A challenging high-risk surgery for necrotizing pneumonia in a right bilobed lung.

BACKGROUND: Necrotizing pneumonia is rare in children and is one of the most serious complications of a lung infection caused by antibiotic failure. We present a 12-year-old leukopenic child with a long-lasting lung infection, presenting as having a lung hydatid cyst, but diagnosing with necrotizing pneumonia in the right bilobed lung. Failure to medical treatment and ongoing leukopenia justified surgical intervention with positive results. CASE PRESENTATION: The patient was referred to our teaching hospital's pediatric surgery department. He had previously been diagnosed with intestinal tuberculosis (TB) and received anti-TB treatment. On referral to our hospital, the patient was suffering from restlessness, frequent coughing, fever, vomiting, and diarrhea. Following the completion of the clinical work-up, a blood test revealed leukopenia (white blood cell count of 2100/microliter), a normal platelet count, and a lesion in the right lung. Computerized tomography scanning (CT-Scan) image reported a lung hydatid cyst. In the pediatrics ward, a broad-spectrum antibiotics regimen with triple-antibiotic therapy (linezolid, vancomycin, and metronidazole) was instituted and continued for a week with no response, but worsening of the condition. In the pediatric surgery ward, our decision for surgical intervention was due to the failure of medical treatment because of a pulmonary lesion. Our team performed right lung upper lobe anterior segment wedge resection due to necrotizing pneumonia and followed the patient 45 days post-operation with a reasonable result. CONCLUSION: Living in remote rural areas with low resources and inaccessibility to proper and specialized diagnostic and treatment centers will all contribute to an improper diagnosis and treatment of lung infection. In total, all of these will increase the morbidity and mortality due to lung necrosis in the pediatric population, regardless of their age. In low-resource facilities, high-risk patients can benefit from surgical intervention to control the ongoing infection process.

Adenomatoid tumour of the uterus is frequently associated with iatrogenic immunosuppression.

AIMS: Uterine adenomatoid tumour (AT) is a benign proliferation of cells showing mesothelial differentiation within the myometrium that usually presents as a single nodule. Rare diffuse uterine ATs have been reported, often in patients undergoing immunosuppressive therapy. Herein, we aimed to elucidate the general association between the incidence of uterine AT and iatrogenic immunosuppression by cohort analysis. METHODS AND RESULTS: We analysed 611 consecutive hysterectomy specimens to determine the incidence of AT and its correlation with the immunosuppressive status. Mesothelial lineage, p16 expression, mismatch repair (MMR) protein alterations, and the possible integration of tumorigenic viruses were examined by in situ hybridizasion and immunohistochemistry. ATs were detected in 14 of 611 hysterectomy cases (2.3%). The incidence of AT was significantly higher in the immunosuppressed (IS) group (5/20, 25.0%) than in the non-IS group (9/591, 1.52%), with a relative risk of 16.4. Of the five ATs in the IS group, three were multifocal or diffuse. Latent uterine AT was detected, by in toto sectioning, in one of four immunosuppressed autopsy cases. The tumor cells of ATs commonly expressed calretinin and podoplanin. Characteristic block-type (≥90%) positivity for p16 was observed in most ATs. None of the ATs were positive for human herpes virus type 8, Merkel cell polyomavirus, SV40 large T antigen, Epstein-Barr virus, and human papilloma virus, and the MMR proteins were retained. A TRAF7 mutation was identified from macrodissected tissue in one of 12 ATs by Sanger sequencing. CONCLUSION: Uterine AT is an immunosuppression-associated mesothelial lesion characterised by p16 overexpression.

Claudin-18 overexpression in intestinal-type mucinous borderline tumour of the ovary.

AIMS: Mucinous borderline tumours of the ovary are subclassified as intestinal-type (IMBT) and endocervical-like (EMBT), which differ in their clinicopathological features. In this study, we attempted to elucidate characteristics of the mucinous epithelium in each subtype. METHODS AND RESULTS: The expression of claudin-18, a marker of gastric differentiation, MUCs, CDX2, CK7, CK20, oestrogen receptor (ER), progesterone receptor (PgR), CA-125 and vimentin in IMBTs (n = 54), EMBTs (n = 25) and serous borderline tumours (SBTs) (n = 22) were compared by immunohistochemistry. Claudin-18 positivity was identified in 98% of the IMBTs, whereas only 4% of the EMBTs were claudin-18-positive. Expression of intestinal markers such as CDX2 and MUC2 was relatively infrequent in IMBTs (48% and 33%, respectively). Müllerian-lineage markers such as ER, PgR and vimentin were expressed rarely in IMBTs, while most EMBTs and SBTs were positive for these markers. Hierarchial clustering revealed a close association between EMBTs and SBTs, while IMBTs were clearly separate. CONCLUSIONS: Claudin-18 positivity is a specific phenotype that is characteristic of IMBTs. Frequent and diffuse expression of gastric markers, along with less frequent and usually focal expression of intestinal markers, suggests that IMBTs are essentially composed of gastrointestinal-type mucinous epithelium (gastric-type epithelium with a variable degree of intestinal differentiation).

Childhood mesenteric cyst: A rare intra-abdominal entity with literature review.

INTRODUCTION AND IMPORTANCE: Mesenteric cysts are uncommon intra-abdominal benign masses that appear in childhood with varying degrees of clinical manifestations, ranging from being asymptomatic to presenting as an acute abdomen. The diagnosis is made incidentally during the work-up for other abdominal pathologies such as acute appendicitis, bowel obstruction, etc. The treatment is mostly surgical and varies depending on the clinical type of the lesion. CASE PRESENTATION: A 26-month-old child was referred to our teaching hospital's pediatric surgery department with an abdominal mass. The patient had previously complained of constipation and been treated symptomatically with laxatives. Ultrasonography reported ovarian cysts confirmed by computerized tomography scanning (as a misdiagnosis report of an ovarian cyst instead of a mesenteric cyst), done outside the hospital in a private diagnostic center. CLINICAL DISCUSSION: The patient was prepared for operation and during the surgical procedure, she was found to have a duplex cyst, which was mostly incorporated in the mesentery of the distal 1/3 of the transverse mesocolon. The cyst was enucleated through a lower midline laparotomy incision without bowel resection and anastomosis. The histopathological analysis of the specimen confirmed a mesenteric cyst. CONCLUSION: Mesenteric cysts are rare lesions in children and should be considered when approaching any intra-abdominal mass. Except for the rare cases where intestinal resection and/or partial cyst excision are required, all mesenteric cysts can be excised while preserving intestinal integrity and vascular supply.

Predisposing Factors of Difficult Tracheal Intubation Among Adult Patients in Aliabad Teaching Hospital in Kabul, Afghanistan - A Prospective Observational Study.

BACKGROUND: Airway management may be a considerable challenge for anesthesiologists. Currently used preoperative screening tests are known to lack sufficient specificity and sensitivity. Nevertheless, preoperative screenings and the combination of various tests are highly recommended to reduce the risk of unexpected difficult or failed airway management. PURPOSE: This study aims to determine if socio-demographic characteristics can predict difficult intubation among adult patients scheduled for elective surgeries under general anesthesia in Aliabad Teaching Hospital, Kabul, Afghanistan. METHODS: A total of 341 patients were selected based on consecutive sampling method. Informed consent forms were obtained before inclusion in the study. Data were collected using a data collection form. Age, gender, ASA physical status and ethnicity were recorded for each participant. Airway assessment tests such as mouth opening (MO), thyromental distance (TMD), and Mallampati classes, inability to prognath (AP) and neck mobility and size (NM) category were conducted by research team. Data were initially entered into an Excel data sheet and then exported to SPSS Statistics version 22 for analysis. RESULTS: From 28 October 2018 to 30 January 2019, a total of 341 patients included in the study. Of these, 193 (56.6%) were male and 148 (43.4%) were female. The mean age of the subjects was 36.98 ± 15.048 years. More than half (54.5%) of the study population were Tajiks. Patients from the Hazara ethnicity, female patients, older patients and those suffering from systemic diseases found to be more difficult to intubate. We recognized that, Mallampati classes ≥3, small MO, short TMD, AP, reduced NM were also associated with difficult intubation. Multiple logistic regression analysis of the associated factors determined that increased age more than 40 years, AP and small MO were independent predictors of difficult intubation. CONCLUSION: The study findings show that Hazara ethnicity, female patients, increasing age and systemic disease have significant associations with difficult intubation. Mallampati classes III and IV, MO ≤4 cm, TMD ≤6 cm, and reduced NM had higher risks of difficult intubation. Multiple logistic regression analysis determined that increased age, AP and MO were independent predictors for difficult intubation.

Comprehensive immunohistochemical analysis of the gastrointestinal and Müllerian phenotypes of 139 ovarian mucinous cystadenomas.

Mucinous cystadenoma is one of the most common benign ovarian neoplasms. The immunophenotypes and histogenetic relationships of mucinous cystadenomas with a Müllerian-type epithelium have not been fully explored. We elucidated the direction of differentiation of the mucinous epithelium that constitutes mucinous cystadenomas. Special attention was paid to the existence of gastrointestinal (GI)-type mucinous epithelium, and its association with background Müllerian-type epithelium. Immunohistochemistry was performed in 139 cases of mucinous cystadenoma to evaluate the expression of Claudin-18 (CLDN18), a novel marker of gastric differentiation; CDX2, a marker of intestinal differentiation; and estrogen receptor (ER), a marker of Müllerian differentiation. We found that GI differentiation characterized by CLDN18 and/or CDX2 positivity was observed in mucinous epithelium of most mucinous cystadenomas (129/139 cases, 93%). In a subset of these cases, the tumor was composed of mucinous epithelium exhibiting an intermediate GI and Müllerian phenotype (CLDN18+/CDX2±/ER+). Of note, in 12 cases, a transition from background Müllerian-type epithelium to mucinous epithelium with GI differentiation was identified. A minor subset (6%) of mucinous cystadenomas was considered a pure Müllerian type because the epithelium exhibited a CLDN18-/CDX2-/ER + immunophenotype. In conclusion, mucinous cystadenomas consist of three major subtypes: GI, Müllerian, and intermediate types. Most mucinous cystadenomas are GI-type, and they should be considered a precursor of GI-type mucinous borderline tumors. The existence of intermediate-type mucinous cystadenomas, and areas of transition from Müllerian-type to GI-type epithelium suggest that GI-type mucinous epithelium can arise from Müllerian duct derivatives or surface epithelium exhibiting Müllerian metaplasia in the ovary.