 patients with spondylolysis (78.8%) and three of the patients without pars interarticularis fracture (3.2%). The difference was statistically significant ( P<0.01). This sign has a specificity of 96.7%, sensitivity of 78.8%, positive predictive value of 95.7%, negative predictive value of 83.3% and accuracy of 88.2% for diagnosis of spondylolysis. Epidural fat interposition between the dura mater and spinous process may be a helpful sign for the diagnosis of spondylolysis on mid-sagittal MR imaging of the lumbar spine.

Sonographic measurement of calcaneal volume for determination of skeletal age in children.

PURPOSE: The purposes of this study were first to prospectively evaluate the feasibility of using sonographic measurements of volume of the ossified part of the calcaneus to determine skeletal age in healthy children and second, to provide normal ranges of this volume by sex and age up to 6 years. METHODS: Four hundred normal girls and boys ranging in age from 1 day to 6 years were examined sonographically to determine the volume of the calcaneal ossification center. The children were randomly divided into 2 groups. The first group (300 children) was used to determine normal values for the mean calcaneal volume by age and sex. The second group (100 children) was used to validate those normal values. RESULTS: The sonographically determined volume of the calcaneal ossification center correlated well with the chronologic age of the children. The calcaneal ossification centers of boys were larger than those of girls within the same age groups from ages 2 to 10 months, but from 11 months to 6 years old, they were larger in the girls. The differences, however, were not statistically significant. The volume of the calcaneal ossification center increased the most between the first and second years of life, reaching 183% and 140% in girls and boys, respectively. Using the normal values obtained from the first group, we correctly predicted the chronologic age in 91% of children in the validation group. Among the remaining 9%, the error in prediction of chronologic age never exceeded 1 age interval. CONCLUSIONS: The use of sonography provides a quantitative means of measuring calcaneal volume, and its use is feasible for determining skeletal age in children. The normal values we obtained may be used as a baseline for sonographic assessment of skeletal maturation and diagnosis of growth retardation.