Asymptomatic Man Research Articles

Lymphatic and venous malformation or “lymphangiohemangioma“ of the anterior mediastinum: case report and literature review

Lymphatic and venous malformations (LVM) are tumor-like lesions combining dysplastic lymphatic and venous vessel structures. They are rarely found in the mediastinum. We present a case of mediastinal LVM, with review of the literature. An asymptomatic 60-yearold man presented for evaluation of an anterior mediastinal mass. On chest computed tomography (CT), the mass demonstrated contrast enhancement and its 7-mm vein draining directly into the left brachiocephalic vein. The tumor was resected completely using video-assisted thoracoscopic surgery. The surgical specimen revealed combined features of venous and lymphatic dysplasia, and was diagnosed it as LVM, so-called mediastinal lymphangiohemangioma. Management plans based on precise imaging studies using magnetic resonance imaging and multi-detector-row CT phlebography could be helpful in guiding both preoperative diagnosis and subsequent treatment decisions for mediastinal LVM.

Pulmonary Tumor With Notochordal Differentiation

Intraosseous benign notochordal cell tumor (BNCT) is a lesion postulated to be of notochordal cell origin. BNCT has recently been recognized as a potential precursor of classic chordoma, a rare malignant neoplasm usually presenting in the sacrococcygeal region, skull base, or mobile spine. Extra-axial chordoma is extremely rare, and only 2 cases of pulmonary chordoma have been reported previously. We describe herein 2 cases of hitherto-unreported lung tumors that were diagnosed as BNCT. The patients were a middle-aged asymptomatic man and woman who were each incidentally found to have a 15-mm pulmonary nodule on computed tomography. They underwent surgical resection of the tumors under a diagnosis of probable benign tumor of uncertain nature. Histopathologically, both tumors showed solid sheets of peculiar adipocyte-like univacuolated cells, multivacuolated cells, and less vacuolated cells with small, round nuclei and mildly eosinophilic cytoplasm. Mitosis was absent. These features were typical of BNCT. Immunohistochemically, the tumor cells in both cases were positive for brachyury, a transcription factor essential for notochordal cell differentiation and for other markers of notochordal cells including cytokeratins, vimentin, and S-100 protein. Postoperatively, extensive radiographic examination of the whole body revealed no evidence of a primary tumor elsewhere, and both patients are alive and well, with no evidence of disease 1 year after surgery. These 2 cases raise the possibility of a new explanation for the histogenesis of extra-axial chordomas: BNCT may be a precursor lesion of not only conventional axial chordoma but also of extra-axial chordoma.

Open surgical repair using a reimplantation technique for a large celiac artery aneurysm anomalously arising from the celiomesenteric trunk

Celiac artery aneurysms anomalously arising from the celiomesenteric trunk (hepatosplenomesenteric trunk) are rare, with only four patients reported thus far. Surgical intervention for this condition is challenging, particularly when the aneurysm is large and in a retropancreatic location. We report an open repair surgery in a 54-year-old asymptomatic man who presented with a saccular calcified aneurysm (diameter, 4.0 cm) of the celiac artery originating from the celiomesenteric trunk. Our technique involved minimal dissection of the surrounding vessels and complete aneurysm resection, along with revascularization of the hepatic, splenic, and superior mesenteric arteries with a single anastomosis.

Variable Prostate-specific Antigen Management Patterns by Nonurologist Providers at a Tertiary Care Medical Center

To determine prostate-specific antigen (PSA) management patterns of nonurologist providers. Urologists are involved in the management of men's prostate health. In practice, nonurology providers are more likely to see patients in the screening setting. Survey questions were designed to evaluate a nonurologist's approach to PSA screening. The survey instrument was distributed to physicians and physician extenders in fields of internal medicine and family practice at a tertiary-care medical center. Of 116 nonurologist providers, 86 (74%) completed the survey. There was variability with respect to the age at which to screen the index patient (asymptomatic white man without a prostate cancer family history): 16% initiated screening at 41-50 years of age and 77% at 51-60 years. Additionally, heterogeneity was found with regard to categorizing an elevated PSA level, with 62% of providers using an absolute PSA cutoff of >4 ng/mL and only 27% citing age-specific criteria. When diagnosing an asymptomatic man with an elevated PSA level, most providers will recheck PSA in 3-6 months (38%) or initiate a trial of empiric antibiotics (30%). Only a smaller fraction will refer the patient to a urologist (21%) or repeat PSA test immediately within 2-4 weeks (11%). We noted variability in PSA management patterns by nonurologists. Only 27% of providers used age-specific criteria, and almost 70% managed an elevated value by rechecking at a delayed interval or initiating a trial of antibiotics. This suggests that education might be necessary to create uniformity in PSA screening amongst nonurologists.

Isolated Dissection of the Superior Mesenteric Artery with Associated Median Arcuate Ligament Compression of the Celiac Artery in an Asymptomatic Patient

Introduction A 45-year-old man presented to the vascular laboratory for evaluation of an abdominal bruit and was found to have a superior mesenteric artery (SMA) dissection in conjunction with median arcuate ligament syndrome. This case study details the course of his evaluation and the importance of thorough examination in ultrasound exams. Methods A duplex ultrasound exam was performed with an ATL HDI 3500 sonographic unit with a 5.2 MHz curvilinear transducer. Results A 45-year-old asymptomatic white man reported to his physician for a routine physical. During the examination, the physician heard an abdominal bruit and referred the patient to the vascular lab for a mesenteric duplex ultrasound. The duplex ultrasound showed chronic dissection of the SMA with severe narrowing in the true lumen, and the celiac artery Doppler showed classic velocity increase with respiratory variation consistent with Median Arcuate Ligament Syndrome. A computed tomography angiogram later confirmed the diagnosis. Conclusion Isolated SMA dissection is an exceedingly rare condition that has only been reported 55 times in literature. Median arcuate ligament syndrome occurs more frequently, but its presence in conjunction with SMA dissection has only been reported in literature once. Undiagnosed SMA dissection can lead to bowel necrosis, mesenteric ischemia, or death. The careful attention by the referring physician to an abdominal bruit and the prompt use of Duplex ultrasound facilitated the discovery of a rare, serious, and potentially fatal dissection of the SMA, as well as median arcuate ligament syndrome.

A giant right coronary artery aneurysm as an incidental finding

We present the case of a 63-year-old asymptomatic man, with a diastolic murmur who was submitted for echocardiographic assessment. He was hypertensive and smoker. Two-dimensional transthoracic echocardiogram revealed a moderate aortic insufficiency and an abnormal extracardiac shadow on the right cardiac border ( Figures A and B , arrows). There were no other …

Real time three-dimensional echocardiographic evaluation of a congenitally corrected transposition of the great arteries in a 64-year-old asymptomatic man

Real time three-dimensional echocardiographic evaluation of a congenitally corrected transposition of the great arteries in a 64-year-old asymptomatic man

A Clear Cell Tumor of the Lung Presenting as a Rapidly Growing Coin Lesion: Is It Really a Benign Tumor?

There are few reported cases of clear cell tumor of the lung, a very rare benign mesenchymal neoplasm. We describe a 41-year-old asymptomatic man who presented with a coin lesion in a routine chest roentgenogram that was absent in a roentgenogram performed a year earlier. After a thorough workup, including radionuclide scintigraphy, the diagnosis of cell tumor of the lung was established. Somatostatin receptor positivity was demonstrated, and this clear cell tumor of the lung had a rapid growth rate. Because of these features, the benign nature of such a tumor remains questionable.

Imaging findings of myomatous-type angiomyolipoma of the liver

Angiomyolipoma of the liver is a rare benign mesenchymal tumor, comprising three tissue components: blood vessels, smooth muscles, and adipose cells. Depending on the predominance of these components, tumors are categorized into various types, out of which the myomatous variant is the most rare. Most of these tumors are detected incidentally and are solitary when discovered. Definitive preoperative diagnosis is often difficult because the radiological appearance of hepatic angiomyolipoma can be non-specific and varied. This is because the distribution and relative proportion of the three tissue components vary widely from tumor to tumor. Here, we present ultrasonography (US), multidetector computed tomography (CT), and magnetic resonance imaging (MRI) findings with pathological correlations of myomatous angiomyolipoma of the liver in a 21-year-old asymptomatic man who had no history of liver disease, hepatitis, or tuberous sclerosis. The tumor was hypoechoic on US and showed wash-in in the arterial phase and wash-out in the portal-venous phase on both dynamic contrast-enhanced CT and MRI. Additionally, the lesion was hypointense in the hepato-biliary phase on MRI obtained two hours after gadobenate dimeglumine administration and was not clearly identified from fat tissue in the in-phase/opposed-phase T1-weighted sequences.

Central Corneal Melting Associated with Reformulated Generic Diclofenac in a Patient with Inferior Fornix Foreshortening

PurposeTo report a case of corneal melting in a patient with fornix foreshortening being treated with reformulated generic diclofenac.MethodsCase report.ResultsAn asymptomatic 76-year old man presented with central corneal melting while being treated with reformulated generic diclofenac. This formulation did not contain the vitamin E derivative, tocophersolan, which has been felt to contribute to corneal melting associated with generic diclofenac in the past. Other factors for corneal melting included multiple medication use and altered forniceal architecture, but did not include previous corneal or cataract surgery. Following discontinuation of the topical medications and temporary tarsorrhapy, the defect reepithelialized.ConclusionIn patients with a compromised ocular surface, reformulated generic diclofenac has the potential to cause corneal melting without prior cataract or refractive surgery. Use should not be indiscriminate or without close supervision.

Complete Left-sided Pericardial Defect in a Lung Cancer Patient Undergoing Pneumonectomy without Closure of the Defect

A 61-year-old asymptomatic man underwent a left pneumonectomy for Stage IIIA lung cancer. At thoracotomy, the pericardium was found to be completely absent; however, we did not close the defect. Although the heart was rotated toward the left pleural cavity in the postoperative chest computed tomography (CT), the postoperative course was uneventful, and the patient has remained asymptomatic for 7 months, since the resection. We reviewed the preoperative chest CT, which showed the heart extending unusually to the left, but the pericardial defect was not evident. Complete pericardial defects usually do not endanger the lives of patients, and if the patient is asymptomatic, surgical repair of the defect may be unnecessary even during a left pneumonectomy.

An Unusual Cause of Hemoptysis-Aberrant Origin of the Left Pulmonary Artery from the Ascending Aorta in the Adult

Aberrant origin of a pulmonary artery from the ascending aorta is an uncommon congenital vascular malformation with poor survival without surgery. In this case report, we describe the unusual late diagnosis of this congenital malformation in an otherwise asymptomatic young man presenting with mild hemoptysis. We review the natural and modified history of this defect and the relevant aspects of follow-up in adult life.

Fine-needle aspiration of intrapancreatic accessory spleen, mimic of pancreatic neoplasms.

Intrapancreatic accessory spleen (IPAS) is a congenital abnormality, which mimics neoplasm. Distinguishing IPAS from pancreatic neoplasm/malignancy is extremely important from a treatment perspective. We report the case of a 67-year-old asymptomatic man who had a 1.3-cm, incidentally detected, pancreatic tail mass. The mass was round, well-circumscribed, and hypervascular with uniform enhancement. The image findings were highly suggestive of a pancreatic endocrine neoplasm. An endoscopic ultrasound-guided fine-needle aspiration was performed. Conventional smears revealed a polymorphous population of lymphocytes admixed with a subset of other inflammatory cells. Hematoxylin-eosin–stained cell block sections showed conspicuous thin-walled blood vessels in addition to inflammatory cells. Immunostaining for CD8 demonstrated strong positivity in endothelial cells of the thin-walled vessels. By correlating the cytologic findings with the result of immunostaining, we rendered the diagnosis of IPAS. Our experience supports the view that endoscopic ultrasound-guided fine-needle aspiration may enable a reliable, preoperative diagnosis of IPAS and thus prevent unnecessary surgery.

Fine-Needle Aspiration of Intrapancreatic Accessory Spleen, Mimic of Pancreatic Neoplasms

Intrapancreatic accessory spleen (IPAS) is a congenital abnormality, which mimics neoplasm. Distinguishing IPAS from pancreatic neoplasm/malignancy is extremely important from a treatment perspective. We report the case of a 67-year-old asymptomatic man who had a 1.3-cm, incidentally detected, pancreatic tail mass. The mass was round, well-circumscribed, and hypervascular with uniform enhancement. The image findings were highly suggestive of a pancreatic endocrine neoplasm. An endoscopic ultrasound-guided fine-needle aspiration was performed. Conventional smears revealed a polymorphous population of lymphocytes admixed with a subset of other inflammatory cells. Hematoxylin-eosin–stained cell block sections showed conspicuous thin-walled blood vessels in addition to inflammatory cells. Immunostaining for CD8 demonstrated strong positivity in endothelial cells of the thin-walled vessels. By correlating the cytologic findings with the result of immunostaining, we rendered the diagnosis of IPAS. Our experience supports the view that endoscopic ultrasound-guided fine-needle aspiration may enable a reliable, preoperative diagnosis of IPAS and thus prevent unnecessary surgery.

The Utility of Cardiopulmonary Exercise Testing to Detect and Track Early-Stage Ischemic Heart Disease

Evidence demonstrating the potential value of noninvasive cardiopulmonary exercise testing (CPET) to accurately detect exercise-induced myocardial ischemia is emerging. This case-based concept report describes CPET abnormalities in an asymptomatic at-risk man with suspected early-stage ischemic heart disease. When CPET was repeated 1 year after baseline assessment, his cardiovascular function had worsened, and an anti-atherosclerotic regimen was initiated. When the patient was retested after 3.3 years, the diminished left ventricular function had reversed with pharmacotherapy directed at decreasing cardiovascular events in patients with coronary artery disease. Thus, in addition to identifying appropriate patients in need of escalating therapy for atherosclerosis, CPET was useful in monitoring progression and reversal of abnormalities of the coronary circulation in a safe and cost-effective manner without the use of radiation. Serial CPET parameters may be useful to track changes marking the progression and/or regression of the underlying global ischemic burden.

Asymptomatic Mediastinal Lipomatosis

A 58-year-old asymptomatic man with a history of gout presented for a routine physical examination. He was obese (weight, 91 kg; body-mass index [the weight in kilograms divided by the square of the height in meters], 31.1) and had decreased breath sounds at the right lung base. A chest radiograph revealed mediastinal widening with increased lucency (Panel A, arrows). Computed tomography (CT) of the thorax performed after the intravenous administration of contrast material revealed posterior collections of fat on both sides of the mediastinum, extending from the superior mediastinum to the diaphragm. The fat surrounded the heart and mediastinal structures . . .

Hepatic Paragonimiasis Revealed by FDG PET/CT

A 72-year-old asymptomatic man with a hepatic lesion incidentally detected by ultrasonography in routine examination undertook fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography for further evaluation. The images revealed increased FDG activity in the lesion, which was suggestive of malignancy. However, the pathologic examination demonstrated that the lesion was a granuloma caused by Paragonimus westermani, a lung fluke. Although increased FDG activity in the lung due to P. westermani infection is expected and reported previously, such lesion identified in the liver by FDG positron emission tomography/computed tomography is unusual.

Fortuitous Discovery of Partial Uhl Anomaly in a Male Adult

We report the case of a 44-year-old man referred to our institution for suspicion of arrhythmogenic right ventricular (RV) cardiomyopathy. Both familial and personal medical histories were unremarkable, except the notion of a slight unexplored heart murmur during childhood. He decided to undergo a “40s” medical checkup. On presentation to the general practitioner, he had described a slight fatigue for 8 months without concomitant stress. Physical examination revealed no abnormality. ECG showed a type I atrioventricular block and a complete right bundle-branch block (Figure 1A). Transthoracic echocardiography showed an unusual left ventricle (LV) with a leftward curveted interventricular septum (IVS) and preserved global and segmental LV systolic function, suggestive of high systolic RV pressure or takotsubo cardiomyopathy (Figure 1B and Movie I in the online-only Data Supplement). However further analysis showed normal systolic pulmonary artery pressure and LV filling pressures. The apical 4-chamber view showed an abnormal RV with an aneurysm-like shape of the basal lateral free wall (Figure 1B and Movie II in the online-only Data Supplement) but with normal kinetics. A first cardiac magnetic resonance image showed biventricular abnormalities, particularly focused on RV wall motion, which justified additional morphological investigations. No abnormal pulmonary venous return was noticed. Invasive coronary angiogram was normal. The patient was later referred to our unit by his attending cardiologist and underwent invasive hemodynamics and biventricular contrast angiography. Cardiac index (pulmonary artery thermodilution) and biventricular volumes were normal. Blood gas content analysis disclosed an intracardiac shunt. RV angiography (Figure 2A and 2B) showed a truncated RV apex and the absence of trabeculations in the anteroapical and inferoapical zones, therefore characterized by a smooth …

Bilateral phacomorphic angle-closure glaucoma in a highly myopic patient secondary to isolated spherophakia

Background Angle closure most commonly occurs in older hyperopic patients as a result of primary relative pupil block. Less frequently, angle closure occurs in highly myopic patients with conditions other than primary relative pupil block. This report presents the diagnosis, pathophysiologic mechanism, and management of a patient with both high myopia and bilateral advanced phacomorphic angle-closure glaucoma caused by isolated spherophakia. Case A 40-year-old asymptomatic man with very high myopic astigmatism presented with chronic angle closure and an intraocular pressure of 42 mmHg in both eyes. Additionally there was a nonmyopic fundus and 24-mm axial length, with a clear crystalline lens protruding through the pupillary plane in each eye, confirmed by B-scan ultrasonography. Gonioscopy and A-scan and B-scan ultrasonography identified the pathogenesis of intraocular pressure elevation, angle closure, and high myopia to be lenticular in origin. Initial medical therapy and subsequent laser iridotomy relieved the pupil block angle closure and successfully lowered intraocular pressure. Conclusion Angle closure can occur in highly myopic eyes. Careful gonioscopy and ultrasonography can lead to the correct diagnosis and tailored management for these eyes. Phacomorphic angle-closure glaucoma from spherophakia is associated with Weill-Marchesani syndrome as well as a few other uncommon syndromes. Isolated pseudophakia is a rarely reported cause of phacomorphic angle closure.

S1269 Screening, Referral Practice and Management of Hepatitis B and C in Primary Care: A Survey of General Practitioners

Introduction In order to optimise our viral hepatitis service, we wished to assess the knowledge and referral practice of primary care physicians in our local area. General practitioners (GPs) have a vital role in the identification of patients who require screening for hepatitis B (HBV) and C (HCV), referring appropriately, and in supporting treatment in conjunction with the hepatitis clinic. The area around QEH has a prevalence rate of 3% positive HBsAg in the antenatal population and ∼100 new positive HCV antibody tests per year. Aim to assess GP knowledge of and attitudes to HBV and HCV with respect to transmission, screening, serological tests, referral to secondary care and treatment. Methods A survey containing 32 questions was sent to GPs within our catchment area. Where there was no response after several months, the questionnaire was reissued. Results 45/161 (28%) questionnaires were completed and returned. Demographics: Mean age 46 years (20f; in general practice 14 years (1–35); 96% of practices had >5000 patients. 90% of respondents would attend an educational seminar on viral hepatitis. Only 36% of GPs thought all patients with chronic HBV should be managed in secondary care, compared with 59% for HCV. 8/45 (17%) knew how to correctly screen for HBV and 30/45 (67%) knew how to assess response to HBV vaccination. Two scenarios for HBV were presented: a pregnant woman found to be surface antigen positive on screening; and a Nigerian man known to be surface antigen positive, who had an alanine aminotransferase (ALT) four times the upper limit of normal. Only 24/45 and 16/45, respectively, would refer these patients to a specialist. Further scenarios for HCV: an asymptomatic woman with a reactive HCV antibody at blood donation and normal ALT; and an asymptomatic man with a reactive HCV antibody and an ALT five times the upper limit of normal, yielded 21/45 and 29/45 potential referrals, respectively. Conclusion Without a basic understanding of chronic viral hepatitis, including a knowledge of who and how to screen for HBV and HCV, and when to refer, a significant proportion of patients will not receive appropriate treatment. In the longer term this will result in an increased incidence of the complications of HBV and HCV with important implications for hepatology services. Improved training and education are required for general practitioners and hospitals should provide clear management guidelines to local GPs.