Salivary gland secretory carcinoma presenting as a cervical soft tissue mass: a case report.

BACKGROUND: Secretory carcinoma (SC) has been described as a distinct salivary gland tumor in the fourth edition of the World Health Organization (WHO) classification of head and neck tumors. SC is generally considered as a slow-growing low-grade malignant tumor, while several cases have been reported with high-grade features, and even metastases in the literature up until now. In this article, a soft tissue SC case is discussed with high-grade microscopic features and neural invasion. A review of the salivary gland SC cases with aggressive behavior is also debated. CASE PRESENTATION: A 65-year-old Caucasian man presented with a left neck mass for the past six months. The imaging studies demonstrated a very large cystic cervical mass (46 × 23 mm) with papillary projections in the anterolateral aspect of the left neck zone Vb. He underwent left radical neck dissection (level I-V) and was followed up for 12 months with the diagnosis of Secretory carcinoma. CONCLUSION: Although SC generally has a good outcome, multiple recurrences and unusual metastases may occur, which should be considered by either the pathologists or clinicians.

Hands and feet radiologic involvements in systemic sclerosis.

AIM: Systemic sclerosis (SSc) is a rare autoimmune disorder characterized by vascular and fibrosing involvement of the skin and internal organs. In this study, we determined the prevalence and characteristics of radiological hands and feet involvements in Iranian SSc patients to identify the associations between clinical features and radiologic findings. METHODS: 43 SSc patients (41 women and 2 men), with a median age of 44.8 years (ranges 26-70 years) and a mean disease duration of 11.8 years (ranges 2-28 years) were studied in this cross-sectional study. RESULTS: 42 patients had radiological changes both in their hands and feet. Only one patient had alteration just in hand. The most frequent changes that we found in hand were Juxta-articular Osteoporosis (93%), Acro-osteolysis (58.2%), and Joint Space Narrowing (55.8%). The prevalence of joint space narrowing or acro-osteolysis was higher in subjects with active skin involvement [modified Rodnan skin score (mRSS) > 14] [16/21 vs. 4/16 for patients with inactive skin involvement (mRSS < 14); p = 0.002]. The most frequent changes that we found in the foot were Juxta-articular Osteoporosis (93%), Acro-osteolysis (46.5%), Joint Space Narrowing (58.1%), and subluxation (44.2%). The presence of anti-ccp antibody was detected in 4 (9.3%), while positive rheumatoid factor was found in 13 (30.2%) of SSc patients. CONCLUSION: This study corroborates that arthropathy is common in SSc patients. The introduction of the specific radiological involvements of SSc needs to be confirmed by further studies, in order to define the appropriate prognosis and treatment of patients.

Minor lobulation of the testis, mimicking polyorchidism when inflammed, discussion of a rare case: A case report.

INTRODUCTION: Bilobed testis is an uncommon congenital malformation with only eight cases reported up to now. It seems that bilobed testicle is a form of polyorchidism which is not yet thoroughly divided. This report could provide information about diagnosing minor lobulation on ultrasound and MRI for the first time. PRESENTATION OF CASE: In this report, a 13-year-old boy presented with extreme Epididymo-orchitis on the right testis, without any history, which showed itself on ultrasound as type A3 polyorchidism or bilobed testis. CLINICAL DISCUSSION: Recent studies have not shown an apparent association between bilobed testis with testicular torsion and malignancy. In our case, because the minor lobulation is small, it probably has no association with torsion. The bilobed testis seems benign, so there is no requirement to check tumor markers. An inflamed testicular appendix and epididymitis can appear similar to a major lobulation which must be accurately found and evaluated on ultrasound as separate entities. CONCLUSION: Inflamed minor lobulation of the testicle can demonstrate itself as polyorchidism or bilobed testicles; thus, Ultrasound and MRI can assist in diagnosing minor lobulation. Serial examination and imaging are recommended for managing minor lobulation.

The youngest surviving COVID-19 patient: A case report.

Introduction and importance: Vertical transmission of the novel coronavirus, known as severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has not yet been proven. However, several case reports and case series worldwide, including ours, support this certain type of transmission. Although COVID-19 has been mostly treated supportively, in some cases, including ours, medical treatment seems to be essential. Case presentation: Herein, we present a case of a neonate born to an asymptomatic mother with no known history of COVID-19 during pregnancy who was diagnosed as an asymptomatic silent carrier following the confirmation of COVID-19 in her newborn. Although bacterial pneumonia, early-onset sepsis, and meconium aspiration syndrome were the possible differential diagnosis, positive COVID-19 real-time reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed the diagnosis. Due to the neonate's critical lung involvement leading to a critical condition, remdesivir, intravenous immune globulin (IVIG) and corticosteroid were administered. The patient fully recovered and was discharged after around 20 days. Clinical discussion: Although treatment in most cases of neonatal COVID-19 has been mainly supportive, in a few case reports remdesivir, corticosteroids and IVIG have been successfully used. Since a satisfying clinical improvement was not noticed following sepsis workup, all the three aforementioned medications were administered. Conclusion: Immunomodulatory medications as well as antiviral therapy should be considered in severe neonatal COVID-19 cases, as were shown to be lifesaving in our patient. Interestingly, to date, this case seems to be the youngest survived patient who has received medicines other than supportive care.

Usefulness of Doppler ultrasound for the early diagnosis of diabetic nephropathy in type 1 diabetes mellitus.

PURPOSE: Early diagnosis and management of diabetic nephropathy (DN) might prevent or delay its progression to end-stage renal disease. The purpose of this study was to investigate whether changes in the duplex Doppler resistivity index (RI) are useful for the early identification of renal involvement in children and adolescents with insulin-dependent diabetes mellitus and associated conditions. MATERIALS AND METHODS: A total of 49 diabetic patients (two groups: 21 with DN and 28 without DN) were included in this study. DN was defined as 30-300 mg/l of albumin excretion in a random urine sample. The RI of the main renal arteries and their intrarenal branches (arcuate, interlobar) were evaluated with duplex Doppler ultrasound and correlated with age, renal length, duration of diabetes, and laboratory examinations. RESULTS: The mean age did not significantly differ between the two groups. The patients with DN had a significantly longer duration of type 1 diabetes (p = 0.02). The majority of patients (90.5%) had mild renal involvement with microalbuminuria and normal renal function. The mean RI was normal in both groups of patients, with no significant difference between the two groups. CONCLUSION: The RI did not increase in the early clinical stage of DN and was not a reliable marker for the screening of DN in patients with type 1 diabetes mellitus.

Clinical Presentations of the Survivor and Non-survivor Hospitalized Patients with COVID-19 in the Golestan Province of Iran during the First Peak of the Epidemics.

Background: Considering the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, which causes coronavirus disease 2019 (COVID-19), we aimed to report the clinical features of 427 patients with COVID-19 and the outcomes after one-month admission to major teaching hospitals in the northeast of Iran. Materials and Methods: Data of patients hospitalized with COVID-19 from 20 February 2020 to 20 April 2020 was analyzed using the R software. The cases and their outcomes were monitored up to one month following their admission. Results: Among 427 patients with a median age of 53 years (50.8% male), 81 (19%) were directly admitted to the ICU ward, and 68 (16%) died during the study. The mean (SD) lengths of hospital stay were significantly higher in the non-survivors (6 (9) days) than survivors (4 (5) days) (P = 0.018). Ventilation need was reported in 67.6% of the non-survivors and 0.8% of the survivors (P < 0.001). Cough (72.8%), fever (69.3%), and dyspnea (64.0%) were the most common symptoms. There were more comorbidities in the severe cases (73.5%) and non-survivor (77.5%). Liver and kidney damage were significantly more common in non-survivors. Ninety percent of the patients had at least one abnormal chest CT scan finding, including crazy paving and consolidation patterns (27.1%), followed by the ground-glass opacity (24.7%). Conclusion: Results showed that the patients' age, underlying comorbidities, levels of SpO2, and laboratory findings at the time of admission may predict the progress of the disease and can be considered mortality-related factors.

Ewing's Sarcoma of Mandible: Practical Approach to a Challenging Case.

As a rare entity, sarcomas of the head and neck are challenging cases. In this paper, we represent a unique case of Ewing sarcoma of mandible, serving as an example of multidisciplinary team importance in a developing country.

Case Report: Detection of SARS-CoV-2 From Cerebrospinal Fluid in a 34-Month-Old Child With Encephalitis.

Novel coronavirus (severe acute respiratory syndrome-coronavirus-2: SARS-CoV-2), which arose from Wuhan, China, has rapidly spread to other countries and developed into a pandemic. Although the respiratory manifestations of SARS-CoV-2 are well-documented, there is a considerable challenge regarding the direct and/or indirect infection in other organs. Several preliminary reports confirmed neurological manifestations in the SARS-CoV-2-infected patients. Here, we report the detection of SARS-CoV-2 from the nasopharyngeal swab and cerebrospinal fluid (CSF) in a 34-month-old child with encephalitis. This finding expands the spectrum of the neurological manifestations associated with SARS-CoV-2 infection.

CovidCTNet: an open-source deep learning approach to diagnose covid-19 using small cohort of CT images.

Coronavirus disease 2019 (Covid-19) is highly contagious with limited treatment options. Early and accurate diagnosis of Covid-19 is crucial in reducing the spread of the disease and its accompanied mortality. Currently, detection by reverse transcriptase-polymerase chain reaction (RT-PCR) is the gold standard of outpatient and inpatient detection of Covid-19. RT-PCR is a rapid method; however, its accuracy in detection is only ~70-75%. Another approved strategy is computed tomography (CT) imaging. CT imaging has a much higher sensitivity of ~80-98%, but similar accuracy of 70%. To enhance the accuracy of CT imaging detection, we developed an open-source framework, CovidCTNet, composed of a set of deep learning algorithms that accurately differentiates Covid-19 from community-acquired pneumonia (CAP) and other lung diseases. CovidCTNet increases the accuracy of CT imaging detection to 95% compared to radiologists (70%). CovidCTNet is designed to work with heterogeneous and small sample sizes independent of the CT imaging hardware. To facilitate the detection of Covid-19 globally and assist radiologists and physicians in the screening process, we are releasing all algorithms and model parameter details as open-source. Open-source sharing of CovidCTNet enables developers to rapidly improve and optimize services while preserving user privacy and data ownership.

COVID-19 in Pediatrics: Demographic, Clinical, Laboratory, and Radiological Characteristics of Infected Patients With SARS-CoV-2.

The COVID-19 disease usually leads to mild infectious disease in children, but some develop serious complications. Here, we describe the characteristics of children with COVID-19 in northern Iran, the Golestan province. Ninety-one confirmed cases were enrolled in the study, aged 0-18 years. Demographic, clinical, comorbidity, laboratory, and radiological data were compared based on the disease severity (admitted to intensive care unit (ICU) or not) and disease outcome (recovered or deceased). Sixteen (17.5%) cases were hospitalized in ICU, and 8/91 (8.8%) deceased. Fever and cough were the most common clinical symptoms. Among all symptoms notified there were no significant differences between severe and milder cases, or between those who deceased and recovered. Failure to thrive (FTT), malignant disease and neurological disease were significantly more prevalent in severe cases as was frequently reported comorbidities. Laterality, ground-glass opacity, and lung consolidation were the most common findings in chest computed tomography. The data confirms that the COVID-19 disease has various presentations in children, and clinical, laboratory, and radiological findings may help predict the development of severe forms of COVID-19 among children.

Letter to the editor: efficacy of different methods of combination regimen administrations including dexamethasone, intravenous immunoglobulin, and interferon-beta to treat critically ill COVID-19 patients: a structured summary of a study protocol for a randomized controlled trial.

OBJECTIVES: There is little information about Coronavirus Disease 2019 (COVID-19) management for critically ill patients. Most of these patients develop acute respiratory distress syndrome (ARDS) due to excessive inflammatory response and the ensuing cytokine storm. Anti-inflammatory drugs including corticosteroids can be used to effectively reduce the effect of this cytokine storm and lung damage. However, corticosteroids can have side effects, so simultaneous administration of immunoglobulin (IV-IG) and interferon-beta can help manage treatment using corticosteroids. Therefore, we designed a trial to test our hypothesis that early administration of dexamethasone in combination with IV-IG and interferon-beta can reduce the effect of the cytokine storm in critically ill patients COVID-19. TRIAL DESIGN: A phase two multi-center randomized controlled trial (RCT) with three parallel arms (1:1:1 ratio). PARTICIPANTS: They will be hospitalized patients with severe COVID-19 who have positive RT-PCR test and have blood oxygen saturation levels (SpO2) less than 90% and respiratory rate higher than 24 per minute or have involvement of more than 50% of their lung when viewed using computed tomography (CT)-scan. The age range of patients will be 18-70 years old. EXCLUSION CRITERIA: the need for intubation; allergy, intolerance, or contraindication to any study drug including dexamethasone, IV-IG, and interferon-beta; pregnancy or lactation; known HIV positive or active hepatitis B or C. The study will be conducted in several hospitals of the Golestan province, Iran. INTERVENTION AND COMPARATOR: The study subjects will be randomly allocated to three treatment arms: two experimental groups (two arms: Intervention 1 and Intervention 2) and one Control Group, which will be matched for age and sex using frequency matching method. Each eligible patient in the control arm will receive the standard treatment for COVID-19 based on WHO guidelines and the Ministry of the Health and Medical Education (MOHME) of Iran. Each patient in the Intervention Group 1 will receive the standard treatment for COVID-19 and dexamethasone, at the first 24 hours' time of admission. The intervention begins with the administration of dexamethasone based on the SpO2 levels. If the level of SpO2 does not improve after 24 hours, IV-IG (400 mg/kg once daily for 5 days) and interferon-beta (7 doses every other day) will be prescribed along with dexamethasone administration. In Intervention Group 2, the administration of dexamethasone will be started within the first 24 hours' time of admission and will be continued for 48-72 hours and then the SpO2 level will be checked. Then, if the level of SpO2 has not improved after that time, IV-IG and interferon-beta will be prescribed as the same dosage as Group 1. If the percentages of the SpO2 level are between 85 and 90/ 80 and 85/ 75 and 80/ less than 75, the dosages will be 4 mg every 12 hours/ 4 mg every 8 hours/ 8 mg every 12 hours/ 8 mg every 8 hours, respectively. According to the WHO recommendation, all participants will have the best available supportive care with full monitoring. MAIN OUTCOMES: Primary: An increase in the SpO2 level to reach more than 90% in each case, which will be assessed by the oximeter. Secondary: The duration of hospital stays; intubation status and the percentage of patients who are free of mechanical ventilation; the mortality rates during hospitalization and one month after the admission time. RANDOMISATION: Participants will be allocated into either control or intervention groups with a 1:1:1 allocation ratio using a computer random number generator to generate a table of random numbers for simple randomization. BLINDING (MASKING): The project's principal investigator (PI) is unblinded. However, the PI will not analyse the data and interpret the results. An unblinded researcher (a pharmacist) will cover the drug's bottles with aluminium foil and prepare them interventions and control drugs in a syringe with a code so that patients are blinded. This person will have no patients contact. The staff and nurses, caring for the patients, will be unblinded for each study group due to the nature of this study. The staff that take outcome measurements will be blinded. The laboratory technicians will also be blinded as well as the statistical team. These study statisticians will have access to coded data and will analyse the data labelled as group X, group Y, and group Z. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): The target sample size will be 105 critically ill COVID-19 patients, who will be allocated randomly to the three trial arms with 35 patients in each group. TRIAL STATUS: Recruitment is ongoing. The study began on April 18 2020 and will be completed June 19 2020. This summary describes protocol version 1; April 2 2020. TRIAL REGISTRATION: https://www.irct.ir/. Identifier: IRCT20120225009124N4 version 1; Registration date: April 2 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting the dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The full protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines.

Accuracy of Rapid Ultrasound in Shock (RUSH) Exam for Diagnosis of Shock in Critically Ill Patients.

BACKGROUND: Rapid ultrasound in shock (RUSH) is the most recent emergency ultrasound protocol, designed to help clinicians better recognize distinctive shock etiologies in a shorter time frame. OBJECTIVES: In this study, we evaluated the accuracy of the RUSH protocol, performed by an emergency physician or radiologist, in predicting the type of shock in critical patients. PATIENTS AND METHODS: An emergency physician or radiologist performed the RUSH protocol for all patients with shock status at the emergency department. All patients were closely followed to determine their final clinical diagnosis. The agreement between the initial impression provided by RUSH and the final diagnosis was investigated by calculating the Kappa index. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of RUSH for diagnosis of each case. RESULTS: We performed RUSH on 77 patients. Kappa index was 0.71 (P Value = 0.000), reflecting acceptable general agreement between initial impression and final diagnosis. For hypovolemic, cardiogenic and obstructive shock, the protocol had an NPV above 97% yet it had a lower PPV. For shock with distributive or mixed etiology, RUSH showed a PPV of 100% but it had low sensitivity. Subgroup analysis showed a similar Kappa index for the emergency physician and radiologist (0.70 and 0.73, respectively) in performing rush. CONCLUSIONS: This study highlights the role of the RUSH exam performed by an emergency physician, to make a rapid and reliable diagnosis of shock etiology, especially in order to rule out obstructive, cardiogenic and hypovolemic shock types in initial exam of shock patients.

How can a radiologist reveal more practical information using dynamic study of cavernosal artery after injection of vasoactive agents?

BACKGROUND: Erection is a dynamic multi-stage neurovascular phenomenon consisting of 4 phases. Conventional protocol of color Doppler study can easily overlook these ongoing dynamic events. OBJECTIVES: Here, we tried to designate patterns for these dynamic spectral waveform changes of cavernosal arteries in patients with erectile dysfunction and subsequently better describe the extent of their underlying problem. PATIENTS AND METHODS: We evaluated 59 men who were referred for post-intracavernosal injection (ICI) color Doppler investigation of suspected erectile dysfunction (ED). The demographic data and medical history were recorded. Afterwards, first scan injection was done. Then scanning of cavernosal arteries was started about one minute after the injection and was continued thereafter. For better description of temporal changes in the waveform of cavernosal arteries, new patterns were defined and used. Patients were also classified based on previously known etiologic categories (i.e. arterial insufficiency, venous leak, mixed type, and normal response). RESULTS: The mean age was 45.6 ± 13.1 (24 to 74 ) years. Twenty-two were normal responders [considered as non-organic causes (37.3% of all patients)], 27 were classified as venous leakage, eight had arterial insufficiency and two were mixed type. Maximum PSV occurred before the fifth minute in 47 patients (92.2%). Eight patients completed all phases of erection in the first 5 minutes. We defined 8 patterns for the temporal changes in cavernosal arterial waveform. Pattern 5 was the most common pattern of venous leak; while, patterns 3 and 4 were considered as the uncommon group. Six patients demonstrated the uncommon patterns of venous leak (22.2%). Hypertension was more prevalent in the uncommon pattern of venous leak. CONCLUSIONS: We highlight the considerable role of continuous evaluation starting one minute after intra cavernosal with ICI injection of the vasoactive agent for better description of the underlying pathologies of ED especially in patients with venous leak etiology.

Unusual tonsillar herniation in meningeal melanocytoma: a case report.

Meningeal melanocytoma is a primary melanocytic neoplasm with certain MR and immunohistochemical characteristics worthy to note. In a 38-year-old man with a complaint of headache for a couple of years and recently added nausea, vomiting, diplopia, progressive visual blurring and hearing loss, magnetic resonance imaging (MRI) was remarkable for T1 shortening of leptomeninges and certain nodules in precontrast study. Subsequent contrast-enhanced MR imaging of the brain and spine revealed enhancement in the basal cisterns extending throughout the spinal canal. Contrast-enhanced MRI revealed diffuse enhancement in the basal cisterns extending throughout the spinal canal. Immunohistochemical analysis on one of the intraspinal nodules proposed leptomeningeal melanocytoma. The characteristic shortening of T1 and T2 relaxation times in MRI as a result of the paramagnetic stable free radicals that exist within melanin, often suggests a diagnosis of a melanocytic leptomeningeal process. Moreover, there are unique immunohistochemical characteristics for these varied lesions. In appropriate clinical settings, certain radiologic findings, especially both T1 and T2 shortening in nodular CNS lesions should propose meningeal melanocytoma.