IJCR (2018), Volume 2

  • Primary lymphoma of bone, myeloma mimicker: a case report and review of literature

    Primary lymphoma of the bone (PLB) primarily arising from the medullary cavity is an extremely rare entity, with only limited number of studies and sporadic cases reported in the literature. The current study presents one case of PLB presented with unique presentation and treated with chemotherapy only. A 66 year old male presented with severe pain in the left hip that persisted for two months. Initial laboratory work up showed anemia, hypercalcemia and increase in free light chains kappa to lambda ratio, a diagnosis of multiple myeloma was suspected, magnetic reso¬nance imaging of the vertebral spine extensive involvement of bone marrow of the vertebrae. An 18F fluorodeoxyglucose positron emission tomography computed tomography (FDG PET CT) scan showed widely scattered moderate to intense uptake in multiple lytic of skeleton, Impression was : Image compatible with extensive multiple myeloma, No extra osseous involvement was found. Bone marrow examination was performed confirmed a diagnosis of extensive bone marrow involvement by High grade B-cell neoplasm with areas of bone marrow necrosis. The patient received six cycles of R-CHOP regimen (Rituximab, cyclo-phosphamide, Anthracycline, vincristine and prednisone) and achieved a complete response, as confirmed by FDG PET CT. At present, the patient is in a good condi¬tion.so this patient presentation mimicking multiple myeloma, which represent diagnostic dilemma. Primary lymphoma of the bone is rare disease entity, there is no strong evidence supporting some diagnostic and therapeutic decisions, and therefore, case presentation of the rare disease may facilitate treatment of similar diseases. A review of the literature to elucidate the clinical, radiological, pathological phenotype and optimal treatment of PLB done.

  • Multiple peripherally “ring” enhancing lesions of the brain in a young man: A diagnostic dilemma

    Primary central nervous system (CNS) lymphomas are tumours localised only in the brain, spinal cord, and rarely, the eyes (i.e. involving only the CNS). These can be detected by imaging modalities, namely computed tomography (CT) and magnetic resonance imaging (MRI), in which they appear as lesions, most often with surrounding enhancement (i.e. peripherally-enhancing or ring-enhancing lesions). However, similar lesions can be seen in a variety of other conditions and differentiating these diagnoses by imaging alone is difficult. We report a case of primary CNS lymphoma in a 21-year old gentleman who was misdiagnosed as and treated for neurocysticercosis and brain tuberculomas due to misleading investigation results, in addition to the relative unlikelihood of CNS lymphoma in this patient compared to other similar individuals. Fortunately, appropriate management was initiated as soon as CNS lymphoma was confirmed by biopsy of the brain lesion, with good treatment response.

  • Morel-Lavallee Lesions: A Non-Operative Case Series

    In the late 1800’s, Morel-Lavallèe described a pattern of injury to the proximal thigh involving a fluid collection associated with a de-gloving type of injury. These injuries typically result from blunt trauma and falls. There is existing literature that suggests surgical management as primary treatment, although no rigorous controlled trials are found in English language medical literature. Non-surgical aspiration with sclerodesis is an option, however individual case reports suggest that using multiple aspirations without sclerodesis could be effective. This series illustrates that nonsurgical management (i.e. aspiration without sclerodesis) is a viable option for these injuries.

  • Panniculitis in Cutaneous Leishmaniasis: a Study in Sri Lanka

    Introduction: Panniculitis is the inflammation of subcutaneous adipose tissue which is caused by many infectious and inflammatory conditions. It is high time to document panniculitis in the skin lesions with cutaneous leishmaniasis (CL) in Sri Lanka. Objectives: This study was performed to assess demographic data and to describe panniculitis in patients with CL. Methods: A descriptive cross-sectional study was done from 2013 to March 2018 at Teaching Hospital Kandy, Sri Lanka. The skin biopsies clinically suspected as CL evaluated histologically for diagnostic or indicative evidence of CL, and patients responded completely to the specific anti-leishmaniasis treatment were taken as the study population. Skin biopsies of 123 patients were assessed in view of dermal granulomata, Leishman-Donovan bodies and panniculitis. Results: The majority of patients were in the age group of 36 to 50 years (N= 36:29.3%: mean=41.64 years: SD18.15 years) and there was a slight female predominance in the study (N=65:52.8%). A majority of skin biopsies revealed Granulomata (N=95: 77.2%). Leishmania Donovan bodies were identified among 43.1% of the lesions (N=53). Though there were 123 patients, only 66 (53.6%) skin biopsies were deeper enough to reveal subcutaneous tissue. A significant amount of skin lesions showed subcutaneous tissue inflammation (N=59:89.39%), predominantly non-granulomatous in morphology (N=44:74.6%). Conclusion: Subcutaneous tissue inflammatory infiltrates in the non-granulomatous morphology is an important feature of the skin biopsies of CL especially in the granulomatous variant of the CL, which can be achieved by a deeper elliptical biopsy.

  • Sweet syndrome associated with differentiation syndrome in a patient with acute promyelocytic leukemia – a case report and review of literature

    Sweet Syndrome (SS) (acute febrile neutrophilic dermatosis) is an inflammatory disorder characterized by the appearance of painful, edematous, and erythematous papules, plaques, or nodules on the skin. It might also cause fever and internal organs’ involvement. There are three clinical settings in which SS has been described: classical or idiopathic, malignancy-associ¬ated and drug-induced. (1) SS is described in patients with acute promyelocytic leukemia (APL), and is a rare side effect of all-trans retinoic acid (ATRA), which causes differentiation of promyelocytes and used in therapy of APL. ATRA may also cause Differentiation Syndrome (DS), previously called retinoic acid syndrome, and there is overlap with SS. (2) There is a limited number of case reports describing SS in association with DS. We present here a case of SS associated with DS in a patient with APL treated with ATRA.

  • Goblet Cell Carcinoid (GCC) of the Appendix presenting as a Small Bowel Obstruction: Case Report and Literature Review

    Goblet Cell Carcinoid (GCC) is a rare, low grade malignancy, and GCC presenting as a small bowel obstruction (SBO) is incredibly rare. Hereby, we presenting a 68-year-old male presented to our Emergency Department with a one-day history of right sided abdominal pain, distention and vomiting, he had no previous abdominal surgery and had no significant other medical problem. Abdominal Computed Tomography (CT) demonstrated a high grade, closed loop small bowel obstruction involving the terminal segment of the ileum, and a low-density appendiceal nodule. He had laparoscopy converted to open caecectomy, the histology, confirmed the diagnosis of Goblet Cell Carcinoid of the appendix, eventually he had right hemicolectomy, progressed well, and made a good post-operative recovery, discharged home. As presentation of GCC of the appendix with sbo is a very rare incidence, we discussed this through a case report with its immunohistochemical, behavioral features, presentation and treatment options.

  • T Prolymphocytic Leukemia, a rare disease, case presentation with typical pathological findings and review of management

    Background: Prolymphocytic leukemia (PLL) is a rare disease, accounting for < 2% of lymphoid leukemias [1].There are 2 quite different entities with distinct pathologic features and different therapeutic strategies, T-cell and B-cell [2]. T-PLL is more common [3]. Although termed ‘prolymphocytic,’ T-PLL is characterized by the proliferation of post-thymic T-lymphocytes. It is estimated that physicians will see a case of T-PLL every five to ten years [4]. Over the last 15 years, 3 cases of T-PLL were diagnosed in our center. We present here the latest case, with typical pathological findings. Case Report: A 63-year-old British gentleman, previously healthy with good performance, presented with fatigue for 6 – 8 weeks with puffiness of face and eyelids and weight loss of 5 kilograms. Physical exam showed periorbital edema and conjunctival injection (Figure 1), cervical lymphadenopathy, and hepatosplenomegaly. Initial complete blood count (CBC): white blood cells (WBCs) 331.9 x109/L (4.0 – 10.0), with 94% lymphocytes, hemoglobin (Hb) 119 gm/L (130 – 170), platelets (Plts) 128 x109/L (150 – 400). Lactate dehydrogenase 10.4 µkat/L (2.1 – 3.7), uric acid 537 µmol/L (210 – 420). Abdomen ultrasound showed markedly enlarged spleen (20.3 cm). The peripheral blood smear showed profound leukocytosis with 94% abnormal lymphoid cells. The cells were small to medium in size with high nucleo-cytoplasmic ratio, moderately condensed chromatin and almost all with prominent nucleolus. Substantial number of the cells show irregular nuclear contour with short indentation. The cytoplasm was basophilic agranular and many cells show irregular cytoplasmic protrusions (Figure 2). Flow cytometry on peripheral blood revealed one homogenous abnormal population positive for cluster of differentiation 45 (CD45) and express the pan T-cell markers (CD3, CD2, CD5 and CD7). All were positive for CD4, T-cell receptor (TCR) alpha/beta, CD43 and BCl2 with partial expression of CD38. These cells were negative for CD56, CD57,...

  • Use of Benzodiazepines and Hypnotic Medications in Psychiatry Older Adult Outpatients

    Benzodiazepines have anxiolytic, hypnotic, anticonvulsant, and muscle-relaxing properties, therefore, a widely prescribed treatment for anxiety and insomnia. They bind to gamma-aminobutyric acid type A (GABAA) receptors, which are responsible for most of the inhibitory neurotransmission in the central nervous system and these receptors are a major target of alcohol, barbiturates, muscle relaxants, and other medications with sedative effects, resulting in tolerance and dependence [1]. Benzodiazepines are categorized into short (15 to 30 minutes), intermediate (30 to 60 minutes), and long-acting agents (one hour or longer). Benzodiazepines are frequently prescribed for elderly patients living in the community and for those in hospitals and institutions. Prolonged use of benzodiazepines is particularly likely in old age for the treatment not only of insomnia and anxiety, but also of a wide range of nonspecific symptoms. Long term users are likely to have multiple concomitant physical and psychological health problems [2]. Benzodiazepines produce dependence, reduce attention, memory, and motor ability. They can cause disinhibition or aggressive behavior, facilitate the appearance of delirium, and increase accident and mortality rates in people older than 60 [3]. According to Maudsley guidelines, benzodiazepines use in elderly are poorly supported for their link to cognitive decline, increase risk of falls and hip fractures [4]. And, if indicated, short acting agents should be avoided. Long acting agents should be started in low doses and patients need to be followed and reassessed regularly. Zolpidem or melatonin are indicated for insomnia, clonazepam and diazepam for agitation and pregabalin for generalized anxiety disorder [5].

  • A Rare Reason of Ileus: Atypical Hemolytic Uremic Syndrome

    Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy that is characterized by intravascular hemolytic anemia, thrombocytopenia and acute renal failure. Typical form occurred with the shiga-like toxin produced by Escherichia coli bacterium or Shigella dysenteriae bacterium while atypical HUS is sporadic or familial form of the disease which develops due to uncontrolled activation in alternative complement pathway. It may present with recurrent attacks and it has a potential of poor prognosis. In this case report we presented a 36-year-old woman in her 22nd week pregnancy without any history of chronic disease or medication whom admitted to hospital with abdominal pain, bloody diarrhea, oliguria and diagnosed with atypical HUS. She was diagnosed with ileus at the first month of Eculizumab treatment and a polyploid lesion obstructing the lumen of the colon was detected. Pathologic examination of the mass revealed a chronic active inflammatory lesion.

  • Cardiovascular Disease Associated with the Chronic Use of Ergotamine: A Case Report

    Ergotamine and its derivatives were used for multiple diseases; in the nineties, its use in association with caffeine was considered a standard treatment for migraines, although it has been in decline, due to the evidenced toxic effects related to its chronic use including vascular, cardiovascular and central nervous system manifestations. In this article is reported a case of a 59-year-old female with chronic use of caffeine plus ergotamine for more than 20 years; afterwards she develops peripheral artery disease, severe mitral and tricuspid valve regurgitation with requirement of valve replacement. In the absence of past cardiovascular history and rheumatic fever, its clinical evolution and pathology results are associated with ergotism.