Differential Diagnosis Of Women Research Articles

The role of sacro-iliac joint magnetic resonance imaging in the diagnosis of axial spondyloarthritis: focus on differential diagnosis in women.

To review the role of sacro-iliac magnetic resonance imaging (MRI) in the diagnosis of axial spondyloarthritis (AxSpA), with a focus on gender differences. The experience of the authors and the results of an informal literature review are reported. Inflammatory changes of the sacro-iliac joint are the hallmark of AxSpA. Early, non-radiographic sacroiliitis may be diagnosed with MRI through the assessment of bone marrow edema (BMO) as well as concomitant structural damage. The MRI protocol should include three necessary sequences, i.e., fat-saturated T2-weighted sequences on two orthogonal planes, T1-weighted semi-coronal sequence, and fat-suppressed T1-weighted semi-coronal sequence. Inflammatory changes comprise required signs (BMO and/or osteitis) and additional signs, including synovitis (better defined as joint space enhancement), enthesitis, and capsulitis. Structural changes consist of erosions, sclerosis, fat metaplasia, and ankylosis. Due to mechanical axial strain, inflammatory changes in the sacro-iliac joint can be found in healthy individuals, runners, and patients with nonspecific low back pain. The prevalence of BMO is higher in women during pregnancy and postpartum, even 12 months after childbirth, but the extent and distribution of MRI findings may help in the differential diagnosis. Other challenges in the MRI diagnosis of sacroiliitis are subchondral T2 hyperintensity during developmental age, periarticular sclerosis in healthy subjects, or osteitis condensans ilii, and several pathological conditions that may mimic AxSpA, some of which are more frequently found in women. The described diagnostic challenges impose a multidisciplinary approach combining imaging findings with clinical and laboratory data.

Traumatic Rupture of Dermoid Cyst in Early Pregnancy: Diagnosis and Management in Peki Government Hospital Resulting in a Successful Delivery at Term

Introduction: Dermoid cyst is the commonest germ cell tumour, constituting about 20% of adult ovarian tumours. They are mostly asymptomatic, but complications such as torsion, rupture, and malignant transformation have been reported. Only a few cases of ruptured mature cystic teratoma in early pregnancy have been described and even fewer are those in early pregnancy with the pregnancy successfully carried to term with successful delivery. Case Presentation: We present a case of a grand multiparous woman who presented to Peki Government Hospital at 11 weeks gestation with an acute abdomen following a fall. She had been diagnosed with a dermoid cyst a week with dimensions of 20cm x15 cm before the presentation. Ultrasound diagnosis of a possible rupture of the cyst was made on admission. Right oophorectomy was done at laparotomy. She had progesterone support for the succeeding 4 weeks and the pregnancy was successfully carried to term with good outcomes at delivery for both mother and baby. The APGAR score for the baby at 1minute and 5minute after birth were 7/10 and 8/10 respectively. Conclusion: Traumatic rupture of dermoid cyst should be considered as a differential diagnosis in women presenting with acute abdomen in early pregnancy. Laparotomy with abdominal lavage is a viable management option in a low-resource setting.

Foot drop and cyclic sensory disturbance of the right lower limb due to endometriosis

We report the case of a 40-year-old woman, with endometriosis, who presented with a history of foot drop and cyclic sensory disturbance of the right lower limb. She was initially diagnosed with lumbar disc herniation. Neurological examination revealed muscle weakness and sensory disturbance associated with the right sciatic nerve. Nerve conduction studies revealed a low amplitude sensory nerve action potential in the right superficial fibular and sural nerves. Pelvic magnetic resonance imaging revealed an endometriotic cyst in the right ovary, and an endometriotic lesion extending from the right ovary, pelvis, and the right sciatic nerve. Though her symptoms moderately improved with hormonal therapy, the foot drop remained. Our case and previous reports suggest that endometriosis with sciatic neuropathy shows cyclic neurological symptoms during menstruation, with a higher incidence on the right extremity. This case highlights that endometriosis should be considered as a potential differential diagnosis in women of reproductive age with sciatic nerve dysfunction. Its cyclic neurological manifestations should be investigated.

The haunting diagnosis of malignancy in women with treatable reproductive system tuberculosis

This study reports a case of female genital tuberculosis in a 46-year-old woman who presented to emergency department with abdominal pain and progressive abdominal distension. The patient was initially thought to have ovarian cancer based on clinical diagnosis and elevated cancer antigen-125 (CA-125) levels. Intra-operatively, no obvious ovarian tumor was encountered instead; disseminated creamy white patches on the uterus and left adnexa were seen. About 4500-mL straw-colored ascitic fluid and disseminated creamy white patches were also found on the bowels and omentum giving an impression of carcinomatosis. However, histopathology of the fallopian tube and ovary confirmed the diagnosis of female genital tuberculosis as the underlying cause. Female genital tuberculosis often mimics tumors in its clinical appearance and symptoms, leading to misdiagnosis and unnecessary treatment. The key to diagnosing female genital tuberculosis is being suspicious as it is challenging to diagnose through laboratory tests or radiology. The mainstay of treatment for female genital tuberculosis is a combination of four antituberculosis drugs. Consideration of female genital tuberculosis as a differential diagnosis in women presenting with symptoms mimicking reproductive tumors is highly recommended as highlighted in this case report.

Peritoneal endometriosis presenting as fever of unknown origin, ascites and peritoneal miliary spread: A rare case report and review of the literature

Endometriosis associated with ascites is a rare form of endometriosis. We identified only 81 publications describing women with this pathology. The purpose of this review was to search the existing literature and to understand the clinical presentations and possible treatment options. A 28-year-old patient was admitted due to a fever of unknown origin and lower abdominal pain. Her CT scan was normal with some non-specific lymph-node enlargement up to 1.6 cm and the presence of ascites. Diagnostic laparoscopy revealed a large amount of hemorrhagic ascites. The entire peritoneal surface was covered with milliary nodules. The pathology report revealed peritoneal stromal endometriosis. Endometriosis is an important differential diagnosis in women with ascites and treatment of this form of endometriosis is a real dilemma.

Sclerosing stromal tumor: a rare ovarian neoplasm

Sclerosing stromal tumor (SST) is an extremely rare and distinctive sex cord stromal tumor, which occurs predominantly in the second and third decades of life. SSTs make up 2-6% of ovarian sex-cord stromal tumors. Due to the solid and distinct vascular structure of the tumor, it can be mistaken as a number of malignant ovarian tumors. As this specific neoplasm is very rare, it is not always possible to diagnose the tumor preoperatively with clinical and ultrasonographic findings. Furthermore, histopathological and immunohistochemical analysis does not always confirm the diagnosis. In this case report, clinical findings, histopathological features, and macroscopic appearance during laparoscopy of an SST are presented in a 20-year-old woman with pelvic pain. SST should be considered among the differential diagnosis of women with adnexal masses.

Right-side inguinal canal endometriosis at ultrasound: A case report

Background The first case of inguinal endometriosis was described by Cullen. Endometriosis in the round ligament could be in the pelvic or inguinal area and is a rare disease occurring in 0.6% of women. Women with inguinal endometriosis have a painful inguinal mass during menstrual cycles and they mostly have a history of surgery. The right side is more commonly involved in inguinal endometriosis than the left side (90-94%). A history of gynecologic or abdominal surgery is common in women with inguinal endometriosis.Case presentation In our case, a 39-yr-old virgin woman presented with localized pain in the right inguinal that had been present for 4 yr. She did not have any history of previous surgery, and abdominal ultrasonography showed a hypoechoic mass with minimal vascularity. Inguinal endometriosis was correctly diagnosed by two expert radiologists preoperatively, and she underwent laparoscopic surgery.ConclusionConsidering inguinal endometriosis in the differential diagnosis of women with inguinal masses is important, even if there is no history of gynecologic or abdominal surgery.

CIRCULATING MIR-132, MIR-146A, MIR-222, AND MIR-320 EXPRESSION IN DIFFERENTIAL DIAGNOSIS OF WOMEN WITH POLYCYSTIC OVARY SYNDROME.

The aim of the study was to investigate whether the circulating miR-132, miR-146a, miR-222, and miR-320 levels are used in the differential diagnosis of women with polycystic ovary syndrome (PCOS) and healthy women. This prospective case-control study included 50 women with PCOS and age- and body mass index- matched 50 healthy controls. The hormone and lipid profiles, levels of microRNAs (miRNAs), and parameters of carbohydrate metabolism were measured. Expression levels of miRNAs were assessed using the two-step quantitative real-time polymerase chain reaction. Circulating miR-132, miR-146a and miR-222 levels were significantly downregulated in the PCOS group compared with the control group. The miR-320 levels did not differ between the two groups. Free testosterone was negatively correlated with miR-132, miR-146a and miR-222. Insulin was negatively correlated with miR-132 and miR-146a. The results of the study revealed that miRNA expression, may suggest a possible distinction between healthy women and PCOS patients. miR-132, miR-146a, and miR-222 may have key functions in the pathogenesis of PCOS.

Abdominal wall endometriosis: Case-series study and a systematic review

Abdominal wall endometriosis (AWE) is the presence of endometrial gland and stroma in the abdominal wall that should be kept in mind in differential diagnosis of pelvic pain due to especially increased C-section rates. Between January 2000 and July 2018, MEDLINE and EMBASE databases were systematically reviewed using the search criteria "abdominal wall endometriosis," "abdominal wall endometriomas,”. Only the studies having over 20 patients were included. Case-series, case-control studies, and articles in languages other than English were excluded. Number of the patients, patients ‘age, study design, previous surgical history, most common symptom, time interval to symptoms, treatment, recurrence rate, and tumour size were investigated. In Total, 18 studies and 994 women were included in the study. Case studies, studies with less than 20 cases, non-English articles were excluded from the study. In the included studies, the numbers of minimum and maximum woman were 20 and 227, respectively. AWE significantly impairs the quality of life in reproductive age patients and is commonly seen in women with previous history of laparotomy, especially those who underwent cesarean section. Therefore, it must be kept in mind in the differential diagnosis of women who have a history of pain and a history of previous surgery.

A Case Report of Microperforate hymen presented with primary infertility

Micro perforate hymen is an uncommon congenital defect in which the hymen has a microscopic pinpoint aperture. It is a different entity from imperforate hymen, but it might present with more or less similar complaints. Here we are discussing about a unique case of pinpoint hymenal opening or microperforate hymen where the patient presented to us with primary infertility. Most cases of micro perforate hymen present in the paediatric age group with recurrent urinary tract infections and recurrent vulvovaginitis. Rare cases in a review of literature noted that a patient was seen to present with urethral dilatation during coital activity. In this case report, we present a patient who came with primary infertility who has never been examined in the past. She had regular menstrual cycles but scanty flow with the main complaint of dyspareunia. After examination, she was found to have microperforate hymen and suspected transverse vaginal septum defect. Hence, routine investigations were done, and we proceeded with hymenectomy. This example demonstrates the importance of a thorough genital examination and the inclusion of hymenal abnormalities in the differential diagnosis of women with recurrent dysuria, vaginitis, primary infertility, and oligomenorrhoea, so that early intervention can be done to improve the woman's quality of life and reduce pregnancy difficulties.

Vertebral artery dissection in term pregnancy after cervical spine manipulation: a\xa0case report and review the\xa0literature

BackgroundVertebral artery dissection is an uncommon, but potentially fatal, vascular event. This case aimed to describe the pathogenesis and clinical presentation of vertebral artery dissection in a term pregnant patient. Moreover, we focused on the differential diagnosis, reviewing the available evidence.Case presentationA 39-year-old Caucasian woman presented at 38 + 4 weeks of gestation with a short-term history of vertigo, nausea, and vomiting. Symptoms appeared a few days after cervical spine manipulation by an osteopathic specialist. Urgent magnetic resonance imaging of the head was obtained and revealed an ischemic lesion of the right posterolateral portion of the brain bulb. A subsequent computed tomography angiographic scan of the head and neck showed a right vertebral artery dissection. Based on the correlation of the neurological manifestations and imaging findings, a diagnosis of vertebral artery dissection was established. The patient started low-dose acetylsalicylic acid and prophylactic enoxaparin following an urgent cesarean section.ConclusionVertebral artery dissection is a rare but potential cause of neurologic impairments in pregnancy and during the postpartum period. It should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women with a history of migraines, hypertension, or autoimmune disorders in pregnancy are at higher risk, as well as following cervical spine manipulations. Prompt diagnosis and management of vertebral artery dissection are essential to ensure favorable outcomes.

Perinatal Sacroiliitis Diagnostic Challenges: A Case Report

Background: Lumbo-pelvic (LPP) pain is common and non specific problem during pregnancy and post partum. Despite the fact that perinatal pyogenic sacroiliitis (PSI) during this period is rare, it should be considered as a vital differential diagnosis in women who have debilitating lower back and pelvic girdle pain. Case: A 34 years old primigravida presented to the emergency department with extreme right sided lower back pain radiating to the right gluteal region and down to the back of the right thigh. This pain began twelve days prior to her presentation and eventually worsened to the point that she couldn't stand or walk. Her vital signs were within normal limits, and she was febrile. Apart from a slight widening of the symphysis pubis, her pelvic and lumbo-sacral plain x-rays revealed no important findings. With the clinical impression of right LPP, the patient was admitted for pain management and further inquiries. Conclusion: Despite the fact that lower back and pelvic girdle pain are normal throughout pregnancy and the postpartum period, perinatal PSI is uncommon. It's a tough diagnosis to make because the symptoms and signs aren't clear, and the tests aren't definitive. When pathognomonic clinical and radiologic signs indicate an infectious process and isolation of pathogenic bacteria is not possible, medical management with empirical antibiotics should not be delayed.

Herlyn-Werner-Wunderlich syndrome: Case report

Introduction: Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital malformation of the urogenital tract characterized by the triad of uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis, which is usually diagnosed after menarche. It is treated by resecting the vaginal septum and draining the obstructed hemivagina and has a favorable postoperative prognosis. Case presentation: This is the case of 22-year-old woman with a 9-year history of dysmenorrhea, pelvic pain, and irregular menstrual cycles that started after she had her first menstruation, who visited the gynecology service of a secondary care hospital in Sogamoso, Boyacá (Colombia). The patient reported having visited multiple specialists and being treated with vitamin E, metformin, and contraceptives, without experiencing an improvement of symptoms and signs. After being assessed, and taking into account ultrasound and MRI findings, she was diagnosed with HWW syndrome. She underwent a colpotomy plus resection of right paracervical mass of approximately 60x60mm and vaginal septum, achieving complete resolution of symptoms. Finally, 10 months after the surgery, she reported being pregnant without complications. Conclusion: HWW syndrome is a rare malformation that should be considered as a differential diagnosis in women of any age with paramesonephric duct anomalies, pelvic pain, dysmenorrhea, and presence of masses in the genital tract, since its early diagnosis and timely treatment considerably improve the quality of life of these patients by reducing the severity of symptoms, decreasing the incidence of complications, and improving obstetric prognosis.

Chronic Inversion of Uterus Following Spontaneous Abortion: A Case Report

Uterine inversion is a rare entity but poses a serious threat if not diagnosed and managed timely. Here we present a case of chronic uterine inversion in a 30-year-old lady who presented in emergency with a mass coming out per vagina, blood mixed vaginal discharge, and lower pain abdomen for the last 15 days. She underwent laparotomy and was found to have uterine inversion. The patient was attempted for repositioning of uterus with the Huntington’s approach, but it was unsuccessful, hence Haultain’s operation was done with a total abdominal hysterectomy and bilateral salpingectomy with right-sided ovarian cystectomy for a dermoid cyst. Our case emphasizes the importance of keeping chronic uterine inversion as a differential diagnosis in women presenting with pain abdomen, mass, and bleeding per vagina, and with a recent history of second-trimester abortion. Timely recognition, especially in chronic inversion, will decrease the morbidity and mortality associated with this rare but life-threatening condition.

Systemic recurrence of endometrial cancer more than 10\u2009years after hysterectomy: a report of two cases and a brief review of the literature

BackgroundEndometrial carcinoma is one of the most common female cancers in developed countries. Disease stage is associated with the risk of disease relapse after radical treatment. Typically, the risk of disease relapse peaks at 3 years from local radical treatment and then diminishes over time, so that late relapses (i.e., from year 5 afterward) are extremely infrequent. Here, we report two cases of women with endometrial cancer who developed a disease relapse more than 15 years after radical treatment. A review of the literature revealed other seven reports of women with relapse from endometrial cancer occurring more than 10 years after radical treatment.Case presentationCase report 1 is a 56-year-old woman with an endometrioid cancer who underwent a hysterectomy with bilateral salpingo-oophorectomy in 1998. She relapsed in the lung in 2014, 16 years from radical surgery. Case report 2, a 75-year-old woman, with an endometrioid cancer, was treated by hysterectomy with bilateral salpingo-oophorectomy and adjuvant radiotherapy. The disease relapse in the lung was detected in 2019, 22 years from radical treatment.ConclusionAlthough guidelines do not support oncological follow-up beyond 5 years from surgery, oncologists should consider late recurrence of endometrial carcinoma in the differential diagnosis of women presenting with metastases of uncertain origin and prior history of this disease.

Postpartum vertebral artery dissection: case report and review of the literature

BackgroundHypertensive disorders of pregnancy are associated with vascular complications, including ischemic stroke and cervical artery dissection. Vertebral artery dissection (VAD), however, is rare. We describe a 31-year-old female who presented with vertigo, nausea, and vomiting and was found to have a VAD. In addition, we discuss the presentation, differential diagnosis, and pathogenesis of this uncommon but clinically significant vascular event and summarize other cases of vertebral artery dissection described in the medical literature.Case presentationA 31-year-old Hispanic woman presented 10 days postpartum with a one-day history of vertigo, nausea, vomiting, and frontal headache. The patient’s pregnancy course had been complicated by preeclampsia, chorioamnionitis, and iron-deficiency anemia, and her delivery was complicated by acute hemorrhage. Physical examination was significant for left leg ataxia. Laboratory studies showed marked thrombocytosis. Emergent computed tomography (CT) scan of the head was obtained and revealed a left cerebellar ischemic large vessel stroke. Subsequent CT angiography of the head and neck showed a left VAD. Based on correlation of the clinical history and laboratory and imaging findings, a diagnosis of vertebral artery dissection secondary to reactive (secondary) thrombocytosis from overlapping iron-deficiency anemia and acute hemorrhage was established. The patient was started on a heparin infusion and experienced significant improvement after a four-day hospitalization.ConclusionVAD is a rare but important cause of neurologic symptoms in the postpartum period and should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women aged 30 years or older and those with a history of a hypertensive disorder of pregnancy are at particularly high risk. Prompt diagnosis and management of VAD is essential to ensure favorable outcomes.

2-D and 3-D ultrasonographic characteristics of the ovary in women with PCOS and multifollicular ovaries

In this prospective study, seventy-six patients (PCOS group; n = 36, multifollicular ovary group; n = 40) were evaluated by 2-D and 3-D ultrasonography. VOCAL programme, echogenicity, number of follicles and blood flow parameters were evaluated. The patients with PCOS had a higher total ovarian volume, mean stromal volume and stromal echogenicity (18.6 ± 4.75 to 10.2 ± 3.4 p < .01; 12.23 ± 2.53 to 5.02 ± 2.44 p = .02; score 1:28 to 10 p < .01, respectively). There was no statistically significant difference in terms of mean RI and PI values between the groups (p > .05). 3 D power Doppler parameters included VI, FI, and VFI values of the patients with PCOS were higher when compared to those of the patients with multifollicular ovary (3.82 ± 2.65 to 1.78 ± 1.2, p < .01; 50.76 ± 4.45 to 40.6 ± 3.64, p = .03; and 2.34 ± 1.02 to 1.12 ± 0.65, p = .02, respectively). Our results revealed that total ovarian volume, stromal volume and echogenicity; VFI, VI, and FI could be useful for differential diagnosis in women with PCOS and multifollicular ovaries. Impact statement What is already known on this subject? Ultrasonography is considered the new diagnostic tool for PCOS. Enlarged ovaries with multiple small follicles peripherally located around increased ovarian stroma with increased stromal echogenicity are the sonographic features of polycystic ovaries. What do the results of this study add? 3-D Doppler ultrasonography may be more specific in the determination of multifollicular and polycystic ovaries when compared to RI and PI in 2-D Doppler ultrasonography. Moreover, 3-D power Doppler ultrasonography could be useful for differential diagnosis in women with PCOS and multifollicular ovaries. What are the implications of these findings for clinical practice and/or further research? In clinical practice, the differentiation of multifollicular ovaries and polycystic ovaries (PCO) is difficult with the use of 2-D sonography alone. Therefore, 3-D ultrasound and power Doppler may also be used in addition to 2-D ultrasound for the differentiation of multifollicular ovaries and PCO.

Endometriosis-induced massive hemoperitoneum misdiagnosed as ruptured ectopic pregnancy: a case report

BackgroundEndometriosis, an estrogen-dependent inflammatory disease, is commonly observed in gynecologic practice. Spontaneous hemoperitoneum is a rare but serious complication of endometriosis. Most cases of endometriosis-induced hemoperitoneum are attributable to a ruptured endometrioma or utero-ovarian vessel hemorrhage. We report a case of massive hemoperitoneum secondary to intra-abdominal bleeding from the peritoneal endometriotic deposits with spontaneous abortion that was misdiagnosed as a ruptured ectopic pregnancy.Case presentationA 36-year-old Korean woman was admitted to our hospital for acute abdominal pain and vaginal bleeding. She was suspected of ruptured ectopic pregnancy on the basis of a positive serum human chorionic gonadotropin test result and ultrasonographic evidence of pelvic fluid collection. During hospitalization, her symptoms deteriorated with peritoneal irritation sign on physical examination, hypotension, and tachycardia. Emergency exploratory laparoscopy was performed and revealed active bleeding from the peritoneal endometriotic deposit, which was treated with laparoscopic electrocoagulation. The patient’s postoperative course was uneventful. Spontaneous abortion was diagnosed on the basis of decreased serial serum human chorionic gonadotropin level estimation.ConclusionsAlthough rare, gynecologists should consider endometriosis-induced hemoperitoneum with spontaneous abortion in the differential diagnosis in women of reproductive age presenting with a positive serum human chorionic gonadotropin test result and acute abdomen with intra-abdominal bleeding.

Bladder Leiomyomatosis: A case Report

Introduction: Bladder leiomyoma which is commonly found in middle aged females is a rare, benign, and mesenchymal tumor of the bladder. Its incidence rate is lower than 0.5% among all types of bladder tumors. There are fewer than 250 reports on bladder leiomyoma. Herein, we report a case of bladder leiomyoma in a 37 years’ female. Case Presentation: A 37-year-old multiparous woman presented with complaints of occasional hematuria and dysuria and irritative symptoms. In the examination and imaging, a mass with size of 8 cm was reported in anterior border of uterus with firm consistency. Surgery was performed and the mass was resected. Postoperative histopathology review confirmed bladder leiomyoma. Conclusion: Leiomyoma should be kept in mind as a differential diagnosis in women presenting with dysuria, frequency or hematuria and a firm consistency mass even in unusual site as the bladder. Complete resection leads to very good outcome with almost no recurrence.

Umbilical endometriosis: a\xa0case series

BackgroundEndometriosis is the presence of endometrial tissue outside the uterine cavity. The lesions are typically found in the pelvic cavity but can occur in other extrapelvic areas. Umbilical endometriosis, also known as Villar’s node, is a rare disease comprising 0.5–1% of all extrapelvic disease. It commonly presents with cyclical pain and bleeding from an umbilical nodule.Case seriesWe present a retrospective case series of five African patients with umbilical endometriosis diagnosed and treated between July 2015 and February 2019 at a tertiary health facility. The patients were aged between 31 and 47 years, and all presented with an umbilical swelling and pain. They had lesions with diameters ranging from 1.6 cm to 4 cm. The duration of symptoms ranged between 3 and 60 months. Their diagnoses were made on the basis of clinical presentation followed by surgical excision. In all the cases, diagnosis was confirmed by histopathology with no malignancy detected.ConclusionUmbilical endometriosis is a rare condition that should be considered as a differential diagnosis in women with umbilical lesions. Diagnosis is mostly clinical; most patients present with umbilical swelling, cyclical pain, and bleeding or discharge. Imaging has a limited role. Surgical excision is the treatment of choice with low risk of malignancy or recurrence.