Diagnostic Dilemma Research Articles

Plasmoacanthoma of Lip-A Rare Case with Review of Literature.

Plasmoacanthoma is an extremely rare benign verrucous lesion, with few cases reported in the literature, and it often goes misdiagnosed. An attempt was made to discuss the features and compare them to reduce the diagnostic dilemma in cases of plasmoacanthoma, which mimics squamous cell carcinoma, both for the clinician and pathologist. Written informed consent was obtained from the patient for the case report. Institutional ethical clearance was obtained. A review of the literature was conducted after a PubMed search with the keyword "Plasmoacanthoma" on September 20, 2023. Nine articles were obtained, out of which two were not available. One was excluded since it was on plasma cell cheilitis. Five articles, all of which were in the English language, with a diagnosis of plasmoacanthoma were retrieved for the study. A 70-year-old female presented with an ulcer-exophytic lesion involving the lower lip, mimicking a typical squamous cell carcinoma, for which an edge biopsy of the lesion was taken to confirm. Histopathology revealed it to be plasma cell mucositis. The patient was put on the medical line of management with corticosteroids as per guidelines, with no response. A wedge excision was later done as the patient was not responding to medical therapy, and the final histopathology came out to be "plasmoacanthoma". Due to their close resemblance to malignant lesions and histologically mimicking plasma cell mucositis, such lesions often get misdiagnosed, leading to inadequate management. Various sources of literature related to plasmoacanthoma were compared, and the features and histological findings were tabulated so that if any cases were similar to the present case reports, then we could have other differential diagnoses and work accordingly. Plasmoacanthoma may be present in any age group, and the clinical features may be similar to those of squamous cell carcinoma. PCM and plasmoacanthoma are clinically and histologically mimicking conditions that should be confirmed by excisional biopsy on histopathological examination rather than incisional biopsy to avoid pathological adversity, as seen in our case. IHC with kappa and lambda light chains will help identify clonal plasma cells seen in plasmoacanthoma.

Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report

BackgroundIsolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. Case ReportA 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. Why Should an Emergency Physician Be Aware of This?Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.

P-61 From Cushing to Nelson Syndrome: Diagnostic challenges and Surgical Dilemma

Abstract Introduction Diagnosis of the origin of ACTH-dependent Cushing's syndrome (CS) can be difficult in some cases, especially when MRI of the pituitary gland does not reveal an adenoma. Inferior petrosal (IPSS) or cavernous sinus sampling (CSS) with CRH stimulation helps confirm the central origin in most cases. CSS also helps lateralize the tumor within the pituitary gland with a sensitivity of 80%. Because transsphenoidal pituitary surgery is successful in the majority of MRI-negative cases, bilateral adrenalectomy is performed less frequently. Even with advanced radiologic studies, the origin may not be detected. Adrenalectomy may be an option in these cases. However, loss of feedback inhibition of the hypothalamic-pituitary-adrenal axis; can lead to aggressive transformation of an existing ACTH-secreting pituitary adenoma into Nelson's syndrome within 1-5 years. Clinical Case A 46-year-old female patient complaining of hot flashes and unable to lose weight was evaluated for CS and referred to the Department of Neurosurgery for a pituitary adenoma (Table 1). Since the adenoma was <6mm CSS with CRH stimulation was performed. The results did not support central origin (Table 2). Ectopic ACTH secretion was considered, but without finding the origin of the tumor on radiological examination, and treatment with ketoconazole and metyrapone was started for CS. However the patient then discontinued outpatient follow-up. The patient presented to our clinic 6 years later with a new pituitary MRI showing tumor growth (Fig.1b). She complained of fatigue and obesity. She was depressed and anxious. The skin on her face, hands and hump was dark and patchy (Fig.1c). During these years, she consulted several endocrinologists. MRI was performed annually. Brain MRI had showed a fronto-basal extraaxial mass lesion. The patient underwent microsurgical resection and pathology revealed a microcystic meningioma (WHO grade I). 3 months later bilateral nodular hyperplasia of adrenal gland was detected; she underwent bilateral laparoscopic adrenalectomy (no neoplasia). ACTH gradually increased up to 418pg/ml; the diagnosis of Nelson's syndrome was established. The patient underwent endoscopic transsphenoidal adenomectomy. The ACTH level was found to be 12pg/ml on the 2nd postoperative day. Pathological examination revealed a ACTH secreting pituitary adenoma (Ki-67:7%). CS patients suffer from emotional lability due to the effects of elevated cortisol and to the physical changes of their body. Proximal muscle weakness and obesity causes fatigue symptoms. The diagnosis is often delayed until complications occur. Differential diagnosis could be difficult and challenging. Patient's emotional lability could adversely affect treatment/follow-up compliance. The presented case had meningioma resection which could be delayed until remission from CD and bilateral adrenalectomy which could be avoided by endoscopic pituitary surgery. This case is a good example of the need for pituitary centers of excellence.Figure.Fig.1.a. MRI scan of the pituitary gland at first admission shows (a) a lesion extending posteriorly inferior to the right half of the pituitary gland, hyperintense at T2-weighted, iso-hypointense at T1-w, with heterogeneous contrast enhancement consistent with pituitary microadenoma (4mm*2mm) Fig.1.b. Progression in size of the adenoma (6mm*4mm) Fig.1.c. Darkening of the skin due to hypersecretion of ACTH. Table 1.Cavernous sinus sampling with corticotropin-releasing hormone stimulation Table 2.Laboratory tests in different times

A Case Report of Rheumatoid Meningitis – A Rare Condition Presenting with Neurological Deficits

Rheumatoid meningitis (RM) is a rare condition seen in patients with longstanding rheumatoid arthritis (RA). It can present with a variety of neurological symptoms and is often mistaken for other neurological conditions, especially in the setting of immune suppression in these patients. We present a rare case of RM in an elderly woman with RA that presented with focal neurological symptoms and was eventually diagnosed on brain biopsy. Our case serves to highlight the diagnostic dilemmas faced while evaluating and treating patients presenting with such an exceedingly rare condition and the importance of multidisciplinary collaboration in the management of such complex patients.

Predictors of an informative or actionable cytological diagnosis on repeat breast aspiration after an insufficient aspirate: a multicentre retrospective review

An insufficient/inadequate diagnosis on fine-needle aspiration cytology (FNAC) of the breast is not an uncommon diagnostic dilemma. This study aims to review the rate and clinical features predicting an informative...

Yolk Sac Tumor in Ascitic Fluid – Cytodiagnosis of a Rare Case

Abstract Yolk sac tumor (YST) is a germ cell tumor of gonads presenting in children and young adults. It is rare to find metastasis of the YST in effusion fluid. We report a case of a YST in a 17-year-old female diagnosed on cytological examination of ascitic fluid and confirmed histologically after resection as YST. This case not only highlights the rare possibility of metastasis of the YST in ascitic fluid cytology but also emphasizes the diagnostic dilemma it causes in diagnosing such cases in body fluids. Detailed clinical history including the age of the patient, along with serum alpha-fetoprotein (AFP) levels is essential to a make a preoperative diagnosis. Histopathology with AFP immunohistochemistry confirms the diagnosis of such lesions.

Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis.

This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis. We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery. Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/μL [standard deviation, 52 576.3/μL] vs 92 162.7/μL [59 330.6/μL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/μL [95% confidence interval, -65 355/μL to -20 213.90/μL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/μL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02). The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.

APPLICATIONS OF WEIGHTBEARING CT IN JOINT INSTABILITY

Acute syndesmotic ankle injuries continue to impose a diagnostic dilemma and it remains unclear whether weighbearing or external rotation should be exerted rotation during the imaging process. Therefore, we aimed to implement both axial load (weightbearing) and external rotation in the assessment of a clinical cohort of patients with syndesmotic ankle injuries syndesmotic using weightbearing CT imaging. In this retrospective comparative cohort study, patients with an acute syndesmotic ankle injury were analyzed using a WBCT (N= 20; Mean age= 31,64 years; SD= 14,07. Inclusion criteria were an MRI confirmed syndesmotic ankle injury imaged by a bilateral WBCT of the ankle during weightbearing and combined weightbearing-external rotation. Exclusion criteria consisted of fracture associated syndesmotic ankle injuries. Three-dimensional (3D) models were generated from the CT slices. Tibiofibular displacement and Talar Rotation was quantified using automated3D measurements (Anterior TibioFibular Distance (ATFD), Alpha Angle, Posterior TibioFibular Distance (PTFD) and Talar Rotation (TR) Angle) in comparison to a cohort of non-injured ankles.ResultsThe difference in neutral-stressed Alpha° and ATFD showed a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (P = 0.046 and P = 0.039, respectively) The difference in neutral-stressed PTFD and TR° did not show a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (P = 0.492; P = 0.152, respectively).ConclusionApplication of combined weightbearing-external rotation reveals a dynamic anterior tibiofibular widening in patients with syndesmotic ankle injuries. This study provides the first insights based on 3D measurements to support the potential relevance of applying external rotation during WBCT imaging. However, to what extent certain displacement patterns are associated with syndesmotic instability and thus require operative treatment strategies has yet to be determined in future studies.

Pneumobilia – a diagnostic dilemma between emphysematous cholecystitis and cholecysto-enteric fistula

Pneumobilia – a diagnostic dilemma between emphysematous cholecystitis and cholecysto-enteric fistula

Paediatric Clear Cell Sarcoma of Scalp Masquerading as Benign Sebaceous Cyst: A Diagnostic Dilemma

Clear Cell Sarcoma of Soft Tissue (CCSST) is a rare and aggressive tumour comprising 1% of all soft tissue sarcomas. They tend to recur locally and have a high predilection for regional, as well as, distant metastases. These tumours usually occur in a young age group; however, their presentation in childhood is extremely rare. They are also known as Malignant Melanoma (MM) of soft parts due to similar histological and Immunohistochemical (IHC) features with MM. Distinguishing between them is very difficult morphologically. Both exhibit high lymph node metastases and positive staining for S-100 protein, Melanoma antigen (Melan-A) and Human Melanoma Black-45 (HMB-45). Here, the authors reported an unusual case of an 11-year-old male child who presented with a slowly progressing scalp swelling that was misdiagnosed as a sebaceous cyst radiologically and on Fine Needle Aspiration Cytology (FNAC), which later turned out to be CCSST on histopathology. Unfortunately, the patient was lost to follow-up, but later presented with multiple cutaneous swellings, emphasising the tumour’s aggressive nature. The index case is being reported as an exception to its age of occurrence and unusual presentation that posed a diagnostic dilemma, leading to a delay in treatment. The treatment for CCSST involves wide surgical resection with negative margins, and adjuvant therapy may be considered based on resection outcomes. In conclusion, the present case underscores the diagnostic challenges posed by CCSST, particularly when it occurs in atypical age groups and locations. Timely recognition and differentiation from similar entities, such as MM, are crucial for appropriate management and improved outcomes.

Isolated Colonic Stricture Due to Crohn’s Disease: Diagnostic Dilemma and Management

Isolated Colonic Stricture Due to Crohn’s Disease: Diagnostic Dilemma and Management

Diagnostic Dilemma in Differentiating Odontogenic Pain and Non Odontogenic Pain: A Case Series

Pain is one of the most common reasons why patients seek medical attention. When experiencing discomfort in the orofacial region, a dentist is usually the first medical professional consulted. While odontogenic factors are the most common causes of acute pain in the maxillofacial region, it can also be non odontogenic, making it challenging to differentiate between the two. However, with a thorough examination, taking a complete history, and ordering necessary diagnostic tests, a dentist can make an accurate diagnosis and evaluate the entire stomatognathic system and other relevant anatomical regions. Misdiagnosis can lead to unnecessary dental procedures and cause trauma to the patients. Case 1 (50-year-old female) and case 3 (63-year-old female) were finally diagnosed as Trigeminal Neuralgia (TN), which were initially misdiagnosed as odontogenic pain and were treated with unnecessary irreversible dental treatments like Randomised Controlled Clinical Trials (RCT). Case 2 ( 28-year-old female) was eventually diagnosed as a case of myofascial pain with loss of muscle tone, for which the patient required palliative physical therapy. Instead, the splint, which was worn day and night by the patient, and soft diet resulted in muscle atrophy. The present case series emphasises the importance of accurate diagnosis to prevent irreversible dental treatment and protect patients from harm.

Potential Application of Hydrops MR Imaging: A Systematic Review.

Diagnostic dilemma between clinical Meniere's disease and radiological endolymphatic hydrops (EH) has emerged since the introduction of hydrops magnetic resonance imaging (MRI). The aim of this study is to explore the potential application of hydrops MRI on diagnosing the EH. This review was developed from peer-reviewed articles published in those journals listed on journal of citation reports. The MEDLINE database of the US National Library of Medicine, Scopus, and Google Scholar were used to collect articles based on the guidelines (PRISMA 2020 statement) for reporting reviews. Initially, 470 articles were retrieved from 1983 to 2023, and 80 relevant articles were ultimately selected. The sensitivity (69%-92%) and specificity (78%-96%) values varied from each laboratory for detecting EH via hydrops MRI, probably due to candidate selection and the grading system employed. The application of hydrops MRI allows (1) differentiation between EH and sudden sensorineural hearing loss; (2) determination of the affected side of EH; and (3) confirmation of the diagnosis of EH concomitant with other disorders. Notably, not all differentials for EH can be visualized on MR images. One of the existing gaps to be filled is that updated hydrops MRI fails to identify distortion, that is, rupture, collapse, fistula, or fibrosis of the inner ear compartments, akin to what histopathological evidence can demonstrate. Hence, enhanced ultrahigh resolution of hydrops MRI is required for demonstrating fine structures of the inner ear compartments in the future.

Twisted Paraovarian Cyst with Secondary Torsion of the Fallopian Tube: A Rare Cause of Abdominal Pain with Diagnostic Dilemma

Acute abdominal pain is one of the common reasons for patients to seek medical attention. There are multiple medical and surgical causes of abdominal pain. One uncommon cause is a twisted paraovarian cyst, which requires prompt intervention to decrease the patient’s morbidity. A paraovarian cyst is a fluid-filled sac that develops in the broad ligament and is often asymptomatic. A 38-year-old woman presented with dull aching pain in her right lower abdomen for four days. Abdominal ultrasonography revealed thickening of the segmental bowel in the right lower abdomen with adjacent oedema. The uterus and both ovaries appeared normal. Contrast-enhanced Computed Tomography (CT) showed a cystic density lesion measuring 4.0×3.3 cm, adjacent to the uterus, and the right ovary could not be visualised separately. Inflammatory changes were observed in the small bowel, extending into the right iliac region, and the appendix could not be visualised separately. An emergency laparotomy was performed, which, however, revealed a twisted paraovarian cyst along with a right fallopian tube showing signs of complete necrosis. The paraovarian cyst and the right fallopian tube were removed, and the patient had an uneventful recovery. Torsion of the paraovarian cyst with secondary torsion of the fallopian tube is a rare phenomenon and should be considered as a cause of abdominal pain in females of reproductive age group.

Foreign Body Causing Diagnostic Dilemma in Koch’s Abdomen Patient Presenting with Acute Intestinal Obstruction: A Case Report

The ileocaecal region is the most commonly affected region in Koch’s abdomen; however, it can involve any part of the Gastrointestinal Tract (GIT). Patients usually present late with either features of acute or subacute intestinal obstruction or with features of perforation peritonitis. Early diagnosis of abdominal Tuberculosis (TB) is still challenging due to the vague and non specific symptomatology of the disease. Hereby, the authors present a case report of 11-year-old boy who was on Antitubercular Treatment (ATT) for suspected abdominal TB, presented with features of subacute intestinal obstruction which subsequently had to be operated for acute obstruction. However, the cause of obstruction was not due to the complications of abdominal TB but due to the mechanical obstruction caused by the seeds of bayberry, which got obstructed in the relatively narrowed part of the ileocaecal region due to thickening of the bowel wall. No similar case reports have been found in the literature earlier. Hence, the present case is being reported.

DLBCL masquerading as synchronous primary pancreatic and testicular tumour vs metastasis: a diagnostic dilemma

DLBCL masquerading as synchronous primary pancreatic and testicular tumour vs metastasis: a diagnostic dilemma

Diagnostic dilemma: Drug reaction with eosinophilia and systemic symptoms or erythema multiforme?

Diagnostic dilemma: Drug reaction with eosinophilia and systemic symptoms or erythema multiforme?

Progressive multifocal leukoencephalopathy in HIV with atypical presentation and prognostic outcome causing diagnostic dilemma: a case report

Progressive multifocal leukoencephalopathy in HIV with atypical presentation and prognostic outcome causing diagnostic dilemma: a case report

Mucin-secreting Adenocarcinoma of the Appendix Presented as Abdominal Lump with Distension: A Case with Diagnostic Dilemma

Appendicular adenocarcinoma is a rare tumour, and the mucin variety is common. It is usually presented with symptoms such as abdominal pain, abdominal tenderness, nausea, vomiting, change in bowel habits, and unexplained weight loss. These symptoms can resemble those of other clinical conditions, making the diagnosis of appendicular adenocarcinoma challenging. Screening modalities such as Magnetic Resonance Imaging (MRI), Computed Tomography (CT) imaging, Contrast-Enhanced Computed Tomography (CECT), blood tests, and histopathological analysis can help confirm the diagnosis. This case is reported to highlight the unusual presentation and diagnostic difficulties associated with appendiceal adenocarcinoma. A 48 years old female patient presented with complaints of dull, continuous abdominal pain for the past six months, along with an abdominal lump and distension, without any other associated symptoms. Laboratory investigations for Cancer Antigen 125 (CA 125), β-Human Chorionic Gonadotropin (HCG), and α-fetoprotein were found to be within normal limits. Further, CECT imaging was suggestive of mucin-secreting adenocarcinoma of ovarian origin. The final diagnosis was confirmed by histopathological analysis as mucinsecreting adenocarcinoma of the appendix with pseudomyxoma peritonei and was managed through cytoreduction surgery.

A diagnostic dilemma in evaluating- acute on chronic right hypochondriac pain: Can two pathologies co-exist?

A diagnostic dilemma in evaluating- acute on chronic right hypochondriac pain: Can two pathologies co-exist?