An Unusual Presentation of a Rare Disease: Eosinophilic Fasciitis.

Eosinophilic fasciitis is an uncommon disorder presenting with diffuse fasciitis and peripheral eosinophilia. Due to the rarity of this disorder and limited literature, its diagnosis and treatment are often delayed. We present the case of a young male wherein the diagnosis of eosinophilic fasciitis was initially delayed due to an atypical presentation. However, after the diagnosis was confirmed, the patient was successfully managed with oral corticosteroids. A well-written informed consent was obtained from the patient prior to the preparation of this manuscript. An 18-year-old right-hand dominant male presented with a sudden onset, progressive, non-traumatic, left forearm swelling associated with a weak hand grip. The swelling was tender on examination with a local rise in temperature. Radiographs taken at the time of presentation revealed no osseous pathology. As the initial blood investigations were suggestive of a localized inflammatory pathology involving the forearm, the patient was managed with non-steroidal anti-inflammatory drugs and analgesics. He returned 6 months later with a recurrence of the symptoms. A magnetic resonance imaging scan of the left forearm was performed to further investigate the pathology and it was suggestive of a diffuse plaque-like thickening involving the myofascial layer of the muscles. Blood investigations showed peripheral eosinophilia, raised immunoglobulin G count, and raised inflammatory markers. A full-thickness forearm biopsy showed the presence of lymphocytic infiltration. A diagnosis of eosinophilic fasciitis was suspected and the patient was managed with oral corticosteroids, given as a tapering dose. Following this, the patient had symptomatic improvement with the resolution of the deranged blood parameters. He was asymptomatic at the latest follow-up of 4 years.

An Analysis of the Structures at Risk from Percutaneous Pinning of Distal Radius Fractures and a Comparison of Two Pinning Techniques: A Cadaveric Study.

Background: A stab incision and blunt dissection prior to wire placement are believed to decrease the risk of injury to underlying structures during percutaneous pinning of distal radius fractures (DRF). However, only a few studies have compared stab incision and blunt dissection to direct wire placement. The aim of this cadaveric study is to analyse the structures at risk during percutaneous pinning of DRF and compare the two methods of wire placement. Methods: A total of 10 cadavers (20 upper limbs) were divided into two groups of five each. Five 2.0 mm Kirschner (K)-wires were inserted into the distal radius under fluoroscopic control in a standard fashion to simulate percutaneous pinning of DRF. In group 1, the K-wires were inserted directly, whereas in group 2, the wires were inserted after making a stab incision and blunt dissection to reach the bone. Each cadaveric limb was then dissected carefully to measure the distance of the K-wires from the branches of the superficial radial nerve (SRN), the cephalic vein and the first dorsal compartment and to determine the structures injured (pierced or in close contact) by the K-wires. Results: Out of the 100 K-wires placed, 18 wires were in close contact or pierced an underlying structure. These included 11 wires injuring tendons, six wires injuring branches of the SRN and one wire injuring the cephalic vein. Direct wire placement (group 1) resulted in injury to eight structures (44.4%) while stab incision and blunt dissection prior to wire placement (group 2) resulted in injury to 10 structures (55.5%). This difference was not statistically significant. Conclusions: Percutaneous pinning of DRF is associated with a high risk of injury to the extensor tendons and branches of the SRN. This risk is not reduced by making a stab incision and blunt dissection prior to K-wire placement.

Rare Case of a Solitary Bone Plasmacytoma of the Proximal Femur Managed with Surgery and Adjuvant Chemotherapy: A Case Report.

INTRODUCTION: Solitary plasmacytoma of the bone is a rare neoplasm characterized by proliferation of neoplastic plasma cells in the bone in the absence of systemic involvement. We present a managed case of a 64-year-old male with solitary bone plasmacytoma of the right proximal femur, who presented as a pathological subtrochanteric femur fracture. CASE REPORT: A 64-year-old male presented to our outpatient department with pain in the right hip and restricted range of motion following a trivial trauma. The radiographs showed an osteolytic lesion in the right proximal femur with a right subtrochanteric femur fracture. A magnetic resonance imaging scan revealed a well-defined lesion in the right proximal femur. A 18F-fluorodeoxyglucose positron emission tomography did not show a lesion at any other site suggesting that the lesion was solitary. A serum protein electrophoresis study was normal and the urine was negative for myeloma protein. The patient had a score of 12 as per Mirel's criteria and hence required operative intervention and fixation. The patient was managed with a thorough mechanical and chemical curettage of the lesion followed by fixation with a proximal femur locking plate and augmentation with fibula and iliac crest bone graft. He was then given a chemotherapy regimen consisting of nine cycles of bortezomib, lenalidomide, and dexamethasone. CONCLUSION: Solitary bone plasmacytoma is a rare neoplasm of the bone. Early diagnosis and intervention are required to manage it and prevent its progression to multiple myeloma, which is a more aggressive entity and lies at the other end of the spectrum of plasma cell dyscrasias. Management of this lesion requires an active participation of the hematologist and a holistic approach which includes radiotherapy or surgery with possible adjuvant chemotherapy.

A Rare Case of Psoas Abscess Secondary to Mucinous Adenocarcinoma of the Appendix: A Case Report.

INTRODUCTION: Iliacus and psoas muscles are located in an extraperitoneal location forming the iliopsoas compartment. Iliopsoas abscess is a myositis involving this compartment. Pseudomyxoma peritonei is characterized by an abundant extracellular collection of mucin in the peritoneal cavity. When this collection is retroperitoneal, it is termed as pseudomyxoma extraperitonei. We present to you the case of a 52-year-old female with psoas abscess secondary to mucinous adenocarcinoma of the appendix, which was later diagnosed as pseudomyxoma extraperitonei. CASE PRESENTATION: A 52-year-old female presented with pain in the right flank with discharging sinuses since one year. She had previously undergone two surgeries in the past 1 year for drainage of the abscess and had taken first line anti-tubercular treatment for around 6 months. She was managed in our institute by an open drainage of the abscess. The culture reports showed an infection with E. coli. The histopathology sections showed abundant pools of extracellular mucin with strips of columnar epithelium which indicated the pathology to be a mucinous adenocarcinoma. A contrast-enhanced computed tomography scan of the abdomen and pelvis showed a ruptured appendix mucocele and a collection in the right psoas muscle showing fistulous communication with the cecum and extending to the suture site in the right flank. Anti-tubercular treatment was stopped and an oncology opinion was taken. The patient was managed with a palliative ileostomy. CONCLUSION: It is important to keep in mind diagnostic possibilities other than tuberculosis of the spine when managing a patient with an iliopsoas abscess. These include pathologies of the gastrointestinal and genitourinary tract, which need to be diagnosed and managed early.