RESUMO
We present a rare case of isolated axillary lymph node tuberculosis. A 66-year-old patient was admitted in order to perform the diagnostics of a painless tumor of the left armpit. Blood biochemistry tests and chest X-ray did not show any abnormalities. In the ultrasound examination a solid structure of the dimensions of 1.8×1 cm of irregular outline with adjacent hypoechogenic lymph nodes was visualized. The diagnosis of tuberculosis was based on histopathologic examination of the excised tumor. In the latter years an increase in extrapulmonary type of tuberculosis has been observed. Extrapulmonary tuberculosis may appear in practically each organ, nevertheless it affects pleura most often. Lymph node tuberculosis is the second, when it comes to the prevalence rate, type of extrapulmonary tuberculosis. In the majority of cases of lymph node tuberculosis it affects superficial lymph nodes. In the ultrasound examination a packet of pathological, enlarged and hypoechogenic lymph nodes is stated. In 1/3 of cases the central part of the nodes is hyperechogenic which indicates its caseation necrosis. Lymph nodes have a tendency to be matted and they have blurred outline. We observed this type of lymph node image in the presented patient. This image may be a diagnostic hint. Nevertheless, in the differentiation diagnostics one should take many other disease entities into consideration, inter alia: sarcoidosis, lymphomas, fungal infections, neoplastic metastases; the latter ones have an image most similar to tuberculosis lymph nodes. Tuberculosis ought to be considered in differential diagnosis of atypical masses.
RESUMO
INTRODUCTION: Normal defecation is a combination of several elements of reflex and voluntary functions. The issue of external anal sphincter innervation is of theoretical and clinical significance; however, literature on the subject is still scarce. Most study reports discuss the course of the pudendal nerve with no close insight into inferior rectal nerves supply to the external anal sphincter. We have not found any statistical "mapping" of the site of the nerve branches insertion into the external anal sphincter. Thus, the purpose of the present study was to determine the least and most typical location of nerve branches to the external anal sphincter. One hundred and ten pudendal nerve preparations were analysed. Following the dissection of the pudendal nerve and its branches, a beam compass was used to take linear measurements from the apex of the coccygeal bone to the point of nerve branch insertion to the external anal sphincter. The distance between coccygeal bone apex and the central tendon of the perineum was also measured. For the purpose of comparison, results are presented as relative Bi/A values. Computer programmes devised by the author of this paper within Turbo Pascal were then used to determine the probability of finding nerve branches to the external anal sphincter. RESULTS: Based on the analysis of 110 preparations of the pudendal nerve and its branches, one might conclude that the former was the main although not necessarily the only source of external anal sphincter innervation. While analysing the most and the least probable location of nerve branches to the external anal sphincter, the muscle length was expressed as percentage, i.e., 0% of sphincter length = the apex of the coccygeal bone; 100% of sphincter length = the central tendon of the perineum. The length was then divided into 5% intervals with the probability of finding nerve branches determined by programmes written in Pascal. Within 30-85% of external anal sphincter length, the probability of finding nerve branches to the external anal sphincter is greater than 0.3 with peak probability of 0.68 in the interval between 55 and 65%. DISCUSSION: Sphincter innervation and clinicoanatomical function of anal canal closure apparatus has been discussed with reference to external anal sphincter injury. Transcutaneous electrostimulation of the pudendal nerve and the use of anal canal electrodes have also been mentioned. CONCLUSIONS: The most probable location of nerve branches to the external anal sphincter is half way of its length, i.e., at hour 3 or 9 of the knee-elbow position or lithotomy position. The external anal sphincter can also be directly supplied by nerve branches originating from the sacral nerve root S4; the branches then go towards the posterior part of the sphincter.