Apical Mass Research Articles

Solitary extramedullary plasmacytoma of the lung with rapid transition to multiple myeloma : A rare case report and brief literature review.

Solitary extramedullary plasmacytomas (SEPs) are disease entities characterized by the local proliferation of neoplastic plasma cells, representing less than 6% of plasma cell tumors. They typically produce monoclonal immunoglobulin and are usually found in the head, neck, and, less commonly, in the lungs. SEP, in rare instances, can transition to multiple myeloma (MM) with an estimated risk between 8 and 31%. We report the case of a 72-year-old woman who sought medical attention at the emergency department due to acute onset dyspnea and syncope. Laboratory results revealed elevated creatinine, hypercalcemia, and anemia, all of which were absent at a hospitalization three months prior for tuberculosis. A chest x-ray showed a right upper lobe opacity, and a computed tomography (CT) scan demonstrated an apical lung mass with calcifications. A CT-guided needle aspiration of the mass indicated SEP. Bone marrow biopsy subsequently confirmed MM. The patient was admitted to the intensive care unit and treated with chemotherapy; however, following a complicated hospital course, she died. SEPs are an exceedingly rare form of malignancy with the potential for conversion to MM. Although the likelihood of transformation to MM in months is rare, we call for attention to the possibility of such transition and the clinical prognosis of patients with SEP. Prompt and aggressive treatment is essential, and this, to our knowledge, is the first case of conversion to MM in less than four months following the initial diagnosis of SEP of the lung.

Clinical and genetic associations of asymmetric apical and septal left ventricular hypertrophy.

Increased left ventricular mass has been associated with adverse cardiovascular outcomes including incident cardiomyopathy and atrial fibrillation. Such associations have been studied in relation to total left ventricular hypertrophy, while the regional distribution of myocardial hypertrophy is extremely variable. The clinically significant and genetic associations of such variability require further study. Here, we use deep learning-derived phenotypes of disproportionate patterns of hypertrophy, namely, apical and septal hypertrophy, to study genome-wide and clinical associations in addition to and independent from total left ventricular mass within 35 268 UK Biobank participants. Using polygenic risk score and Cox regression, we quantified the relationship between incident cardiovascular outcomes and genetically determined phenotypes in the UK Biobank. Adjusting for total left ventricular mass, apical hypertrophy is associated with elevated risk for cardiomyopathy and atrial fibrillation. Cardiomyopathy risk was increased for subjects with increased apical or septal mass, even in the absence of global hypertrophy. We identified 17 genome-wide associations for left ventricular mass, 3 unique associations with increased apical mass, and 3 additional unique associations with increased septal mass. An elevated polygenic risk score for apical mass corresponded with an increased risk of cardiomyopathy and implantable cardioverter-defibrillator implantation. Apical and septal mass may be driven by genes distinct from total left ventricular mass, suggesting unique genetic profiles for patterns of hypertrophy. Focal hypertrophy confers independent and additive risk to incident cardiovascular disease. Our findings emphasize the significance of characterizing distinct subtypes of left ventricular hypertrophy. Further studies are needed in multi-ethnic cohorts.

AN UNUSUAL LEFT VENTRICULAR APICAL MASS COMPLICATING ACUTE MYOCARDIAL INFARCTION

Abstract An 34–year–old man presented to the emergency department of our hospital with palpitations and presyncope. He was a smoker but had no others known cardiovascular risk factors. At admission, his electrocardiogram (ECG) showed sustained monomorphic ventricular tachycardia (VT) at a rate of 187 beats per minute. The VT was successfully treated with synchronized direct current cardioversion. The ECG in sinus rhythm showed Qs from V1 to V6 with ventricular repolarization anomalies in the same site suspicious for previous anterior necrosis. A transthoracic echocardiogram revealed akinetic apex, akinesia of middle segments of the interventricular septum, anterior and lateral walls, Left Ventricular (LV) ejection fraction of 30% and a large apical mass suspicious for LV thrombus. The patient was admitted to the coronary care unit and taken to the Cath lab that showed total left anterior descending mid–segment occlusion. Due to the chronicity of the condition, the patient was recommended to optimal medical therapy. Suspecting LV thrombus, the patient began treatment with unfractionated heparin i.v. and subsequently imbricate therapy with enoxaparin s.c. and warfarin. Additionally, the patient underwent subcutaneous implantable cardioverter defibrillator (S–ICD) implantation for secondary prevention of sudden cardiac death. At echocardiographic follow–up one week after discharge, the apical mass remained unchanged despite warfarin therapy with INR at target. For this reason, the patient was recommended to perform a Cardiovascular magnetic resonance (CMR). Three months after S–ICD implantation, a CMR was performed which showed transmural areas of late gadolinium enhancement involving all apical segments and middle segments of the interventricular septum which allowed the diagnosis of a large intramyocardial dissecting hematoma (IDH) of left ventricle. IDH is a rare complication of ST–elevation myocardial infarction (STEMI), it is an unusual form of subacute cardiac rupture and could be fatal. It usually consists of a cavity or channels within the myocardium. Its prognosis varies according to its location, but generally apical IDH have more favorable outcome with a higher likelihood of spontaneous retraction. We report this case because the IDH is a diagnostic challenge and it represents an extremely rare and poorly described event in the literature.

A 22-Year-Old With a Left Apical Chest Mass.

A 22-Year-Old With a Left Apical Chest Mass.

Successful Excision of the Left Ventricular Thrombus in a Young Stroke Patient

In this case report, a 29-year young male patient who presented with a history of right sided hemiparesis for 12 hours with no apparent cause. He showed no cough, palpitations, breathlessness, chest pain, syncope, or loss of vision. He had no relevant family history but had a history of two times admission in a National Neuroscience hospital for stroke. Echocardiography showed a freely mobile LV apical mass with hypokinetic apical septum and apex. He underwent successful removal of the mass via the LA roof. The postoperative TEE was normal. Histopathological examination of the resected mass revealed organized thrombus and patient had a satisfactory outcome. Bangladesh Heart Journal 2024; 39(1): 69-72

Claw Hand in Parsonage Turner syndrome

An elderly patient with an extensive smoking history presented with acute severe right-hand pain and evolving weakness with patchy sensory deficit. He had minimal relief from multiple analgesics, gabapentin, and acupuncture. Motor deficits in his right-hand progressed. A nerve conduction study confirmed motor-predominant polyneuropathy and magnetic resonance imaging (MRI) of his C-spine and brachial plexus ruled out apical lung mass or other structural lesions. A positive GalNAc-GD1a ganglioside antibody (IgG) was noted. A diagnosis of immune mediated neuralgic amyotrophy or Parsonage-Turner Syndrome was made. Intravenous immune globulin (IVIG) was started with partial improvement in motor function, six months later. Although this patient did not have SARS-CoV-2 infection nor was he recently vaccinated, this case is of interest to hospital-based internists as the Covid pandemic has seen an increase in the in reported cases of neuralgic amyotrophy worldwide due to the virus itself as well as the associated COVID-19 vaccines.

CONTRAST ECHOCARDIOGRAPHY: CURRENT APPLICATIONS AND INNOVATIONS

The ability to opacify the left ventricle and delineate the endocardium after intravenous injection of microbubble ultrasound enhancing agents (UEAs) is of established value to quantify volumes and function in suboptimal unenhanced images, particularly in stress echocardiograms. However, applications other than quantitation of left ventricle structure and function are being used in myriads of other disease states for contrast enhanced left ventricular opacification. Contrast agents enable recording of Doppler velocity signals in patients with poor ultrasound transmission, providing estimates of aortic stenosis gradient and pulmonary artery pressures. Contrast echo is of value in detecting apical hypertrophic cardiomyopathy and accompanying apical aneurysms. Most importantly, ultrasound enhancing agents can identify apical and left atrial masses when they cannot be visualized in unenhanced images, and can distinguish thrombi from tumors by visualizing the vascularity inherent in tumors. Contrast agents distinguish trabecular from compacted myocardium in noncompaction syndrome, and hypertrabeculation with other abnormal conditions. A major potential application of UEAs is myocardial opacification, which can assist in identifying nonviable myocardium. Also, the delayed reappearance of myocardial perfusion after microbubble destruction identifies impaired contrary flow and can diagnose coronary stenosis. Innovative applications of ultrasound contrast agents currently under investigation, include visualizing the vaso vasorum to identify plaques and assess their vulnerability, and theranostic agents to deliver drugs and biologists and to assist in sonothrombolysis. It is anticipated that the role of ultrasound contrast agents will continue to increase in the future.

Routine 4D Cardiac Computed Tomography to Identify Concomitant Transthyretin Amyloid Cardiomyopathy in TAVI candidates with Severe Aortic Stenosis

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Bangerter-Rhyner Foundation, Pfizer, GAMBIT foundation. Background Transthyretin amyloid cardiomyopathy (ATTR-CM) may coexist in patients with severe aortic stenosis (AS) considered for transcatheter aortic valve implantation (TAVI). The diagnosis of ATTR-CM by 99mTechnetium-3,3-diphosphono-1,2-propanodicarboxylic-acid (DPD)-scintigraphy is costly, whereas endomyocardial biopsy is associated with relevant procedural risks and sampling error. Objectives To evaluate whether ATTR-CM may be diagnosed by routine 4D cardiac computed tomography (4DCCT). Methods In a prospective screening study for ATTR-CM, the diagnostic performance of 4DCCT-based left- (LV), right ventricular (RV) and left atrial (LA) dimensions, ejection fraction (EF) and myocardial strain was evaluated against DPD-scintigraphy to identify ATTR-CM. Diagnostic predictors and a newly developed 4DCCT-score were validated by internal bootstrapping. Results Among 263 patients considered for TAVI (57% males,age 83±4.6 years) undergoing 4DCCT, DPD-scintigraphy (Perugini grade 2–3) confirmed co-existing ATTR-CM in 27 (10.3%) patients. Patients with ATTR-CM had impaired 4DCCT-based LVEF, LV global longitudinal strain (GLS), and LA-GLS. LV mass index, LV-GLS, LA-GLS and relative apical longitudinal strain (ratio of apical to basal/midventricular strain), each predicted the presence of ATTR-CM with an area under the curve (AUC) of >0.7. Implementing these parameters with cutoff-values of ≥81g/m2, ≥-14.9%, <11.5% and ≥1.7 in an unweighted score yielded high prognostic accuracy (AUC=0.89; 95%CI:0.81–0.94;p<0.001), robust to internal bootstrapping validation (AUC=0.88;95%CI:0.82–0.94). If two criteria were fulfilled, sensitivity and specificity to detect ATTR-CM were 96.3 and 58.9%, respectively. Conclusions Clinically indicated, routine 4DCCT in patients considered for TAVI provides high diagnostic yield to detect concomitant ATTR-CM, by assessing LV- and LA-GLS, LV relative apical longitudinal strain and LV mass index.

An uncanny case of paraneoplastic calcitriol mediated hypercalcaemia.

A 77-year-old female patient with a history of treated breast cancer and a recently diagnosed laryngeal cancer presented with severe hypercalcaemia associated with suppressed parathyroid hormone (PTH) levels. Her initial investigations included 25-hydroxy vitamin D levels, short synacthen test, bone scan, myeloma screen and thyroid function tests which were within normality. A computerised tomography (CT) scan showed some right lung apical fibrotic changes. Her PTH-related peptide (PTHrP) was normal and sarcoidosis was also excluded. Her previous and current malignancies were thought to be unlikely behind her hypercalcaemia. Her 1,25-dihydroxy vitamin D (calcitriol) levels were found to be elevated. Her hypercalcaemia was initially managed with intravenous fluids and intermittent bisphosphonates infusions which would transiently reduce her calcium levels. Steroid treatment was initiated which improved her hypercalcaemia; however, the calcium levels rebounded on tapering the steroids down, a pre-requisite prior to a positron emission computerised tomography (PET-CT) scan to determine the source of the excess calcitriol production. This was cancelled following an emergency admission with marked hypercalcaemia and acute renal and liver injury. A contemporary CT scan showed a right apical lung mass with hepatic lesions suggestive of a disseminated lung primary. The histology obtained from a liver biopsy was compatible with metastatic small-cell lung carcinoma. Unfortunately, her clinical condition deteriorated further and she did not survive. To the best of our knowledge, this is the first report in the literature describing calcitriol-mediated hypercalcaemia due to a small-cell lung cancer. Paraneoplastic hypercalcaemia may manifest even without overt detection of the primary cancer. The workup for paraneoplastic hypercalcaemia should be meticulous. Both bisphosphonates and steroids are useful in the initial management of calcitriol-mediated hypercalcaemia, but the definitive management is the treatment of the cause.

945 TRANSIENT LEFT VENTRICULAR THROMBOSIS TAKOTSUBO-RELATED

Abstract Background Takotsubo syndrome (TTS) is an increasingly widespread syndrome characterized by an acute and usually transient left ventricular (LV) dysfunction. Despite its transient nature, the acute phase can be characterized by serious complications such as LV thrombosis, as occurred in this case. Case description A 93-year-old woman was admitted to our emergency department due to a recent and self-limiting episode of acute chest pain. The ECG showed ST-elevation in leads V2, V3 and V4 (Fig.1), with cardiac biomarkers elevation. Transthoracic echocardiography (TTE) revealed apical akinesia and hypokinesia of the other LV segments with a severely reduced ejection fraction (EF 35%). Emergency coronary angiography showed normal epicardial coronary vessels. So, Takotsubo cardiomyopathy was hypothesized as diagnosis. A mass suspect for a thrombus was detected into the apex on day 3, despite a mild improvement of the other segments contraction (EF 40%), and clearly confirmed with the contrast echocardiography on day 5 (Fig.2). Unexpectedly, any LV thrombus was identified with cardiac MRI study performed on day 7 (Fig.3). Meanwhile, the patient never showed neurological disorders or other signs of thromboembolic complications. Echocardiography performed on day 11, before discharge, showed a great improvement of regional wall motion with residual LV apical hypokinesia (EF 55%) and no apical masses. Discussion This case emphasizes the need of frequent echocardiographic follow up in stress-induced cardiomyopathy, not only during the akinetic phase but also during the period of wall motion recovery, in order to diagnose and treat as soon as possible a LV apical thrombosis avoiding thromboembolic complications. We hypothesized that the early anticoagulation therapy combined with the initial improvement in LV wall motion facilitated the process of thrombosis resolution. Cardiac MRI played a relevant role in the comprehensive assessment of the functional and structural LV changes; the absence of late gadolinium enhancement (LGE) can be considered as a positive prognostic factor, indicating a complete resolution without residual fibrosis. Conclusion A multimodality imaging approach, based on a frequent echocardiographic follow up combined with cardiac MRI, is fundamental for an early diagnosis and a rapid treatment of LV thrombosis Takotsubo-related.

367 LEFT VENTRICULAR MALIGNANT PERIPHERAL NERVE SHEATH TUMOR, A RARE PRIMARY CARDIAC NEOPLASM

Abstract This is a case of a 71 year-old man, symptomatic for heart failure (NYHA II class), with recent weight loss and occurrence of arthralgia. In the last month episodes of non sustained ventricular tachycardia were observed. Transthoracic echocardiography showed a dilated left ventricle with reduced ejection fraction (30%) and the presence of an apical left ventricular cyst (dimensions 33×36 mm), with no doppler signal inside. No relevant valvular diseases were found. The first hypothesis was a cystic echinococcosis with left ventricle localization, but the serological testing resulted negative. In order to obtain a better characterization of the apical lesion a Cardiac Magnetic Resonance (CMR) was performed: it confirmed the apical mass with thin wall, high T2 and T1 signal and no contrast enhancement. CMR findings raised the suspicion of cardiac tumor. The case was discussed in the local heart team, and the patient was scheduled for cardiac surgery with mass removal. The histological examination showed a malignant mesenchymal neoplasm related to a primary cardiac schwannoma. Follow up outpatient visit showed a decrease of the arrhythmic burden and a progressive improvement in patient's symptoms. Echocardiography reported little improvement in EF (38%) and no suspicious lesions. MPNST (malignant peripheral nerve sheath tumor) is a type of cancer extremely rare and not fully considered in literature with a poor prognosis. CMR and echocardiography could help to early diagnose this neoplasms when dimension and localization are not prohibitive for operating.

299 LEFT VENTRICULAR APICAL THROMBUS

Abstract LV thrombus is a complication of AMI. It is estimated that 40-60% of patients with large anterior wall MI will develop a LV thrombus. The risk is highest during the first 3 months following AMI. Accurate and timely detection is important as it poses a high risk for thromboembolic events. Advances in technology have improved the detection rate of intracardiac thrombi, but several uncertainties still remain regarding the optimal treatment strategy within daily clinical practice. We report a case of large LV thrombus in a 61-year-old male with extensive anterior wall MI. A 61-year-old man, hypertension, former smoker, subjected to epatic orthotopic transplant for HCC and treated with immunosuppressive therapy (Everolimus), following development of lymphocytic leukemia in fu. He underwent thoracic ct, wich showed a hypodense imaging in the left ventricular apex referable to thrombotic formation large 2cm, with endocardial rim hypointense like ischemic outcomes. The ECG demonstrated Q waves in anterior leads and biphasic T waves in the same leads. The patient was absolutely asyntomatic. A transthoracic echocardiography, showed the apical mass (2×0,9cm) very mobile and akinesia and thinning of the left ventricol middle-apical wall with apical aneurysmatic evolution. A CMR, confirmed the presence of the thrombus and showed defects at the subendocardial layer of the anterior wall and interventricular septal with also involvement of all the apex; the burden of late gadolinium enhancement (ischemic pattern) extended to the same segment. Coronary angiography showed subocclusion involving the second tract of the left anterior descending (99%) and critical coronary stenosis of the third tract of the right coronary (70%). The thrombus was completely removed surgically through left atriotomy, in prevention of embolization due to the thrombus dimension, the motility and the labile docking station. The histological examination confirmed the thrombotic nature of the mass. International guidelines agree on recommending anticoagulation therapy for patients affected by left ventricular thrombosis. OAC with vitamin K antagonists should be started as soon as LVT is identified, as first-line therapy and parenteral anticoagulation should be discontinued when effective therapeutic range with warfarin has been achieved (INR of 2–3). European and American guidelines stressing the efficacy of parenteral therapy with heparin; there are no randomized trials that have examined the efficacy of VKA anticoagulation compared with parenteral therapy. DOACs are attractive alternatives because of their potential efficacy and safety even though there is no trial that proves the effect of DOACs in LVT. Oral anticoagulation should be discontinued as soon as thrombus resolution has been established. Surgical removal of the LVT is an option for patients with high embolic risk, as in our patient. The high morbidity and mortality of this approach outweigh the benefits of performing surgery solely for the indication of LVT.

Abstract 13682: Not All Apical Left Ventricular Masses Are Thrombi: An Unusual Case of an Apical Left Ventricular Lipoma Presenting as Chest Pain and Palpitations

Introduction: Cardiac lipomas are rare primary cardiac tumors. Depending on the location, they can present with vague symptoms such as chest pain, palpitations, dizziness, or arrhythmias. Case Presentation: A 58 y.o. female with a PMH of HLD and HTN presents for evaluation of chest pain and palpitations. An initial CvCTA was negative for significant CAD. A TTE showed a 1.6cm x 1.42 cm echolucent mobile mass attached to the lateral wall of the LV (Figure 1.A). Initially, there was a reasonable concern for an LV thrombus. However, it was unusual since the TTE revealed a normal EF and overall wall motion. Due to suspicions of a non-thrombus LV mass, a cardiac MRI was performed which showed a highly mobile mass attached to the mid anterior/anterolateral wall and a chordae within the LV cavity (Figure 1.B, Figure 1.C). The lesion was T2-hyperintense with loss of signal during fat suppression, highly suspicious for a lipoma. Given the mass mobility and strong patient preference, an elective robotic surgical resection was performed with a surgical biopsy confirming a lipoma (Figure 1.D). Discussion: Cardiac lipomas are often silent; however, symptoms can range from benign palpitations to life-threatening arrhythmias and outlet obstruction. TTE is typically the first-line imaging choice, followed by either cardiac CT or MRI imaging used for further diagnostic evaluation. Treatment options include conservative observation or prophylactic resection for asymptomatic patients, and therapeutic resection for symptomatic patients. Conclusion: Cardiac lipomas should be considered in the differential for any cardiac mass. TTE is the first-line imaging choice followed by a cardiac CT or MRI. Treatment remains a discussion between the patient and physician, varying from conservative management of symptoms to definitive treatment with surgical resection.

Established and emerging roles for ultrasound enhancing agents (contrast echocardiography).

The ability to opacify the left ventricle and delineate the endocardium after intravenous injection of microbubble ultrasound enhancing agents is of established value to quantify volumes and function in suboptimal unenhanced images, particularly in stress echocardiograms. However, applications other than quantitation of left ventricle structure and function exist for contrast enhanced left ventricular opacification. Contrast agents enable recording of Doppler velocity signals in patients with poor ultrasound transmission, providing estimates of aortic stenosis gradient and pulmonary artery pressures. Contrast echo is of value in detecting apical hypertrophic cardiomyopathy and accompanying apical aneurysms. Most importantly, ultrasound enhancing agents can identify apical and left atrial masses when they cannot be visualized in unenhanced images, and can distinguish thrombi from tumors by visualizing the vascularity inherent in tumors. Contrast agents distinguish trabecular from compacted myocardium in noncompaction syndrome, and hypertrabeculation with other abnormal conditions. A major potential application of ultrasound enhancing agents is myocardial opacification, which can assist in identifying nonviable myocardium. Also, the delayed reappearance of myocardial perfusion after microbubble destruction identifies impaired contrary flow and can diagnose coronary stenosis. Innovative applications of ultrasound contrast agents currently under investigation, include visualizing the vaso vasorum to identify plaques and assess their vulnerability, and theranostic agents to deliver drugs and biologists and to assist in sonothrombolysis. It is anticipated that the role of ultrasound contrast agents will continue to increase in the future.

IGG4-RELATED LUNG DISEASE MASKING LUNG CANCER

IGG4-RELATED LUNG DISEASE MASKING LUNG CANCER

Large pulmonary metastasis or primary lung cancer? Management particularities of an osteosarcoma case

Abstract Osteosarcoma is the most frequent malignant tumor of the bone which is diagnosed most frequently in children or young adults, with a high possibility of metastasis, especially in the lung. We report a case of 39-year male patient with a history of an above-the-knee left limb amputation after tibial osteosarcoma with no follow-ups in the last two years and with an expansive apical and left paramediastinal mass found on chest X-ray. We performed a bronchoscopy and the histopathological diagnosis of swabbed samples was fibroblastic type of classic osteosarcoma with focal areas of telangiectatic osteosarcoma and areas showing giant cells. The particularity of the case consisted in the challenge of establishing the origin of pulmonary mass. Whilst increased dimensions militated for a primary pulmonary neoplasm, the histological examination ascertained the metastatic etiology of the tumor.

A leaking food pipe: Bronchoesophageal fistula secondary to lung cancer

A 58-year-old female with advanced lung cancer, hypertension, hyperlipidemia, pulmonary artery thrombosis, bilateral subclavian artery stenosis, and vocal cord dysfunction presented to the ER with cough, shortness of breath, dysphagia, and weight loss. HR 114 bpm, RR 24/min, SpO2 95% on 4L, Temperature 36.2o C. She was lethargic, chronically ill-looking, and had bronchial breath sounds and crackles in the right upper lobe. Chest x-ray revealed enlarging previously known right upper lobe mass and loculated right pleural effusion. Contrast CT of the chest showed unchanged necrotic right apical mass, increased consolidation inferior to a mass in the right middle lobe, and metastatic infiltration of the right lateral 6th rib. She also had purulent secretions in all airways on bronchoscopy. Shortly after bronchoscopy, she had an episode of aspiration and required Intensive Care Unit (ICU) admission.

Pupillary Abnormalities After Excision of Orbital Cavernous Venous Malformations.

The aim of this study was to determine the incidence and recovery rate for pupillary abnormalities after excision of orbital cavernous venous malformations (OCVMs). Retrospective case-note and imaging review for patients with OCVMs, with an estimation of odds ratios (ORs) in relation to the position of the mass and surgical approach. The 287 included patients (176 female; 61%) presented at a mean age of 46.5 years: 243/287 (85%) OCVMs were intraconal, 253/287 (88%) located in the posterior two-thirds of the orbit, and 29/287 (11%) wedged tightly in the apex. Pupillary changes-varying from minor sectoral paresis (only evident on slit-lamp examination) to a marked mydriasis-were noted in 21% (60/287) of patients and were strongly associated with removal of intraconal (60/243 [25%]; p < 0.001), apical (14/29 [48%]; OR, 4.3; p < 0.001), inferior or inferotemporal (41/105 [39%]; OR, 5.5; p < 0.001) masses. Lateral approaches-either with (23/129; 18%) or without (30/71; 42%) osteotomy-were associated with 88% (53/60) of all abnormalities (OR, 4.1; p < 0.001). Where known, the abnormalities improved in 43/50 (86%), although 15/43 (35%) had a persistent tonic pupil. Pupillary abnormalities after excision of OCVMs can occur in up to a quarter of intraconal lesions-particularly those located inferotemporally or inferiorly-and in about a half of apical lesions. Lateral or inferolateral orbital approaches that disrupt the inferior intraconal fat appear to be associated with a higher risk. Most changes resolve or improve markedly, although a third of those affected may have a persistent tonic pupil.

A RARE PRESENTATION OF TB

TYPE: Late Breaking Abstract TOPIC: Chest Infections INTRODUCTION: Tuberculosis infection presents as persistent cough, hemoptysis, fever for more than 2 weeks , chest pain , weight loss , night sweats , loss of appetite. Tuberculosis and lung cancer have similar presenting complaints. TB often presents as a cavity , consolidation, pleural effusion or miliary tuberculosis. Here we are gong to discuss about TB presenting in a rare manifestation – A mass! CASE PRESENTATION: A 24-year-old female presented with the complaint of dry cough for 10 days. No history of dysponea , chest pain ,loss of weight, loss of appetite, hemoptysis. No known comorbidities. No history of tuberculosis previously. No relevant family history. She is a non-smoker with normal immune status. On inspection, a left supra clavicular and infra clavicular fullness is present with decreased movements. On percussion, there is dullness and absent breath sounds on auscultation in supra clavicular and infra clavicular areas. HRCT chest revealed a well defined left apical mass with minimal cavitation. CT guided biopsy revealed features suggestive of TB. DISCUSSION: TB is very common in a country like India. Even such rare presentations should not be missed in TB endemic countries. WHO initiated the STOP TB CHALLENGE which aims on eliminating tb by 2050 worldwide. One quarter of the world is estimated to be infected by TB. CONCLUSIONS: Around 1.3 million people died due to tuberculosis worldwide in 2020. TB is a curative disease if correctly diagnosed and treated timely. In such rare presentations of TB , diagnosis should be made worldwide. DISCLOSURE: No significant relationships. KEYWORD: Tuberculosis

Left Ventricular Apical Mass with Normal Ejection Fraction in a Suspected COVID-19 Patient Suffering from Acute Ischemic Stroke.

Left Ventricular Apical Mass with Normal Ejection Fraction in a Suspected COVID-19 Patient Suffering from Acute Ischemic Stroke.