Xanthogranulomatous osteomyelitis of pubic bone mimicking neoplasm: a case report and literature review.

BACKGROUND: Xanthogranulomatous osteomyelitis (XO) is a rare disease characterized radiologically by an osteolytic lesion with cortical expansion or disruption. Differentiating this condition from other osteolytic diseases such as primary or metastatic bone neoplasms is imperative. Several case reports have been published on XO, with previous reports predominantly identifying bacteria such as Pseudomonas or Staphylococcus as causative organisms. However, fungal infection-induced XO has not yet been reported. CASE PRESENTATION: We present the case of a 23-year-old woman with a tumor-like osteolytic lesion in the pubic bone. The patient had experienced pelvic pain and intermittent febrile episodes for 2 months. Plain radiography revealed an osteolytic lesion in the right pubic tubercle. Magnetic resonance imaging suggested a cystic bone tumor or tubercular infection. Surgical intervention included curettage of the lesion and irrigation with normal saline. Histopathological examination of the specimen revealed abundant foamy histiocytes with inflammatory infiltrates consistent with XO. Culture of the osteolytic lesion confirmed an Aspergillus species infection and antifungal treatment was initiated. At 1-year follow-up, no evidence of local recurrence was observed. CONCLUSIONS: Although rare, XO requires differentiation from similar conditions and is treated with surgical intervention and targeted medical therapy based on the identified organisms. Clinicians should be mindful that XO can also be induced by fungal infections and that combination antifungal treatments may be beneficial in such cases.

Modifications of surgical techniques in laparoscopic percutaneous extraperitoneal closure of inguinal ring for childhood inguinal hernia to achieve zero recurrence and zero subcutaneous stitch granuloma.

PURPOSE: To present our technical modifications of single incision laparoscopic percutaneous extraperitoneal closure (SILPEC) of the internal inguinal ring (IIR) for pediatric inguinal hernia (PIH). METHODS: The prospectively collected data of all children diagnosed with PIH undergoing SILPEC at our center from 2016 to 2023 were reviewed and divided into two groups for result comparison: Group A: before and Group B: after the implementation of full modifications. Our modifications included using a nonabsorbable monofilament suture, creating a peritoneal thermal injury at the internal inguinal ring (IIR), employing a cannula to ensure the suture at the IIR ligates only the peritoneum, and double ligation of the IIR in selected cases. RESULTS: 1755 patients in group A and in group B (1 month to 14 years old) were enrolled. There were no significant differences regarding baseline patient characteristics between the two groups. At a median follow-up of 40 months, the rate of recurrent CIH and subcutaneous stitch granuloma (SSG) was 2.3% and 1.5% in group A vs. 0% and 0% in group B (p < 0.001). There were no hydroceles, no ascended or atrophic testis. CONCLUSIONS: Our SILPEC technical modifications can achieve zero recurrence and zero SSG for PIH.

Can near-infrared imaging distinguish a gelatin-based matrix granuloma from a malignancy in a kidney?

Aim: Differentiating granulomas from cancerous tissue poses a significant challenge in upper urinary tract surgery. We present the case of a 62-year-old male with a gelatin-based matrix (SurgifloTM) granuloma in the kidney following renal cyst decortication eight years earlier.Methods: Contrast-enhanced abdominal tomography revealed a Bosniak type-4 cyst at the previous operation site. The patient underwent laparoscopic partial nephrectomy with near-infrared imaging.Results: The lesion presented as hypofluorescent relative to normal kidney tissue. Histopathological examination revealed a foreign body granuloma due to unabsorbed Surgiflo.Conclusion: The fluorescence pattern could not distinguish a Surgiflo granuloma from a malignant lesion of the kidney.

Orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles: report of two cases.

BACKGROUND: Two cases of orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles were reported to understand image findings, clinical and histopathologic features of orbitofrontal cholesterol granuloma to improve its diagnosis and treatment. CASE PRESENTATION: Two East Asian patients aged 41 and 27 without personal or familial medical or trauma history presented with the common complaint of proptosis and inferomedial displacement of the eyeballs. The computed tomography (CT) of both cases showed an irregularly shaped, well-defined lesion in the left frontal bone associated with bony erosion. The lesions resulted in the bone absorption of frontal bone and orbital roof, which extended into the superior orbital space. Anterior orbitotomy through subbrow incision by drainage and curettage resulted in a curative outcome. The histopathological examination revealed inflammatory granulation tissues, fibrous capsule wall, cholesterol clefts with altered blood pigments, and calcifications, consistent with the diagnosis of cholesterol granuloma. No recurrence was observed for one year after surgery in one case and three years in the other. CONCLUSIONS: When the following features are observed: orbital CT exhibits cystic lesion with irregular bone destruction in the superolateral orbit, magnetic resonance imaging (MRI) depicts lesions are hyperintense signals on T1 weighted images (T1WI), and T2 weighted images (T2WI), and the contrast-enhanced imaging reveals that the most of tumor is showed a non-significant enhancement, orbitofrontal cholesterol granuloma should be considered.

Tympanomastoid cholesterol Granulomas presenting as a Blue Eardrum in children.

OBJECTIVE(S): This clinical study was performed to analyze the characteristics of cholesterol granuloma (CG) and evaluate our results in children. METHODS: The clinical records of children diagnosed with CG were retrospectively reviewed. RESULTS: The total of 17 children (20 ears) with CGs were included in this study. Endoscopy revealed pars flaccida retractions and lipoid tissue deposition behind the intact blue tympanic membrane (TM). CT scan revealed bony erosion and extensive soft tissue in the middle ear and mastoid. No ossicular chain destruction was found. All 20 ears underwent canal wall-up mastoidectomy and ventilation tube (VT) insertion, 3 sets of VT were performed in 5 ear and 2 sets in one. The residual perforation was seen in 2 ears following VT. The CT revealed well-pneumatized antra and tympanic cavities at postoperative 12-24 months. CONCLUSION(S): The CG should be suspected for the patients with yellow lipoid deposition behind the blue TM. CT of CG usually revealed bony erosion and extensive soft tissue in the middle ear and mastoid. Mastoidectomy combined with VT insertion and etiological treatment have a favorable prognosis for CG in children.

An inflammatory granuloma in right ventricular: Preliminarily diagnosed by echocardiography.

Inflammatory granuloma is a rare non neoplastic benign disease that rarely reported in the heart tissue, and surgical resection is the final treatment with satisfactory results. Hereinafter, we report a case of inflammatory granuloma in the right ventricle of a 25-year-old man who underwent multimodality imaging and successful resection of the mass. Results of the case suggested that when evaluating patients with cardiac mass in unusual locations, it was necessary to comprehensively consider multiple imaging features and combine laboratory examination to make clinical suspicion.

[Undistinguishable Cryptococcus-related granulomatous lesion from carcinoma in the tail of the pancreas: a case report].

Abdominal computed tomography revealed a 19×13mm delayed enhancing mass and dilation of the distal pancreatic duct in the head of the pancreas. Magnetic resonance cholangiopancreatography showed pancreatic duct stenosis in the tail of the pancreas. Endoscopic retrograde pancreatography revealed an abrupt interruption of the main pancreatic duct at the tail of the pancreas. We could not assess the distal side of the pancreatic stenosis due to the large extent of obstruction. The pancreatic head mass was diagnosed as adenocarcinoma using endoscopic ultrasound-fine needle aspiration biopsy. However, we could not determine whether the pancreatic duct stenosis in the tail of the pancreas was malignant. Nevertheless, we performed a total pancreatectomy with splenectomy. Histological examination showed poorly differentiated adenocarcinoma in the pancreatic head mass but the pancreatic duct stenosis in the tail of the pancreas was diagnosed as pancreatic granuloma caused by Cryptococcus. Fungal infections may reportedly promote the development of pancreatic cancer, as further suggested by this case of cryptococcal infection.

Symptomatic bilateral choroid plexus xanthogranuloma in a pediatric patient.

INTRODUCTION: Central nervous system xanthogranulomas are uncommon clinical entities, and symptomatic bilateral choroid plexus xanthogranulomas are rare. CASE PRESENTATION: We present the case of a 15-year-old male patient with bilateral choroid plexus xanthogranulomas with symptoms of increased intracranial pressure. Gross total resection of the tumor in the left lateral ventricle was performed. The patient improved, and asymptomatic right-sided tumor was monitored at follow-up. CONCLUSION: The main treatment objective in these tumors is gross total resection. Asymptomatic tumors can be followed without intervention. However, surgery should be performed for symptomatic tumors that cause hydrocephalus or symptoms of increased intracranial pressure.

Cholesterol Granuloma of the Liver Mimicking Malignant Tumor: A Case Report.

Cholesterol granuloma is a benign, tumor-like lesion with an accumulation of cholesterol crystals in the tissue and is a consequence of a chronic inflammatory reaction. It commonly occurs in the middle ear but rarely in the liver. There is only one previous case report of cholesterol granuloma of the liver, which was caused by cholesterol hepatolithiasis. We report a case of cholesterol granuloma of the liver in a patient with no intrahepatic cholesterol stones; it was difficult to rule out malignant liver tumor preoperatively. The patient was a 79-year-old woman in whom a lesion in the liver was detected on abdominal ultrasonography. She was referred to our hospital for detailed examination and treatment. Abdominal contrast-enhanced computed tomography showed a 20 mm lesion with ring enhancement in the lateral segment of the liver during the arterial and delayed phases. Since a malignant tumor could not be ruled out radiologically, laparoscopic lateral segment hepatectomy was performed for definitive diagnosis and treatment. The resection specimen showed a yellowish-white lesion measuring 15 mm in diameter. Pathological examination showed a granulomatous lesion with cholesterol crystals surrounded by foreign body giant cells. The lesion was diagnosed as cholesterol granuloma of the liver. The postoperative course was good, and the patient was discharged on postoperative day 5. She was healthy, and no recurrence of the cholesterol granuloma was detected at the 5-month follow-up. This is the first case report of cholesterol granuloma of the liver mimicking a malignant liver tumor in a patient with no intrahepatic cholesterol stones.

The recurrent factors of idiopathic vocal process granulomas after cold steel excision.

OBJECTIVE: To identify the factors predicting postoperative recurrence after cold steel excision for the market trader with idiopathic vocal process granulomas (VPGs). MATERIAL AND METHODS: The market traders with idiopathic VPGs who do not respond to medical treatment were treated by cold steel excision. The factors considered likely to affect the recurrence were evaluated by univariate and multivariate logistic regression. RESULTS: The total of 80 idiopathic VPGs underwent the cold steel excision. All postoperative 6 months, the complete remission rate was 37.5% (30 VPGs) and 50 recurrences developed (62.5%). The recurrence rate was not significantly associated with sex (P = 0.119), side (P = 0.468), VPG size (P = 0.726), LPR (P = 0.293), diabetes mellitus (P = 0.5611), cerebrovascular disease (P = 0.129), or chronic pulmonary disease (P = 0.190). Multivariate logistic regression showed that only vocalization frequency (P = 0.006) and smoking and alcohol consumption (P = 0.001) were independent predictors of recurrence. There was no significant correlation between age and recurrence (P = 0.59). However, recurrence was more common in those aged 51-60 years than those aged ≥61 years (P = 0.019). Of the recurrent 49 VPGs treated conservatively via behavioural modification and oral deanxit, the granulomas disappeared spontaneously in 38 (77.6%) within 6-10 months and in 11 (22.4%) within 2-3 years. CONCLUSIONS: The market traders with VPG would be a high recurrence rate after cold steel excision, the frequency of voice use and smoking and alcohol consumption were significant independent predictors of recurrence. Antidepressant medications and behavioural modification could effectively improve the outcome of VPG.

Radiofrequency ablation of intubation granulomas.

OBJECTIVE: We explored the outcomes and voice parameters of patients undergoing plasma radiofrequency (RF) ablation to treat intubation granulomas. STUDY DESIGN: Prospective case series. METHODS AND MATERIALS: Patients with intubation granulomas who met the inclusion criteria underwent RF ablation. The complete remission rate and voice function were evaluated preoperatively and at 6 months postoperatively. RESULTS: We enrolled 13 patients with 25 intubation granulomas. The mean time between intubation and initial diagnosis was 38.6 days and that between intubation and surgical diagnosis was 2.7 months. All 25 granulomas were successfully removed and histologically confirmed. No surgical remnant was evident on the vocal folds and complete glottal closure was observed at 2 weeks postoperatively. No recurrence or RF ablation-related complications were observed during the 6-month follow-up. The complete remission rate was 100% (13/13). In addition, the mean hoarseness, roughness, breathiness, asthenia, and strain (GRBAS) scores, and the maximum phonation time (MPT), improved significantly after treatment (all P < 0.05). CONCLUSIONS: RF ablation is effective and safe for patients with intubation granulomas who failed medical management or request the procedure. In this study, the complete resolution rate was high and voice restoration outcomes were good.

Suture Granuloma Diagnosed and Treated With Bedside Ultrasound.

BACKGROUND: Emergency physicians frequently evaluate patients with postoperative wound issues. The differential is broad, but obviously includes postoperative site infections. We present a case where a suspected postoperative abscess was evaluated with bedside ultrasound prior to incision and drainage. Suture material was recognized, shifting our approach to treatment of the lesion. CASE REPORT: A 24-year-old female patient presented with pain, swelling, and drainage from a left lower quadrant abdominal wound that had been present since undergoing a laparoscopic appendectomy 1 year prior. A computed tomography scan was performed, which was negative for foreign bodies. Prior to incision and drainage, a bedside ultrasound was performed to evaluate the lesion, which was notable for sonographic findings consistent with suture material. Suture granuloma was diagnosed, and ultrasound was then used to successfully guide retrieval of the suture. To our knowledge, this is the first published case where ultrasound was used to both diagnose and dynamically remove the offending suture material. We briefly discuss suture granulomas, their sonographic appearance, and management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently perform ultrasound on suspected abscesses prior to incision and drainage and should be aware of the sonographic appearance of suture material as it would change management if present. If a suture granuloma is suspected due to swelling at a postoperative site, ultrasound use should be strongly considered for evaluation.

Undiagnosed solitary caseating granulomas: Is lung resection surgery a feasible method for diagnosis and treatment?

BACKGROUND: In many patients, low-dose computed tomography (CT) screening for lung cancer reveals asymptomatic pulmonary nodules. Lung resection surgery may be indicated in these patients; however, distinguishing malignancies from benign lesions preoperatively can be challenging. METHODS: From 2013 to 2018, 4181 patients undergoing surgery for pulmonary nodules were reviewed at National Taiwan University Hospital, and 837 were diagnosed with benign pathologies. Only patients with pathological diagnosis as caseating granulomatous inflammation were included, sixty-nine patients were then analyzed for preoperative clinical and imaging characteristics, surgical methods and complications, pathogens, medical treatment and outcomes. Mycobacterial evidence was obtained from the culture of respiratory or surgical specimen. RESULTS: Overall, 68% of the patients were asymptomatic before surgery. More than half of the nodules were in the upper lobes, and all patients underwent video-assisted thoracoscopic surgery (VATS). Some patients (14.5%) developed grade I complications, and the mean postoperative hospital stay was 4 days. The final pathology reports of 20% benign entities postoperatively, and caseating granulomatous inflammation accounted for a significant part. MTB and NTM were cultured from one-fourth of the patients respectively. All patients with confirmed MTB infection received antimycobacterial treatment, while the medical treatment in NTM-infected patients was decided by the infectious disease specialists. The mean follow-up period was 736 days, and no recurrence was found. CONCLUSION: Lung resection surgery is an aggressive but safe and feasible method for diagnosing MTB- or NTM-associated pulmonary nodules, and, potentially, an effective therapeutic tool for patients with undiagnosed MTB- or NTM-associated pulmonary nodules.

Cholesterol Granuloma of the Cranial Mediastinum in a Dog.

A 10 yr old female spayed Pomeranian presented with a history of dyspnea and coughing and was diagnosed with a cranial mediastinal mass presumed to be a thymoma. Surgical removal was elected and occurred without intraoperative complications. Histopathology revealed the lesion to be a cholesterol granuloma. The patient developed a brief period of increased respiratory difficulty 3 days postoperatively. Thoracic radiographs showed mild pleural effusion and the patient improved with supportive care. Five months postoperatively, repeat thoracic radiographs revealed no evidence of recurrence or respiratory pathology. This case report describes a cholesterol granuloma in a unique location and reviews the pathogenesis/pathophysiology of this type of mass.

Cholesterol granuloma mimicking an anterior mediastinal tumor - a case report.

There are many different types of mediastinal masses, which makes it challenging to diagnose them. Furthermore, the clinical presentation can range from asymptomatic to life-threatening. We present the case of a 68-year-old male with an incidental finding of a tumor located in the anterior mediastinum. A computed tomography (CT) of the thorax and an 18-Fluorodeoxyglucose positron emission tomography (PET) suggested a thymoma, which is the most common primary tumor of the anterior mediastinum. The patient was scheduled for a robotic-assisted thoracoscopy (RATS) thymectomy. Both this procedure and the postoperative course were uneventful. The pathology report showed multiple cholesterol granulomas in the mediastinal fat. Furthermore, no malignancy (e.g. a thymoma) could be found. A cholesterol granuloma mimicking an anterior mediastinal tumor is extremely rare.

Penile paraffinoma: a case report.

Penile paraffinoma or sclerosing lipogranuloma is a disease occurring uncommonly in Czechia; a pathologist meets this only rarely. Microscopically, we deal with chronic fibroproductive inflammation localised usually in subcutaneous tissue of the penis. It is caused by previous voluntary injection of liquid paraffin / mineral oil for the purpose of penis circumference augmentation, usually performed by a non-healthcare person or by the patient himself. Human tissues do not have enzymes that can break down synthetic lipids. The application leads, with a variable time lag, to a foreign body giant-cell reaction lasting for years, and often to annoying complications frequently associated with a genital mutilation and sexual dysfunction. The lesion often requires surgical treatment to remove the paraffin substance from the subcutaneous tissue. The surgery does not always lead to satisfying results and the paraffinoma tends to recur. In this article, we describe a case of a man with relapsing paraffinoma, which required excision of subcutis with subsequent plastic surgery with skin graft. During histological examination, lipid droplets were found in dermis and in subcutis, along with xantogranulomatous inflammation. The lipid nature of the material was proven by oil red and Sudan stain. The paper includes clinical and histopathological differential diagnostic consideration, summary of treatment options and relevant literature review.

Chest wall pseudotumor: a case of non-tuberculous mycobacterial infection.

BACKGROUND: Non-tuberculous mycobacterial (NTM) infections are increasing worldwide, making them an international public health problem. Surgical management is often indicated for localized infectious disease; however, most surgeons are unaware of the potential risks of transmission during surgery. CASE PRESENTATION: An 88-year-old Asian female was referred to our hospital for a tumor in the right lateral thoracic region. One month prior, she had a feeling of fullness and complained of localized pain and warmth in the right lateral thoracic wall. Pain and warmth gradually resolved without intervention; however, the fullness was getting worse. Computed tomography (CT) scan showed a mass of approximately 65 × 30 mm with an osteolytic change, involving the right 8th rib. Based on the rapid growth rate and CT findings, we strongly suspected a malignant chest wall tumor, and en bloc tumor resection with the 8th rib was performed. When the specimen was cut, a large amount of viscous pus was drained and its culture showed growth of Mycobacterium avium. Microscopically, the non-caseating epithelioid cell granuloma extended into the rib, infiltrating the bone cortex. On follow-up 1 month after discharge, there were no signs of infection or other adverse events associated with the surgery. CONCLUSIONS: Herein, we report about a patient with a mass diagnosed as an NTM abscess involving the rib cage, which was confused with a malignant tumor and eventually diagnosed following surgical excision. This report emphasizes the need to be aware of the possibility of NTM infection and take appropriate precautions if the patient has a rapidly growing mass in the chest wall.

Post-stapedotomy reparative granuloma following use of acellular porcine small intestinal submucosa.

PURPOSE: There have been multiple proposed etiologies of reparative granuloma following stapes surgery. In this report, we present the first case of post-stapedectomy reparative granuloma following the use of Biodesign (Cook Medical, Bloomington, IN) otologic graft material, an acellular matrix derived from porcine small intestinal submucosa, and review the literature of post-stapes surgery reparative granuloma. PATIENT: 50-year-old woman who developed a reparative granuloma following stapedotomy with acellular porcine intestinal submucosa presenting with profound hearing loss and vertigo. INTERVENTION: Middle ear exploration with excision of granuloma and revision stapedotomy. MAIN OUTCOME MEASURES: Audiologic outcomes as measured by pure-tone air and bone conduction thresholds and word recognition scores. Improvement in vertigo. MAIN FINDINGS: Surgical excision of the reparative granuloma with revision stapedotomy resolved vertigo. Hearing has improved progressively postoperatively. CONCLUSIONS: We report the first case of post-stapedotomy reparative granuloma following the use of acellular porcine intestinal submucosa. Although exact etiology cannot be determined from a single case report, this illustrates the need for careful use of novel foreign graft material. This case additionally confirms that removal of granuloma and inciting materials can salvage serviceable hearing.

Short-term outcome of transcutaneous glucocorticoid injection for laryngeal contact granuloma in females.

OBJECTIVE: To evaluate the short-term efficacy of transcutaneous glucocorticoid injection for laryngeal contact granuloma in females. METHODS: A total of 14 female patients with laryngeal contact granuloma treated in our outpatient department from November 2017 to January 2020 were included in the study. Inspiratory-phase laryngoscopy images were collected before treatment and 1 month after each injection, and the lesion size was measured and evaluated with ImageJ software. RESULTS: Two patients achieved complete remission after one injection, with a percent reduction of 100%. After two injections, 4 patients achieved complete remission, with a percent reduction ranging from 96% to 100%. After 3 injections, 4 patients achieved complete remission (including one patient with bilateral lesions), and the percent reduction ranged from 95% to 100%. Three patients achieved incomplete remission, with a percent reduction of 46%, 55%, and 81%, respectively. In one case, there was no remission, and the granuloma increased in size after treatment. CONCLUSION: In women with laryngeal contact granuloma, transcutaneous glucocorticoid injection therapy can quickly resolve the granuloma in a short period.

Thoracoscopic Lung Cancer Resection with Simultaneous Heart Valve Procedure.

Comorbidity of primary lung cancer and heart valve disease, both requiring surgical therapy, characterizes a high-risk group of patients necessitating prompt diagnosis and treatment. Recently, the rate of minimal invasive approach for patients who were not indicated for conventional thoracotomy surgery due to their high-risk status with the procedure has increased as treatment for heart valve disease. We herein report four patients of lung cancer resection with simultaneous valve procedure though thoracoscopic technique [Bablekos 2016].