Case Report: Multiple Metastatic Primary Multidrug-Resistant Tubercular Abscesses.

This case report presents an atypical manifestation of tuberculosis in a 21-year-old male who presented with multiple subcutaneous swellings in the bilateral heel, left elbow, and base of the left third finger for the previous 6 months. The patient also experienced loss of appetite and unintentional weight loss. Despite initial suspicion of bacterial abscesses, antibiotics did not lead to significant improvement. Further investigations revealed an elevated erythrocyte sedimentation rate and findings suggestive of osteomyelitis on imaging. Gene Xpert testing confirmed multidrug-resistant Mycobacterium tuberculosis as the causative agent. The patient was prescribed a bedaquiline-based multidrug-resistant tuberculosis regimen, which resulted in reduction in swelling size. This report highlights the challenges in diagnosing and managing complex cases of primary multiple tubercular abscesses, especially with drug-resistant strains, emphasizing the importance of timely diagnosis and multidisciplinary management for successful outcomes.

Comparison of conventional diffusion-weighted imaging, diffusion kurtosis imaging and intravoxel incoherent motion in characterization of sonographically indeterminate adnexal masses.

PURPOSE: To evaluate the role of conventional diffusion weighted imaging, diffusion kurtosis imaging (DKI), and intravoxel incoherent motion (IVIM) in distinguishing benign from malignant adnexal masses. METHODS: 38 patients with 45 adnexal masses were enrolled in this prospective study and assessed with multiparametric MRI, including the IVIM-DKI sequence, on a 3 T MRI system. The mean apparent diffusion coefficient (ADC) from conventional DWI, the apparent diffusion coefficient derived from DKI (Dapp), the apparent kurtosis coefficient (Kapp), true diffusion coefficient (Dt), perfusion fraction (f) and pseudo-diffusion coefficient (Dp) were measured. RESULTS: The mean ADC, Dapp, and Dt were significantly higher in benign adnexal masses than in malignant adnexal masses (p < 0.001). f and Dp were also significantly higher in benign adnexal masses, with p values of 0.026 and 0.002, respectively. Kapp was higher in malignant masses (p < 0.001). Among mean ADC, Dapp, and Dt, mean ADC had the highest area under the curve (AUC) of 0.885. However, no statistically significant differences were observed between the ROCs of various diffusion parameters. CONCLUSION: The mean ADC, Dapp, and Kapp are useful parameters in discriminating between benign and malignant adnexal masses. Dt derived from IVIM also helps in distinguishing benign and malignant adnexal masses; however, no incremental role of IVIM and DKI over ADC could be identified in our study.

Incidence of Barrett's Esophagus Following Sleeve Gastrectomy in Southeast Asian Population.

Background: Variable incidences (up to 18.8%) of Barrett's esophagus (BE) have been reported following sleeve gastrectomy (SG), however, there is no published data from the Southeast Asian population. Objective: To determine the incidence of BE following SG in Southeast Asians. Materials and Methods: In this cross-sectional observational study from a tertiary-care center, all patients who had undergone SG from 2008 to 2021 and completed a minimum of 1-year follow-up were contacted to participate. Preoperative data were retrieved from a prospectively maintained database. On recruitment, all patients underwent barium swallow and upper gastrointestinal endoscopy, and weight parameters and reflux symptoms were recorded. Results: One hundred fourteen patients with no preoperative evidence of BE were included. The mean follow-up duration was 5.4 ± 3.1 years. On follow-up endoscopy, Barrett's was suspected in 4 patients. However, 3 patients had columnar-lined epithelium and only 1 patient (0.87%) had evidence of intestinal metaplasia without dysplasia on histology. Reflux esophagitis (grade LA-A) resolved in 9 out of 11 patients, while the rate of de novo esophagitis was reported in 22.3%. The mean reflux Symptom Severity score increased from 0.6 ± 1.8 to 2.6 ± 5.4 (P = .002). The mean body mass index reduced from 44.1 ± 7.1 to 33.6 ± 6.9 kg/m2 (P < .0001), however, 23.7% of the patients experienced significant weight recidivism. Conclusions: Southeast Asians might have a low incidence of BE following SG. Hence, endoscopic surveillance for the sole purpose of diagnosing BE may not be advisable for these patients.

An unusual association of type II Mayer-Rokitansky-Kuster-Hauser syndrome, turner mosaic syndrome and tubo-ovarian inguinal hernia- case report and review of literature.

BACKGROUND: Herniation of ovaries and Mullerian structures into inguinal canal is usually reported in infants and is rare among adults. We are presenting a rare case of Mullerian agenesis and Turner mosaic syndrome with tubo-ovarian inguinal hernia. CASE PRESENTATION: A 17-year-old girl presented with complaints of primary amenorrhea, phenotypical features of Turner syndrome with left inguinal hernia and severe hypertension. Baseline hormonal analysis was normal. Karyotype revealed Turner mosaic with 46XX (85%); 45XO (15%). MRI showed Mullerian agenesis with normally located right ovary in pelvis and left ovary prolapsed through deep inguinal ring into the canal of Nuck. Anti-hypertensives were started and patient optimized for surgery. Laparoscopic hernia repair and repositioning of left ovary into the pelvis was done. Patient had uneventful post-operative course and was discharged in stable condition on anti-hypertensive medication. Future reproductive issues and need of passive vaginal dilatation or vaginoplasty before marriage were explained to the patient and family. CONCLUSION: This is the first ever reported case with unusual association of atypical MRKH, Turner mosaic syndrome and tubo-ovarian hernia into the inguinal canal. The case emphasizes the need and importance of complete work up of these atypical cases as patients may have more than one cause of primary amenorrhea and complete evaluation is must before any medical or surgical intervention.

Imaging features of accessory cavitated uterine mass (ACUM): a peculiar yet correctable cause of dysmenorrhea.

Accessory cavitated uterine mass (ACUM) is a rare form of developmental mullerian anomaly which causes chronic pelvic pain, dysmenorrhea and infertility in young females. It is a non-communicating, accessory cavity within an otherwise normal uterus, lined by functional endometrium and surrounded by myometrium-like smooth muscle cells which imparts it uterus-like appearance. USG and MRI are the imaging modalities which help in reaching the diagnosis. Knowledge of this entity and awareness of its imaging features can help diagnose this often underdiagnosed and surgically correctable cause of dysmenorrhea.

Comparison of Modified Rose Method of Thyroid Palpation Versus Other Methods for the Detection of Retrosternal and Nodular Goitre.

Objectives: This is a diagnostic test research study to evaluate the various existing methods of thyroid examination and their comparison with the novel modified Rose method. It also aims to measure inter-examiner variation in clinical findings based on the level of education and training, as compared to ultrasonography. Methodology: This cross-sectional study was conducted at a tertiary care hospital with 83 patients presenting to surgery OPD with neck swelling. Each patient was examined by one trained Junior Resident and a Surgery Consultant with all the four methods and with ultrasonography. Data was analysed by Stata-14, agreement between the two categorical variables was assessed by Kappa. In case of continuous variable agreement was assessed by Intra class correlation and Bland-Altman plot. Results: Modified Rose method by the consultant has the highest sensitivity (98%) and diagnostic odds (210) as compared to others but its specificity ranges from 46.7-91.1% to diagnose retro-sternal extension of a goiter. It has 93.98% agreement for identification of nodules. It has a high specificity (Consultant - 100%, Resident - 95.5%) with relatively lower sensitivity (Consultant - 94%, Resident - 86.8%) to diagnose solitary thyroid nodule (STN) but the sensitivity and specificity for diagnosing a multinodular goitre (MNG) was high. However, the highest sensitivity to diagnose STN was highest with Crile's method, but specificity was low. Lahey's method was a better clinical method to palpate lymph nodes compared to the other three. Conclusion: Examination in modified Rose's position is a better method of clinical examination of thyroid especially in patients with occult substernal extension. Lahey's method is a better method to examine cervical lymph nodes.

Ingestion poisoning related lung injury- a pictorial review.

Poison ingestion is a medical emergency requiring immediate care in the emergency department. Respiratory symptoms with ingested poisons can occur due to aspiration, cardiopulmonary effects, or direct lung toxicity due to injury of the alveolar epithelium. Chest imaging (chest radiographs/CT) is usually performed in the emergency setting to evaluate such symptoms. It is often impossible to elicit the nature of the poison ingested by the patients due to their unconscious state. Identification of the culprit poison can expedite the patient's management towards a specific antidote or help understand the underlying mechanism causing the pulmonary symptoms. The imaging manifestations depend on the underlying mechanisms, varying for each ingested poison, forming an imaging signature which has not been adequately discussed in existing literature. Poisons like paraquat and organophosphate are important to differentiate as indiscriminate use of oxygen therapy in the former can exacerbate the lung injury caused by redox cycling. In this pictorial assay, we present the chest imaging spectrum of commonly ingested poisons, and further suggest algorithmic approach towards identification of common poisons based on their chest imaging.

Fracture of tissue dilator in the femoral vein during insertion of temporary dialysis catheter: a stitch in time can save nine.

A 48-year-old man presented to the surgery casualty with 1-day history of broken foreign body during the insertion of dialysis catheter and a failed surgical retrieval. A Doppler ultrasonography of the right groin and lower limb and a noncontrast CT of abdomen and pelvis were performed. Eventhough no intravascular foreign body could be identified on imaging, a decision to re-explore the wound was taken in view of definitive clinical history. A 9.5 cm-long, broken piece of tissue dilator was found inside the right external iliac vein, which was removed through venotomy of the femoral vein. Postoperative recovery was uneventful.

Comparison of Non-Operative Mesotherapy and Surgery in the Management of Superficial Lipomas.

BACKGROUND: Lipomas are benign adipocytic tumours. Surgical excision is the gold standard for treating such lipomas, but it results in unaesthetic scarring. METHODS: A total of 126 patients were randomised into two groups. The patients in Group A underwent mesotherapy (n = 66) and those in Group B underwent surgery (n = 60). The patients in Group A group received six sessions of mesotherapy treatment at 2-week intervals. Both groups were followed up for 12 weeks, during which they were assessed for complications arising from treatment, reduction of the size of the lipoma and cosmetic outcomes. RESULTS: The overall mean age of the patients was 32.93 (± 10.1) years old and the mean volume of the lipomas was 2.29 (± 3.8) mL. A 55.86% (P = 0.0032) mean reduction in the volume of lipomas was noted in the patients who received mesotherapy, while one patient showed a gain of 16% by volume. The patients in Group A (cosmetic score ≥ 4: 63%) were happier with the treatment than those in Group B (cosmetic score ≥ 4: 21%). CONCLUSION: Our findings indicate that mesotherapy modestly reduces the volume of lipomas with very few and minor complications and excellent cosmetic outcomes.

Algorithmic Approach to Sonography of Adnexal Masses: An Evolving Paradigm.

BACKGROUND: Pelvic US remains the workhorse for detection and characterization of adnexal masses in most centers worldwide. While the differentiation of benign from malignant masses remains the foremost concern, it is imperative to narrow the differential diagnosis for management of benign masses as well as prognostication of malignant masses. The IOTA group as well as ACR have described a five category classification system for adnexal lesions based on morphological patterns. In addition, a six category risk stratification has been proposed, incorporating the probability of malignancy as well as management recommendations. LEARNING OBJECTIVES: 1) Understand pattern based approach to adnexal lesion classification and the possible entities fitting into each pattern with the help of illustrations. 2) Classify lesions into appropriate risk categories based on diagnostic algorithms provided at the end of each section.

Pneumothorax and pneumomediastinum in patients with COVID-19: A retrospective study from tertiary care institute in India.

COVID-19 is associated with rarer extra-parenchymal manifestations, namely pneumothorax (PTX) and pneumomediastinum (PM) leading to complications and increased mortality. The study aims to describe the prevalence, risk factors for mortality, radiological characteristics and outcome of PTX/PM in patients admitted with COVID-19. This was a retrospective, single-centre, observational study in patients with confirmed COVID-19 presenting with non-iatrogenic PTX/PM from April 2020 to May 2021. Details pertaining to demographics, presentation, radiological characteristics, management and outcome were collected. Cases were classified into spontaneous and barotraumatic PTX/PM and a between-group comparison was performed using Chi-square and t-test. A total of 45 cases (mean age: 53.2 years, 82% males) out of 8,294 confirmed COVID-19 patients developed PTX/PM, the calculated incidence being 0.54%. 29 cases had spontaneous PTX/PM and the remaining 17 cases were attributed to barotrauma. The most common comorbidities were diabetes-mellitus (65.3%) and hypertension (42.3%). The majority of the cases had large PTX (62.1%) with tension in 8 cases (27.5%). There were predominant right-sided pneumothoraces and five were diagnosed with bronchopleural fistula. 37.7% of cases had associated subcutaneous emphysema. The median duration of PTX/PM from symptom onset was delayed at 22.5 and 17.6 days respectively. The mean CT severity score (CTSS) was 20.5 (± 4.9) with fibrosis (53.8%), bronchiectatic changes (50%) and cystic-cavitary changes (23%). There was no statistically significant difference between the spontaneous and barotrauma cohort. 71% of cases died and the majority belonged to the barotrauma cohort. It is imperative to consider the possibility of PTX/PM in patients having COVID-19, especially in those with deterioration in the disease course, both in spontaneously breathing and mechanically ventilated patients. These patients may also have a high incidence of death, reflecting the gravity of COVID-19.

Case 283: Breast Filariasis.

History A 44-year-old woman who was a resident of Bihar, which is a state in eastern India, presented to the surgical outpatient department of our hospital with a history of gradually increasing swelling of the right breast associated with redness, pain, and itching over the past month. She reported a general sense of malaise and experienced episodes of chills over the past 6 months; however, she had no documented fever. There was no history of breast trauma. No history suggestive of a possible hypercoagulable state could be elicited (she was a nonsmoker, had undergone uncomplicated normal vaginal delivery 15 years earlier, was not taking oral contraceptives, and had no history to suggest past deep venous thrombosis). General physical examination findings were unremarkable. On local examination, she was found to have diffuse enlargement of the right breast. The skin over the lateral part of the breast was erythematous and showed the presence of prominent superficial veins. On palpation, few ill-defined firm mobile masses were found in the upper outer quadrant with overlying skin induration. No skin ulceration or nipple discharge was present. Few firm and discrete lymph nodes were palpable in the right axilla. Laboratory investigations showed mild anemia (hemoglobin level, 10 g/dL; normal range, 12-15 g/dL), a total leukocyte count of 14 000 cells per microliter (14 cells × 109/L) (normal range, 4500-11 000 cells per microliter [4.5-11 cells × 109/L]), a normal differential leukocyte count (74% neutrophils [normal range, 40%-80%], 24% lymphocytes [normal range, 20%-40%], and 2% eosinophils [normal range, 1%-4%]), and an erythrocyte sedimentation rate of 31 mm per hour (normal range, 0-29 mm per hour). She underwent both mammography and US. Real-time US showed mobile structures on the series of US images obtained seconds apart. On the basis of the imaging findings, US-guided fine-needle aspiration cytology was performed to confirm the diagnosis, and appropriate treatment was instituted.

Case 283.

History A 44-year-old woman who was a resident of Bihar, which is a state in eastern India, presented to the surgical outpatient department of our hospital with a history of gradually increasing swelling of the right breast associated with redness, pain, and itching over the past month (Fig 1). She reported a general sense of malaise and experienced episodes of chills over the past 6 months; however, she had no documented fever. There was no history of breast trauma. No history suggestive of a possible hypercoagulable state could be elicited (she was a nonsmoker, had undergone uncomplicated normal vaginal delivery 15 years earlier, was not taking oral contraceptives, and had no history to suggest past deep venous thrombosis). General physical examination findings were unremarkable. On local examination, she was found to have diffuse enlargement of the right breast. The skin over the lateral part of the breast was erythematous and showed the presence of prominent superficial veins. On palpation, few ill-defined firm mobile masses were found in the upper outer quadrant with overlying skin induration. No skin ulceration or nipple discharge was present. Few firm and discrete lymph nodes were palpable in the right axilla. Laboratory investigations showed mild anemia (hemoglobin level, 10 g/dL; normal range, 12-15 g/dL), a total leukocyte count of 14 000 cells per microliter (14 cells × 109/L) (normal range, 4500-11 000 cells per microliter [4.5-11 cells × 109/L]), a normal differential leukocyte count (74% neutrophils [normal range, 40%-80%], 24% lymphocytes [normal range, 20%-40%], and 2% eosinophils [normal range, 1%-4%]), and an erythrocyte sedimentation rate of 31 mm per hour (normal range, 0-29 mm per hour). She underwent both mammography (Fig 2) and US (Fig 3). Real-time US showed mobile structures on the series of US images obtained seconds apart (Fig 4). On the basis of the imaging findings, US-guided fine-needle aspiration cytology was performed to confirm the diagnosis, and appropriate treatment was instituted.

Comparison of Lutetium-177 tin colloid and Rhenium-188 tin colloid radiosynovectomy in chronic knee arthritis.

OBJECTIVE: To assess the role of Lutetium-177(Lu-177) tin colloid for radiosynovectomy and compare it with Rhenium-188 (Re-188) tin colloid radiosynovectomy for alleviation of pain in patients with chronic inflammatory arthritis of knee. METHODS: Patients of chronic inflammatory arthritis of the knee underwent pretherapeutic evaluation in a form of knee ultrasonogram, bone scan and clinical evaluation. Fifty-seven recruited patients were allocated at random to receive either intraarticular injections of Lu-177 tin colloid or Re-188 tin colloid. Eventually, 27 patients received Re-188 tin colloid and 30 patients received Lu-177 tin colloid. The joint was then immobilized for 2 days. Response evaluation was done using knee ultrasound, bone scan and clinical findings. RESULT: Of 30, 20 patients responded to radiosynovectomy in the Lu-177 tin colloid group compared to 21/27 patients in the Re-188 tin colloid group. CONCLUSION: Lu-177 tin colloid is an effective alternative to Re-188 tin colloid for radiosynovectomy in patients with chronic inflammatory knee arthritis.

CT Halo sign: A systematic review.

PURPOSE: The CT Halo sign or Halo sign (HS) refers to ground-glass opacity surrounding a nodule or mass in the lung parenchyma. We conducted a systematic review to find the etiological associations of HS. We also evaluated the diagnostic performances of HS for invasive fungal infections (IFI) in immunosuppressed patients. METHOD: The systematic review was conducted as per PRISMA guidelines. We searched the PubMed and EMBASE database till June 2018 without any restrictions. Only case reports, case series and original articles published in English language were included. A database created from the electronic searches was compiled and subsequent analysis was done. [PROSPERO registration: CRD42018094739] RESULTS: 168 studies were eligible, which included 51 case reports, 15 prospective studies, 102 retrospective studies. A total of 1977 patients (out of 6371) with HS were identified with age range between <1year-94years. The most common diagnosis in the immunosuppressed, mixed, immunocompetent and not specified groups were IFI (86.9 %, n = 1194), Cryptococcosis (51.6 %, n = 124), Cryptococcosis (40 %, n = 20) and lung neoplasms (81.8 %, n = 36) respectively. 14 studies (11 retrospective, 3 prospective) were included in quantitative analysis. The pooled sensitivity(sn), specificity(sp) and odd's ratio (OR) of HS for diagnosing IFI were 50.4 %, 91 % and 6.61 respectively. Also, HS could not reliably differentiate IPA from mucormycosis in the pooled analysis. CONCLUSIONS: HS can be seen in a large number of diverse conditions both in immunosuppressed and immunocompetent population. In immunosuppressed patients HS is specific for IFI but cannot rule it out. Additionally, it cannot reliably distinguish between IPA and mucormycosis.

Laparoscopic repair of recurrent traumatic diaphragmatic hernia.

Laparoscopic repair of recurrent diaphragmatic hernia is infrequently reported. We report successful laparoscopic management of such a case in a 23-year-old male who presented with recurrent vomiting and hiccoughs. He had suffered a gun-shot injury to the chest 2 years ago, following which a primary diaphragmatic repair was done by laparotomy and thoracotomy. The patient developed recurrent left diaphragmatic hernia, which was repaired using polypropylene mesh using a laparoscopic approach. At 6 months of follow-up, the patient is doing well, and his symptoms have resolved. Laparoscopic repair of recurrent diaphragmatic hernia is feasible.

Undiagnosed Fever in a TB Contact Patient: An Unusual Cause.

IgG4-Related Disease(IgG4-RD) is a rare disease that can present with myriad clinical features. We report a tuberculosis contact case who presented with fever and constitutional complaints with imaging evidence of paravertebral and retroperitoneal soft tissue thickening. Further workup, including tissue biopsy ruled out tuberculosis and revealed diagnosis to be IgG4-related disease. Patient was started on oral steroids, which led to symptomatic improvement. In a TB endemic country such as ours, for a patient presenting with pleural and/or peritoneal fibrosis, a differential diagnosis of IgG4-RD must be kept.

Interstitial pneumonia with autoimmune features and platypnea-orthopnea syndrome.

Interstitial pneumonia with autoimmune features (IPAF) is a recently proposed terminology for interstitial lung disease (ILD) with evidence of autoimmunity that does not meet the criteria for a defined connective tissue disease (CTD). Although ILD is well recognised in patients with established CTD, it is rarely the sole presenting feature of CTD. We report a case of 22-year-old male patient, who presented with progressive shortness of breath for 2 months and had features suggestive of platypnea-orthodeoxia syndrome (POS). Imaging revealed ILD with usual interstitial pneumonia pattern. Patient had features of autoimmune disorder but did not fulfil the criteria for any CTD and hence was labelled as IPAF. His POS was attributed predominantly to the lower lobe disease. The patient responded well to immunosuppressive treatment. A systematic review of literature of all cases with POS due to pulmonary parenchymal involvement has also been done.

Infectious versus non-infectious causes of oligoarticular inflammatory arthritis: A prospective study from a tertiary care hospital in north India.

Oligoarticular arthritis (inflammation of upto 4 joints) has a wide range of infectious and non-infectious etiologies. The aim of our study was to identify the features which could help in the differentiation of infectious from non-infectious arthritis. The study was prospective and observational, and included 100 patients with oligoarticular inflammatory arthritis. The final diagnosis was made using standard diagnostic criteria and the patients were categorized into infectious and non-infectious groups. Among the 100 patients who were recruited, the following final diagnosis were made: peripheral spondyloarthritis (n = 37), axial spondyloarthritis (n = 11), tuberculosis (n = 19), brucellosis (n = 6), septic arthritis (n = 6), gouty arthritis (n = 5), early rheumatoid arthritis (n = 5), non-tubercular mycobacteria (n = 2), SLE (n = 2), post-chikungunya arthritis (n = 2), acute lymphocytic leukaemia (n = 1), pachydermoperiostosis (n = 1), sarcoidosis (n = 1) and juvenile idiopathoic arthritis (n = 1). The patients were categorized into two groups: infectious (33) and non-infectious (60). The presence of monoarthritis, clinically-significant weight loss, hepatomegaly, splenomegaly and erosive arthritis were significantly more common in the infectious group as compared to the non-infectious group.