The authors report a case of a 6-year-old girl who developed subacute intestinal obstruction after a trivial blunt trauma to her abdomen. Her normal vital signs masked the presence of intestinal bleeding. An incidental finding at surgery of a haematomatous polypoid vascular growth of the ileum was subsequently confirmed to be cavernous haemangioma of the small bowel. Surgical resection was curative in this patient.
Pulmonary Langerhans cell histiocytosis (LCH) in children is more extensive and is a rare cause of spontaneous secondary pneumothorax (SSP) which tends to be recurrent and refractory to conventional treatment. Its occurrence in paediatric patients posed great challenge to the choice of surgical management. Surgery in the form of pleurodesis is only considered if SSP does not improve after chemotherapy and after considering all relevant risk and benefits of surgery to patients. Chemical pleurodesis will not give the expected effect to eradicate SSP in this patient. Therefore mechanical pleurodesis is the treatment of choice. There are various techniques to perform mechanical pleurodesis; from pleural abrasion to pleurectomy. In the authors' experience, bilateral total pleurectomy provided the best outcome for this 9-year-old patient with persistent respiratory distress from SSP due to extensive pulmonary LCH.
A 30-year-old ex-smoker with a background history of childhood asthma presented with worsening shortness of breath despite receiving high doses of oral corticosteroid for pemphigus vulgaris which was diagnosed 5 years earlier. A high-resolution CT examination of the thorax reported non-specific bronchiectatic changes and revealed an incidental suprarenal mass. A subsequent CT scan confirmed a large adrenal mass with areas of necrosis and calcification. Serum renin and aldosterone, urinary catecholamine and 5-hydroxyindoleacetic acid were within normal limits. Surgical intervention was delayed due to difficulty in optimising preoperative respiratory functions. He finally underwent a midline laparotomy for removal of the tumour. Histopathological examinations revealed extrapulmonary inflammatory myofibroblastic tumour arising from the periadrenal soft-tissue, with presence of normal adrenal gland. He showed immediate improvements of his asthmatic symptoms and pemphigus vulgaris following the surgery. His oral steroid was rapidly reduced and he achieved complete remission 2 months later.
Osmotic demyelination syndrome commonly affects the pons and infrequently involves the extrapontine region. We report a patient with severe hyponatraemia who developed osmotic demyelination syndrome as a consequence of rapid sodium correction. The condition manifested as acute severe parkinsonism, bilateral ptosis and gaze impairment. MRI revealed typical features of central pontine and extrapontine myelinolysis. The patient improved gradually after treatment with a combination of levodopa, intravenous immunoglobulin and dexamethasone. However, it is important to emphasise that the improvement of neurological symptoms is not necessarily causal with these experimental therapies.
A middle-aged woman with recurrent malignant melanoma presented initially with massive left pleural effusion. There was a complete obliteration of the left main bronchus on flexible bronchoscopy caused by a mass. Serial cryo-debulking of the tumour was done under rigid bronchoscopy; however, the outcome was not favourable due to the aggressive tumour growth. Vemurafenib was planned after thoracic radiation. She was not keen for the biologics treatment due to financial constraints. We report a case of central airway obstruction due to recurrent aggressive melanoma. More evaluations are needed on the role of interventional pulmonologist for bronchoscopic debulking of this rapidly growing tumour as well as the role of biological agents in treating such cases.
Solid variant of papillary thyroid carcinoma (PTC) is a rare, poorly characterised variant and predominantly reported in children with a history of radiation exposure. This variant has a high propensity for extra-thyroidal extension and cervical lymph node metastases. A 14-year-old Malay girl who had no history of radiation exposure, presented with multiple cervical lymphadenopathy and it was clinically suspicious for tuberculosis or lymphoma. An incisional biopsy revealed a metastatic PTC. The patient underwent total thyroidectomy with bilateral lateral neck dissection and histopathology report was solid variant of PTC. Whole-body I(131) scan was performed which revealed an intense tracer uptake in the neck. She was planned for radioactive iodine ablation and now on regular follow-up for monitoring of possible tumour metastasis.
SummarySchwannoma, a type of benign neurological tumour arising from Schwann cells, is commonly seen in the head and neck region. However, the incidence of cervical lymph node schwannoma is extremely rare, with only two cases reported in the literature. Schwannomatosis is a disease characterised by a constellation of multiple schwannomas seen in a patient, guided by at least one confirmational histological diagnosis. This is a case of a painless progressively enlarging submandibular swelling which is confirmed as a schwannoma based on histology. The patient is also diagnosed with schwannomatosis as the patient has multiple neurological tumours. Nodal schwannoma has a good prognosis and no documentation of recurrence in the literature. It may arise from sympathetic nerves located within the lymph node.
We present a case of a 20-year-old Malay man with underlying tuberculous (TB) lymphadenitis who presented with shortness of breath and found to have submitral left ventricular aneurysm (SLVA). SLVA is well recognised but rare. Incidence of SLVA in Malay has never been documented. This is the first reported case of SLVA in Malays with concomitant thoracic aorta mycotic aneurysm. TB has been reported to be associated with SLVA. Treatment is either surgical or conservative. Imaging is required for diagnosis and preoperative assessment. Multimodality imaging include echocardiography (ECHO), cardiac CTangiography and the robust multiparametric cardiac MR (CMR). ECHO is the first line imaging and useful for initial detection of the aneurysm. CMR including the late gadolinium enhancement allows excellent visualisation of the LV aneurysm, tissue characterisation, cardiac function and detection of associated pathology as shown in this case.
Complications of stroke can include neuropsychiatric symptoms. However, post-stroke psychosis is rare. We report a case where an acute presentation of psychosis, depression and fluctuating cognitive impairment in a middle-aged man turned out to be related to a silent brain infarction. The patient had a background of poorly controlled type 2 diabetes mellitus with glycated haemoglobin level of 9.0-11.0%, hypertension and ischaemic heart disease. His CT brain results showed multifocal infarct with hypodensities at bilateral lentiform nucleus and bilateral corona radiata. His strong genetic predisposition of psychosis and a history of brief psychotic disorder with complete remission 3 years prior to the current presentation might possibly contribute to his post-stroke atypical neuropsychiatric presentation, and posed diagnostic challenges. He showed marked improvement with risperidone 6 mg nocte, chlorpromazine 50 mg nocte and fluvoxamine of 200 mg nocte. The need of comprehensive treatments to modify his stroke risk factors was addressed.
We reported a case of a woman with no past medical illness who presented with a few days' history of fever, myalgia, arthralgia, hypochromic microcytic anaemia and thrombocytopaenia and who was nonstructural protein 1 antigen (NS1Ag)-positive. Haemolytic anaemia including full blood picture work-up revealed high reticulocyte count and haemolysis with positive direct Coombs test. She was started on prednisolone and was discharged well.
Pseudoaneurysm of the ankle involving the posterior tibial artery is a rare presentation with only four paediatric cases previously reported in English literature. We report a new case following blunt trauma with the clinical presentation and management strategy. A 6-year-old boy presented with a pulsatile swelling at the medial aspect of ankle following a history of blunt trauma 3 weeks ago. Imaging confirmed pseudoaneurysm involving the distal posterior tibial artery. Excision of the pseudoaneurysm was performed without any complication.
Metastatic cancer to the oesophagus is rare. Most cases are diagnosed at autopsy or surgery. The breast is the most common organ bearing a primary tumour. Metastatic oesophageal tumours are nearly always located in the submucosal layer with normal benign-looking mucosa, rendering tissue diagnosis difficult. In the absence of breast-related symptoms, the diagnosis of oesophageal metastasis from breast primary would be very challenging. We report a case of a 50 year-old woman, who was referred to our centre for a second opinion after she was offered an esophagectomy for a suspected oesophageal carcinoma. She presented solely with dysphagia and weight loss. Multiple investigations were performed to investigate her dysphagia which eventually led to the diagnosis of metastatic breast cancer with oesophageal involvement. She underwent excision of right breast invasive lobular carcinoma with axillary dissection. She completed her adjuvant chemoradiotherapy and currently on daily dose of tamoxifen, whereby her dysphagia has dramatically improved.
Aggressive angiomyxoma is a benign soft tissue tumour usually affecting the pelvis and perineum predominantly in women. Because of its variable presentation, this tumour is often clinically misdiagnosed as liposarcoma. We describe a case of a 38-year-old woman who presented with a large perineal and gluteal mass which increased in size in one year. Ultrasound showed hypoechoic mixed solid and cystic mass. Contrasted CT and MRI examinations showed typical appearance of swirling and layering pattern. She had undergone TAHBSO as the mass was difficult to dissect intra-operatively. The post-operative specimen confirmed to be an aggressive angiomyxoma.