Extramedullary plasmacytoma of the orbit complicating the evolution of multiple myeloma in complete remission.

Orbital plasmacytoma is rare and has only been reported in the context of the initial diagnosis of multiple myeloma. Moreover, isolated orbital plasmacytoma without any signs of multiple myeloma is extremely rare. We report the case of a 59-year-old female patient diagnosed with IgA Kappa multiple myeloma. It was stage I ISS (International Staging System) and stage I R-ISS (Revised ISS). According to the Tunisian national protocol, the patient was included in the standard-risk group and was eligible for four cycles of CTD (Cyclophosphamide, Thalidomide, Dexamethasone) followed by autologous stem cell transplantation. Taking into account the partial response after the CTD cycles, the patient has benefited from two VTD cycles (Bortezomib, Thalidomide, Dexamethasone). Thus, complete remission was obtained. The patient refused autologous stem cell transplantation. Therefore, maintenance treatment based on Thalidomide only was started and received over a twelve-month period. Five months after the end of maintenance treatment, she reported frontal headaches that were resistant to symptomatic treatment, with ptosis in the right eye in physical examination. Brain MRI revealed the presence of a right cranio-orbital tissue mass with intra-orbital and extra-axial cerebral components. The mass measured 32/36 mm on axial sections and 47 mm in height. The patient underwent a complete resection of the cranio-orbital mass with cranioplasty. The histopathological examination of the mass with Immunohistochemistry staining confirmed the diagnosis of orbital plasmocytoma. An update of the multiple myeloma assessment did not reveal any biological, cytological or radiological signs in favor of multiple myeloma. Therefore the diagnosis of isolated orbital plasmacytoma without signs of multiple myeloma was made. Post-operative brain MRI showed complete disappearance of the right cranio-orbital tissue lesion. There was only a persistent meningeal enhancement of the dura mater at the surgical site, suggestive of post-operative changes. The patient was then referred for cranio-orbital radiotherapy.

Pulmonary embolism versus pulmonary vasculitis in Hughes-Stovin syndrome: Characteristic computed tomography pulmonary angiographic findings and diagnostic and therapeutic implications. HSS International Study Group.

BACKGROUND AND AIM: Hughes-Stovin syndrome (HSS) is a rare systemic vasculitis with widespread venous/arterial thrombosis and pulmonary vasculitis. Distinguishing between pulmonary embolism (PE) and in-situ thrombosis in the early stages of HSS is challenging. The aim of the study is to compare clinical, laboratory, and computed tomography pulmonary angiography (CTPA) characteristics in patients diagnosed with PE versus those with HSS. METHODS: This retrospective study included 40 HSS patients with complete CTPA studies available, previously published by the HSS study group, and 50 patients diagnosed with PE from a single center. Demographics, clinical and laboratory findings, vascular thrombotic events, were compared between both groups. The CTPA findings were reviewed, with emphasis on the distribution, adherence to the mural wall, pulmonary infarction, ground glass opacification, and intra-alveolar hemorrhage. Pulmonary artery aneurysms (PAAs) in HSS were assessed and classified. RESULTS: The mean age of HSS patients was 35 ± 12.3 years, in PE 58.4 ± 17 (p < 0.0001). Among PE 39(78 %) had co-morbidities, among HSS none. In contrast to PE, in HSS both major venous and arterial thrombotic events are seen.. Various patterns of PAAs were observed in the HSS group, which were entirely absent in PE. Parenchymal hemorrhage was also more frequent in HSS compared to PE (P < 0.001). CONCLUSION: Major vascular thrombosis with arterial aneurysms formation are characteristic of HSS. PE typically appear loosely-adherent and mobile whereas "in-situ thrombosis" seen in HSS is tightly-adherent to the mural wall. Mural wall enhancement and PAAs are distinctive pulmonary findings in HSS. The latter findings have significant therapeutic ramifications.

Radiological predictive remission factors of pulmonary involvement in systemic sarcoidosis: a computed tomography scan study.

INTRODUCTION: As little is known about the prognostic value of CT scan findings at onset in patients presenting with sarcoidosis, we aimed to identify factors independently associated with radiological remission of pulmonary involvement in systemic sarcoidosis on CT scan findings. METHODS: We conducted a retrospective descriptive and analytic study of patients with a biopsy proven systemic sarcoidosis. We compared patients on radiological remission (group 1) to those on stabilization or progression (group 2). Multivariate analysis of variables significantly associated with radiological remission in univariate analysis was performed using binary logistic regression. RESULTS: Out of 65 records of systemic sarcoidosis, 43 were analyzed. 18.6% where male and 81.6% female with a sex-ratio of 0.22 and a mean age at diagnosis of 47.2 ±13.6 years. We found atypical lesions in CT scan findings in 16 patients (37.2%). Comparative pulmonary CT scan findings at admission and at 12 months follow-up revealed 13 patients (30.2%) in remission (group1) and 30 patients in radiological stabilization or progression (group 2). On multivariate analysis, lymphopenia, calcifications, and typical CT scan findings at presentation were predictive factors of remission of pulmonary involvement in systemic sarcoidosis (aOR=27.57; 95%IC=2.67-284.63; p=0.005) (aOR= 37.2; 95%IC= 2.08-663.89; p= 0.014) (aOR=47.1; 95%IC= 1.79-1238.7; p=0.021) respectively. CONCLUSION: In patients with systemic sarcoidosis with no lymphopenia at onset or calcifications or typical CT scan findings at presentation, we suggest a close follow-up as well as an intensive treatment.

A case report of small bowel occlusion due to Meckel diverticulum causing a life-threatening condition.

INTRODUCTION AND IMPORTANCE: Meckel's diverticulum is a common congenital abnormality. In this study, we reported a case of small bowel occlusion due to Meckel's diverticulum causing a small bowel obstruction and a life-threatening condition. CASE PRESENTATION: 28-year-old man complaining of abdominal pain for 3 days. The physical examination found the patient appeared profusely unwell with a blood pressure of 80/40 mmHg. The abdominal examination found abdominal rigidity suggesting peritonitis. The patient's C-reactive protein was 210 mg/l with normal white blood cell count. Consequently, the patient was operated on using a laparotomy. A mechanical bowel obstruction due to a gangrenous Meckel's diverticulum was confirmed during the operation. Meckel's diverticulitis with the tip attached to the ileal mesentery through a band. A section of the band was performed followed by a resection of the Meckel's diverticulum and an ileo-ileal anastomosis. The postoperative follow-up was uneventful. CASE DISCUSSION: Meckel's diverticulum results from yolk sac persistence during embryonic development, often remaining asymptomatic. However, it can lead to symptoms like abdominal pain, diarrhoea, and fever when inflamed or infected. Treatment involves surgery (diverticulectomy) for severe cases with complications, with good prognosis but associated surgical risks. CONCLUSION: The diverticulum can present a life-threatening condition. The treatment is essentially surgical. This surgery should be performed emergently to enhance the prognosis.

Pulmonary vasculitis in Behçet's disease: reference atlas computed tomography pulmonary angiography (CTPA) findings and risk assessment-management proposal.

BACKGROUND AND AIM:  Pulmonary artery aneurysms (PAAs) are the most well-defined type of pulmonary vascular complication in Behçet's disease (BD).The aim of this study is to analyze which CT pulmonary angiography (CTPA) signs are associated with serious morbidity and mortality. METHODS: The study included 42 BD patients with pulmonary vascular complications. All patients' medical records were reviewed retrospectively in terms of demographics, disease characteristics, laboratory investigations, pulmonary manifestations, arterial and/or venous thrombosis and CTPA vascular and parenchymal findings. RESULTS: Deep venous thrombosis was observed in 31(73.8%) patients, arterial thrombosis in 13(31%), peripheral arterial aneurysms in 12(286%), haemoptysis in 38 (90.5%), and fatal haemoptysis in 8(19 %) patients. CTPA revealed: in situ thrombosis in 14(33.3%) patients, true stable PAAs in 13(31), true unstable PAAs in 11(26.2%), stable pulmonary artery pseudoaneurysms (PAPs) in 7(16.7%), unstable PAPs in 17(40.5%), the latter were associated with perianeurysmal leaking in 26(61.9%) and bronchial indentation in 19(45.2%).In regression analysis, fatal outcomes were associated with age in years (p=0.035), arterial thrombosis (p=0.025), peripheral arterial aneurysms (p=0.010), intracardiac thrombosis (p=0.026) and positively associated with haemoptysis severity (p<0.001). CONCLUSION: Peripheral arterial thrombosis and/or aneurysms, intracardiac thrombosis and haemoptysis severity are predictor of fatal outcomes in BD pulmonary vasculitis. PAPs with perianeurysmal alveolar haemorrhage and/or bronchial indentation are serious CTPA signs that require prompt identification and aggressive treatment. PAPs are a more serious aneurysmal pattern than true PAAs because they are a contained rupture of a PA branch in the context of pulmonary vasculitis.

A case report of abdominal wall hydatidosis: An uncommon location.

Liver hydatid cyst fistulized in the abdominal wall is rare. The clinical symptoms were often misleading. It often poses a problem of seat diagnosis rather than a problem of its hydatid nature despite the great contribution of modern imagery. We reported this uncommon case to highlight the difficulties of preoperative diagnosis and a better operative approach. 46-year-old men consulted for right flank pain. The clinical exam revealed a right flank subcutaneous mass. An abdominal CT scan showed multicystic lesions on the right flank. The MRI showed multiple cystic lesions on the right flank with several endophytic and exophytic daughter cysts. The patient was operated on. A wide excision was adopted to remove all the cystic lesions. The postoperative follow-up was uneventful. Abdominal subcutaneous hydatid cysts cause a diagnostic problem and the treatment is controversial. Surgery remains the only curative treatment. It avoids the risk of complications such the fistula, infection, and rupture.

Post-traumatic Fibro-Osseous Lesion of the Fourth Rib Simulating a Chest Wall Tumor: A Case Report.

Post-traumatic fibro-osseous lesions (PTFOL) are a rare and benign tumor that typically affects the ribs and is probably caused by an excessive post-traumatic reactive process. PTFOL primarily affects the sixth, seventh, and eighth ribs. Here, we report a case of a PTFOL with an unusual location and expansion that simulated a malignant chest tumor. A 28-year-old male patient with a history of minor chest trauma presented with pain. Chest radiography revealed a large, well-defined lesion on the left fourth rib, and computed tomography (CT) of the chest revealed a lytic lesion-type IC on the posterior and middle arches of the left fourth rib with a cartilaginous matrix and discontinued periosteal reaction without soft tissue mass extension. Additionally, magnetic resonance imaging of the chest revealed an ovoid, expansive mass with cystic lobules and lobulated contours extending almost over the entire left fourth rib, measuring 134×47 mm in size. This mass has a low signal on T1-weighted images and a heterogeneous intermediate signal on T2-weighted images, with intense enhancement after gadolinium injection suggestive of a malignant chest tumor. A CT-guided bone biopsy confirmed the presence of an intramedullary lesion consisting of fibrous connective tissue with fusiform fibroblastic cells without atypical signs. The lesion was delimited by bone trabeculae with nibbled edges, indicating exaggerated osteoclastic activity compatible with a diagnosis of PTFOL. The patient was treated with simple analgesics, and chest pain was relieved, with an unchanged volume of the lesion at 1 year of follow-up.

An unusual occurrence of autoimmune pancreatitis after gam-Covid-Vac (Sputnik V): A case report and literature review.

The safety profile of the Sputnik V vaccine is generally reassuring. Nevertheless, an enhanced risk of new-onset of immune-mediated diseases has been increasingly reported following the adenoviral-based Covid-19 vaccine, including inflammatory arthritis, Guillain-Barré syndrome, optical neuromyelitis, acute disseminated encephalomyelitis, subacute thyroiditis and acute liver injury as well as glomerulopathy. However, no case of autoimmune pancreatitis has been reported yet. Herein, we describe a case of type I autoimmune pancreatitis that may be due to the Sputnik V Covid-19 vaccine.

Post-traumatic lateral abdominal wall hernia: a case report.

Traumatic abdominal wall hernia (TAWH) also known as blunt abdominal TAWH is uncommon. The clinical diagnosis is difficult. The authors present a case report of posthigh-energy abdominal blunt trauma causing a TAWH. Case presentation: A 36-year-women, with unremarkable past medical history, was presented to the Emergency Department after a stuck in high-speed two automobiles. She was hemodynamic, respiratory, and neurologically stable. The BMI was 36 kg/m². The abdomen was not distended with an ecchymotic lesion on the right flank. The thoracic abdominal and pelvic computed tomography (CT) scan revealed a rupture in the lateral abdominal wall muscles with a TAWH in the location of the skin ecchymoses. There was no visceral lesion or intraperitoneal fluid. A conservative treatment was indicated. The follow-up was uneventful, with hematoma resorption and no cellulitis or abscess. The patient was discharged after 1 week. An abdominal repair will be planned using a mesh. Clinical discussion: TAWH is a rare entity. The best imaging modality for diagnosis is the CT scan allowing classification of the hernia and a screen for other injuries. The presence of an isolated TAWH must lower the threshold to closely monitor or to operatively explore, given the high rate of false-negative findings at imaging features. Conclusion: TAWH should be suspected behind any blunt abdominal trauma with high energy. CT scan and ultrasound were helpful for diagnosis and the only curative treatment is surgery to avoid complications.

Acromegaly: an endocrine pathology with serious consequences / L'acromégalie : une pathologie endocrinienne à lourdes conséquences

Acromegaly is a rare endocrine disorder leading to an acquired physical disfigurement and multisystem damage. It is caused in over 95% of cases by a secreting pituitary adenoma. Latency period between disease onset and diagnosis is mainly 10 years due to progressive chronic evolution and exposure to high levels of GH and IGF-1. Here we present a case of acromegaly with over 25 years of diagnostic delay in 69-years-old male with typical features and recurrent urolithiasis. Biochemical diagnosis was confirmed by high levels of IGF-1and lack of suppression of GH during an oral glucose load. Imaging and histological study revealed a co-secreting GH/ prolactine macroadenoma. After three months of complete transphenoidal surgical resection, biochemical remission was not obtained and the patient was treated by a somatostatin receptor ligand. Based on this severe case with atypical manifestations, the diagnosis of acromegaly should be always considered.

L'acromégalie est une maladie endocrinienne rare caractérisée par un syndrome dysmorphique acquis et des atteintes multi-systémiques invalidantes en rapport, dans 95 % des cas, avec un macroadénome hypophysaire. La lente progression et l'exposition chronique aux fortes concentrations de l'hormone de croissance (Growth Hormone : GH) et de l'Insuline Growth Factor-1 (IGF-1) expliquent le retard du diagnostic de 10 ans en moyenne. Nous rapportons le cas d'une acromégalie chez un sujet âgé de 69 ans diagnostiqué après plus de 25 ans d'installation du syndrome dysmorphique et de lithiases urinaires récidivantes. Le diagnostic a été confirmé biologiquement par des concentrations très élevées et non freinables de GH et par la présence d'un macroadénome hypophysaire exprimant doublement la GH et la prolactine. Après résection chirurgicale complète, l'évaluation biologique n'a pas objectivé de rémission, d'où le recours à un traitement adjuvant par un analogue de la somatostatine. En présence de multiples atteintes atypiques et sévères comme chez ce patient, le diagnostic d'acromégalie doit toujours être évoqué.

Chest CT-scan finding of asymptomatic COVID-19 pneumonia: a prospective 542 patients' single center study.

Since asymptomatic infections as "covert transmitter", and some patients can progress rapidly in the short term, it is essential to pay attention to the diagnosis and surveillance of asymptomatic patients with SARS-COV2 infection. CT scan has great value in screening and detecting patients with COVID-19 pneumonia, especially in the highly suspected or probable asymptomatic cases with negative RT-PCR for SARS-COV2. This study aimed to detect incidentally COVID-19 pneumonia on medical imaging for patients consulting for other reasons.