Difficulties In Differential Diagnosis Research Articles

Гломус-ангіома в педіатричній практиці

Glomus angioma i1s a neoplasm of mesenchymal origin, which accounts for about 2% of soft tissue tumors. This is a benign tumor originating from the neuromuscular-vascular skin node (glomus) due to the predominant growth of arterio-venous anastomoses. The neuromyoarterial glomus is a structure whose function is arterio-venous shunting. Purpose - to acquaint a wide range of specialists in pediatric specialties with this pathology, features of the course, diagnostics and treatment tactics. Clinical cases. Two clinical cases are given to illustrate the difficulty of differential diagnosis of glomus-angiomas. In the first, when the formation was localized on the finger of the hand in a child of the first year of life, the differentiation took place with a pyogenic granuloma, the clinical and external signs of which and some morphological characteristics of which are very similar to vascular formations. In the second case, when a glomus angioma was localized in the area of the skin of the mammary gland in a 13-year-old girl, the differential diagnosis was made with a cavernous hemangioma. Both cases testify to the sufficient complexity of making a clinical diagnosis in children of different age groups and different localization of formations. Conclusions. According to the literature, the cause of glomus angiomas is mutations in the glomulin gene, which encodes a 68 kDa protein with an unknown function. Differential diagnosis should be carried out with pronodular hidradenoma, intradermal nevi, melanomas, myopericytomas and myofibromatosis, tumors of non-epithelial, smooth muscle, vascular or nervous origin. Histological examination is an important diagnostic method in the process of making a diagnosis. If a child is suspected of having a glomus angioma, with clinical symptoms and appearance appropriate for this tumor, radical removal of the tumor with mandatory histological confirmation is required. The study was conducted in accordance with the principles of the Declaration of Helsinki. Informed consent of the children's parents was obtained for the study. No conflict of interests was declared by the authors.

Mucinous Cystadenoma of the Cystic Duct

A rare clinical observation of a cystic formation of the biliary system — mucinous cystadenoma of the cystic duct is presented. This type of tumors is benign, but in 20 % of cases their malignancy is described. They are often detected incidentally during routine examination and require surgical treatment, regardless of clinical manifestations. Difficulties in differential diagnosis led to unreasonably long follow-up, ending with malignancy of cystadenomas, which reduces the possibility of radical surgical treatment. Therefore, timely detection and differentiation of biliary mucinous cystadenomas by examination are very important for treatment strategy.

Precise diagnosis of breast phyllodes tumors using Raman spectroscopy: Biochemical fingerprint, tumor metabolism and possible mechanism

BackgroundBreast fibroadenomas and phyllodes tumors are both fibroepithelial tumors with comparable histological characteristics. However, rapid and precise differential diagnosis is a tough point in clinical pathology. Given the tendency of phyllodes tumors to recur, the difficulty in differential diagnosis with fibroadenomas leads to the difficulty in optimal management for these patients. MethodIn this study, we used Raman spectroscopy to differentiate phyllodes tumors from breast fibroadenomas based on the biochemical and metabolic composition and develop a classification model. The model was validated by 5-fold cross-validation in the training set and tested in an independent test set. The potential metabolic differences between the two types of tumors observed in Raman spectroscopy were confirmed by targeted metabolomic analysis using liquid chromatography-tandem mass spectrometry (LC-MS/MS). ResultsA total of 204 patients with formalin-fixed paraffin-embedded (FFPE) tissue samples, including 100 fibroadenomas and 104 phyllodes tumors were recruited from April 2014 to August 2021. All patients were randomly divided into the training cohort (n = 153) and the test cohort (n = 51). The Raman classification model could differentiate phyllodes tumor versus fibroadenoma with cross-validation accuracy, sensitivity, precision, and area under curve (AUC) of 85.58 % ± 1.77 %, 83.82 % ± 1.01 %, 87.65 % ± 4.22 %, and 93.18 % ± 1.98 %, respectively. When tested in the independent test set, it performed well with the test accuracy, sensitivity, specificity, and AUC of 83.50 %, 86.54 %, 80.39 %, and 90.71 %. Furthermore, the AUC was significantly higher for the Raman model than that for ultrasound (P = 0.0017) and frozen section diagnosis (P < 0.0001). When it came to much more difficult diagnosis between fibroadenoma and benign or small-size phyllodes tumor for pathological examination, the Raman model was capable of differentiating with AUC up to 97.45 % and 95.61 %, respectively. On the other hand, targeted metabolomic analysis, based on fresh-frozen tissue samples, confirmed the differential metabolites (including thymine, dihydrothymine, trans-4-hydroxy-l-proline, etc.) identified from Raman spectra between phyllodes tumor and fibroadenoma. Significance and noveltyIn this study, we obtained the molecular information map of breast phyllodes tumors provided by Raman spectroscopy for the first time. We identified a novel Raman fingerprint signature with the potential to precisely characterize and distinguish phyllodes tumors from fibroadenoma as a quick and accurate diagnostic tool. Raman spectroscopy is expected to further guide the precise diagnosis and optimal treatment of breast fibroepithelial tumors in the future.

Biliary gastritis. Pathomorphological features and differential diagnosis

The review article discusses the modern pathogenetic links of biliary gastritis, namely the role of endothelial dysfunction, intestinal metaplasia in inflammation and the influence of Helicobacter pylori infection. The problem of combined damage to the mucous membrane of HP-associated and biliary gastritis remains relevant, since modern foreign studies have not come to a consensus, but most authors state increased carcinogenesis of the stomach with a positive HP status against the background of the course of pathological duodenogastric reflux. The article also presents original materials of histological examination of biliary, HP-associated, autoimmune and hyperplastic gastritis with similar morphological features, thereby demonstrating the difficulties of differential diagnosis.

Ayurved Management of Amyotrophic Lateral Sclerosis (Motor Neuron Disease)

Motor neurons are nerve cells that send electrical output signals to the muscles, affecting the muscles’ ability to function. Motor neuron disease (MND) can appear at any age, but the symptoms usually appear after the age of 50 years. It affects more males than females. The most common type of MND is amyotrophic lateral sclerosis (ALS). A 56-year-old male patient had heaviness and weakness in left lower limb for 4 months. The condition rapidly progressed in the 4 months prior and found difficulty in climbing stairs and swelling in the left foot. Gradually he developed slowness of speech hence consulted allopathic hospital and treated with glutamate blockers, muscle relaxant and physiotherapy. His response to allopathic medications found to be slow. The present case report deals with the case of MND and its Ayurvedic diagnosis and management. Difficulty in differential diagnosis exists between the conditions like Sarvanga Vata, Avrita Vata and Saama Vata. Upashaya- Anupashaya Pariksha is beneficial to solve the problem in differential diagnosis. Swedana and Matra Vasti procedures are found to be beneficial in the management of MND.

Preconditions for radiomics-based approach in differential diagnosis of pancreatic cystic lesions: critical evaluation of meta-analyses and international guidelines

INTRODUCTION: Pancreatic cystic lesions (PCLs) are a heterogenous group of lesions ranging from benign to malignant with variable histological, pathomorphological and prognostic characteristics. The development and improvement of radiation methods provides a great opportunity to diagnose such neoplasms. However, there are still difficulties in differential diagnosis and prediction malignant potential in pancreatic cyst subtypes due to their similar radiation characteristics.OBJECTIVE: To determine the diagnostic performane and difficulties of differentiating PCLs by invasive and non-invasive radiological methods. To determine the preconditions for radiomics-based approach in differential diagnosis of pancreatic cystic lesions based on a review and analysis of international guidelines.MATERIALS AND METHODS: We searched for scientific publications in the PubMed and Springer information and analytical systems for 2009–2023 by keywords: «pancreatic tumors», «pancreatic cyst», «pancreatic cystic lesion», «pancreatic radiomics», «intraductal papillary mucinous neoplasm», «pancreatic cystadenoma». As a result, 49 articles were selected for analysis.RESULTS: Despite the high potential of modern non-invasive radiation methods in the detection of pancreatic cysts, differentiation of PCLs subtypes is still very difficult. Due to the variability of international guidelines and a lack of their specificity, there is no universal consensus for management PCLs. In this regard, introduction new alternative diagnostic methods and markers is an important direction of research. At the moment, the assessment of the malignant potential of PCLs is comes down to only two main signs — the main pancreatic duct diameter and the vascularized solid component.CONCLUSION: Currently, common semiotic features, limitations of invasive diagnostic methods and increasing risks of recurrence and malignancy dictate the need to apply new diagnostic approaches to evaluation of PCLs. Searching and introduction new markers will allow us to analyze the lesion structure, to stratify risks and long-term prognosis more accurately. Textural image analysis is a new and promising noninvasive method with high power. This tool plays an important role to estimate those structural parameters which are impossible to judge according to the standard radiologic features, and to offset the problems of traditional diagnostic approach.

Crohn’s disease penetrating form. Difficulties of diagnostics and preoperative planning (clinical case)

AIM: to demonstrate the difficulties of differential diagnosis of the penetrating variant of Crohn’s disease and malignant neoplasm of the intestine.PATIENTS AND METHODS: a clinical case of a patient of an older age group with the onset of a penetrating variant of Crohn’s disease is presented.RESULTS: according to the results of an urgent check-up on the day of admission, the patient had an abdominal mass in the right iliac region, involving the intestinal wall, anterior abdominal wall, complicated by acute intestinal obstruction. Preliminary diagnosis: colon tumor complicated by inflammation and acute intestinal obstruction. The patient’s condition and two life-threatening complications required an urgent surgical intervention — extended right-sided hemicolectomy. The primary histological examination also did not allow us to exclude the tumor nature, but a second revision of histology with immunohistochemical analysis made it possible to establish the diagnosis of Crohn’s disease.CONCLUSION: Crohn’s disease can debut at any age, including complicated forms. This requires the inclusion of this pathology in the differential diagnosis with malignant neoplasms of the intestine, especially when the changes are located in the right iliac region. This will help to optimize the surgical approach.

Radiological diagnosis of apophyseal injuries of the pelvic region

Avulsion injuries of the pelvis are common sports-related findings in skeletally immature adolescent patients. They usually present as an avulsion of the unfused apophysis, resulting from forced muscular contraction during typical athletic movements or from chronic traction injuries. Acute apophyseal avulsion injuries are usually easily detected with radiography. Occasionally, advanced imaging such as ultrasound or magnetic resonance imaging is required in order to detect or fully assess the extent of injury. Chronic injuries can mimic aggressive entities, such as neoplasms and may thus cause difficulties in differential diagnosis. Profound knowledge of typical locations of apophyseal tendon attachment sites at the osseous pelvis and correct interpretation of imaging findings can facilitate accurate diagnosis. This article discusses the clinical and radiological findings of pelvic apophyseal avulsion injuries in pediatric patients and highlights potential complications and differential diagnoses.

The role of systemic immune-inflammation index (SII) in the differential diagnosis of granulomatous and reactive LAP diagnosed by endobronchial ultrasonography.

Tuberculosis and sarcoidosis are the two most important granulomatous diseases that physicians have difficulty in differential diagnosis. In our study, we aimed to observe the place of systemic immune-inflammation index (SII) level in the differentiation of patients diagnosed with endoboronchial ultrasonography (EBUS). Our study included 494 patients who applied to our hospital's chest diseases outpatient clinic between 2015 and 2020 and underwent endobronchial ultrasonography (EBUS) for mediastinal lymphadenopathy (LAP). Patients' follow-up for at least 2 years after diagnosis and pre-procedural hematologic parameters were retrospectively recorded. In the comparison of SII between groups, it was observed that SII was statistically significantly higher in patients followed up for tuberculous lymphadenitis compared to patients with sarcoidosis and reactive LAP (p=0.01, <0.001). In sarcoidosis patients, SII levels were statistically significantly higher than in patients with reactive LAP (p=0.002). Platelet, sedimentation and SII levels were statistically significantly higher in stage 2 patients compared to stage 1 patients, while lymphocyte levels were lower (p=0.009, 0.001, 0.001, 0.001, 0.001 respectively). In the ROC curve analysis of the SII level of patients with sarcoidosis and tuberculosis LAP, the AUC was 0.668 and when the cut-off value for the SII level was 890.667, the sensitivity was 70% and the specificity was 66% in the differentiation of tuberculosis and sarcoidosis lymphadenitis. SII may be an easily applicable parameter in the differentiation of tuberculosis and sarcoidosis LAP with granuloma and in the differentiation of granulomatous diseases from reactive LAP.

Primary Multiple Metachronous Cervical Cancer: Difficulties in Differential Diagnosis

Primary Multiple Metachronous Cervical Cancer: Difficulties in Differential Diagnosis

Of the difficulties of differential diagnosis of tuberculosis and sarcoidosis: clinical case

Of the difficulties of differential diagnosis of tuberculosis and sarcoidosis: clinical case

Difficulties in differential diagnosis of carbohydrate metabolism disorders in patients with coronavirus infection in real clinical practice. Case report

The problem of the impact of coronavirus infection on carbohydrate metabolism remains open. In the course of the disease, various disorders of carbohydrate metabolism are detected, including newly diagnosed diabetes mellitus and transient hyperglycemia. This article presents two clinical cases with different course and duration of transient stress hyperglycemia against the background of coronavirus infection.

Granulomatosis with polyangiitis under the guise of pulmonary tuberculosis: difficulties in diagnosis

Aim. To present a clinical case of late diagnosis of granulomatosis with polyangiitis (GPA), which for a long time was interpreted as a pulmonary form of tuberculosis with the passage of anti-tuberculosis therapy without effect, which led to severe structural changes and resection of the lungs and deformation of the bones of the facial skeleton.Materials and methods. Patient S., 31 y. o., was hospitalized in the rheumatology department with complaints of bloody discharge from the nose with the formation of crusts, hearing loss on both sides, weakness, nose deformity. From the anamnesis: in 2012, a cough with mucous sputum appeared. During examination at the Center for Combating Tuberculosis, on the basis of multiple rounded foci of both lungs, despite a negative diaskin test and the absence of mycobacterium tuberculosis in the sputum analysis, infiltrative tuberculosis was diagnosed. For two years, combined therapy with anti-tuberculosis drugs was carried out. In 2013, a staged combined resection of the left lung was performed; in 2014, a resection of the lower lobe of the right lung was performed. In 2015, nasal discharge increased, large crusts began to stand out, followed by bleeding, and a change in the shape of the nose was observed. In 2016, due to hearing loss in the left ear, he turned to an otorhinolaryngologist, diagnosed with ulcerative necrotic rhinitis, perforation of the nasal septum. Antibiotic therapy - no effect. Blood tests revealed positive antibodies to proteinase-3. In March 2017, he was hospitalized in the rheumatology department.Results. There were CT signs of fibrotic changes in the lungs with calcifications, areas of compaction of the “frosted glass” type in the upper lobes of the lungs. Laboratory examination revealed positive antibodies to proteinase-3, decreased glomerular filtration and tubular reabsorption. Analysis of the biopsy material from the lung and nasal mucosa revealed morphological signs of granulomatosis with polyangiitis. For the first time in 5 years, granulomatosis with polyangiitis was diagnosed, generalized form, chronic course, moderate activity, with damage to the upper respiratory tract (pansinusitis, rhinitis, chronic bilateral adhesive otitis media), lungs (nonspecific interstitial pneumonia), kidneys (microhematuria, proteinuria), joints (arthralgia). The activity index according to the Birmingham BVAS scale is 16 points, the VDI organ damage index is 6 points. In a retrospective analysis, tuberculosis was not confirmed. Therapy with prednisolone, cyclophosphamide (endoxan), biseptol was carried out, against which the patient's condition improved significantly.Conclusion. The presented clinical case demonstrates the difficulties of differential diagnosis of GPA with other granulomatous processes. Late diagnosis led to damage to vital organs: lungs, kidneys, deformity of the back of the nose, which, most likely, could have been avoided in case of timely diagnosis and early initiation of adequate therapy. As a result of an erroneous diagnosis at the onset of the disease, the patient underwent unjustified resection of both lungs twice. Timely diagnosis of the granulomatous process with the involvement of several pathologists as experts, including those with a torpid course of pulmonary tuberculosis, significantly improves the prognosis of patients and avoids fatal complications.

Celiac disease, non-celiac gluten sensitivity and irritable bowel syndrome: diagnostic difficulties

The article is devoted to the difficulties of differential diagnosis of irritable bowel syndrome (IBS) and gluten-associated diseases. A clinical example illustrating the features of the diagnosis of these conditions is given

Difficulties of differential diagnosis of multisystem inflammatory syndrome associated with SARS-CoV-2 in a teenager (clinical case)

The new coronavirus infection does not lose its relevance, which is due to the ubiquity of the virus, the variety of strains, clinical manifestations and their consequences of COVID-19. In children, one of the severe complications of new coronavirus infection is the multisystem inflammatory syndrome associated with SARS-CoV-2 (MIS-C), which is characterized by a hyperinflammatory response with damage to two or more organs and systems. MIS-C requires differential diagnosis with other diseases with similar symptoms: bacterial infections, sepsis, toxic shock syndrome, Kawasaki syndrome, hemophagocytic syndrome. As an example, the article considers a clinical case of MIS-C in a 13-year-old girl 4 weeks after undergoing new coronavirus infection (confirmed). At the onset of the disease, the leading manifestations were systemic inflammatory response syndrome (fever, increased markers of inflammation) with damage to the cardiovascular system, skin and mucous membranes, lymphadenitis, thrombocytopenia. According to the severity of the condition, the child required observation and treatment in the intensive care unit. The absence of the expected effect of the recommended MIS-C therapy (intravenous immunoglobulin and pulse therapy with methylprednisolone) on the first day did not allow to exclude bacterial infection complicated by sepsis in the above clinical situation, therefore, it was suggested that the combined course of MIS-C and bacterial infection of unspecified etiology, which probably led to a more severe course of the disease. In the outcome of the MIS-C the child had the formation of a long-term depressive state (diagnosed by a psychiatrist), for which the patient received drug therapy and psychological assistance.&#x0D; The described case showed difficulties in the formulation of the final diagnosis due to the presence in the patient of several symptoms and syndromes characteristic of various diseases, the absence of an identified etiological agent and the absence of the expected positive effect with standard therapy of the disease. In addition, a pathology was revealed in the catamnesis, which required dynamic observation of the child by several specialized specialists.

Difficulties of differential diagnosis and treatment of myopathic syndrome in an elderly comorbid patient in the post-сovid period (clinical case)

Difficulties of differential diagnosis and treatment of myopathic syndrome in an elderly comorbid patient in the post-сovid period (clinical case)

MRI Semiotics Features and Difficulties of Differential Diagnosis of Hepatic Metastases from Neuroendocrine Tumours

Relevance: Isolated bilobar multifocal hepatic lesion is consider to be the most common metastatic neuroendocrine tumor(NET) growth pattern. Underestimation of the metastatic burden in the NET patients at the initial diagnosis frequently occurs, thus leading to a high postoperative recurrence rate (more than 60 % of cases within 5 years).Purpose: To identify the MRI-hallmarks of liver metastatic NETs and to present the most difficult diagnostic cases.Material and methods: 103 patients with histology confirmed liver metastatic NET were enrolled in the study. All patients underwent abdominal contrast-enhanced (CE) MRI. A total of 241 lesions were assessed. Quantitative indicators of signal intensity (SI) on native and post-contrast T1-weighted images (WI) were measured in metastases. Additionally, the shape, contours, surface of metastases, SI on native images, characteristics of CE, the presence of hemoglobin degradation products and the boundary levels in the structure of metastases were qualitatively assessed.Results: Metastatic liver disease in NET is mostly multifocal: 78 (75.7 %) patients had 5 or more lesions. Metastases were round in 53.5 % of cases, oval in 17.5 % of cases, irregular in 29 % of cases. In 61 % of cases, the contours of the lesions were clear, in 39 % — indistinct. Smooth and bumpy surface of metastases was determined in 31.5 % and 68.5 % of cases, respectively. The presence of hemoglobin degradation products in the structure of metastases was determined in 26.2 % of patients, the formation of the boundary levels — in 8.1 % of patients. Most of the lesions had a hyperintense signal on T2-WI with and without FS and a hypointense signal on native T1-WI. The proportions of actively, moderately and poorly MR contrast agent (MRCA) enhanced lesions were 30.8, 32.6 and 36.6 %, in the arterial phase and 16.3, 55.4 and 28.3 % in the venous phase, respectively. The apparent diffusion coefficient (ADC) values varied significantly. In some cases, small metastatic NET were visualized only in the arterial phase of CE and were not detected on other MRI sequences, thus requiring differentiation from other hepatic hypervascular lesions.Conclusion. The MRI semiotics features of hepatic metastases from NETs is described. Small flesions of active accumulation of MRCA in the arterial phase in the presence of primary NET must be differentiated from metastatic lesions.

Difficulties and missteps of diagnosis and surgical treatment of patient with multifocal metachronic carcinoma associated with primary hyperparathyroidism

We present a clinical case of a patient with metachronous primary multiple carcinoma of left kidney (2004) with left adrenal metastasis (2021), occult low-grade follicular thyroid carcinoma with lateral neck lymph node metastasis (2019), central lung cancer (2020), primary hyperparathyroidism with coherent parathyroid adenomas with intrathyroid and typical location.Patient had undergone left-side nephrectomy with bilateral adrenalectomy, double-staged thyroidectomy with parathyroidectomy and selective lateral neck dissection and right-side pulmonectomy with 4 sessions of chemotherapy. Almost 20 years after first operation patient has no signs of tumors recurrence. In addition, patient is undergoing hormone replacement therapy (HRT) of adrenal insufficiency and thyroid hormone suppression therapy.This case represents combination of non-hereditary endocrine neoplasms with multiple carcinomas. It also examples mistakes and difficulties of differential diagnosis of primary adrenal tumors and adrenal metastasis.

Establishment and Application of a Triplex Real-Time RT-PCR Assay for Differentiation of PEDV, PoRV, and PDCoV.

Porcine viral diarrhea is very common in clinical practice and has caused huge losses to the pig industry. Porcine epidemic diarrhea virus (PEDV), porcine rotavirus (PoRV), and porcine deltacoronavirus (PDCoV) are important pathogens of porcine viral diarrhea. Co-infection situations among these three viruses in clinics are common, which increases the difficulty of differential diagnosis. Currently, polymerase chain reaction (PCR) is commonly used to detect pathogens. TaqMan real-time PCR is more sensitive than conventional PCR and has better specificity and accuracy. In this study, a triplex real-time RT-PCR assay based on TaqMan probes was developed for differential detection of PEDV, PoRV, and PDCoV. The triplex real-time RT-PCR assay developed in this study could not detect unrelated pathogens and showed satisfactory specificity, sensitivity, repeatability, and reproducibility with a limit of detection (LOD) of 6.0 × 101 copies/μL. Sixteen clinical samples were used to compare the results of the commercial RT-PCR kit and the triplex RT-PCR for PEDV, PoRV, and PDCoV detection, and the results were completely consistent. A total of 112 piglet diarrhea samples collected from Jiangsu province were next used to study the local prevalence of PEDV, PoRV, and PDCoV. The positive rates of PEDV, PoRV, and PDCoV detected by the triplex real-time RT-PCR were 51.79% (58/112), 59.82% (67/112), and 2.68% (3/112), respectively. The co-infections of PEDV and PoRV were frequent (26/112, 23.21%), followed by the co-infections of PDCoV and PoRV (2/112, 1.79%). This study established a useful tool for simultaneous differentiation of PEDV, PoRV, and PDCoV in practice and provided valuable information on the prevalence of these diarrhea viral pathogens in Jiangsu province.

Determination of the affiliation of metastases in metachronous polyneoplasias of the breast and soft tissues of the thigh

A clinical case of primary multiple metachronous malignant breast tumors and a rare malignant schwannoma of the right hip is presented. Difficulties in differential diagnosis arose with the appearance of a metastatic process in the lungs, solving the issue of their source and further treatment. In oncological practice, only morphological examination can finally verify the diagnosis. The choice of treatment regimen depends on the affiliation of metastases to a particular tumor. At the first immunohistochemical examination, tumor foci in the lung were regarded as breast cancer metastases, which it allowed to conduct 4 courses of polychemotherapy according to the TS scheme (paclitaxel + cyclophosphane) with negative dynamics. This led to doubt about the correctness of determining the source of the metastatic process. Repeated immunohistochemical examination revealed that the metastatic lesion of the lung tissue was a consequence of the progression of malignant schwannoma of the right hip. Appropriate polychemotherapy was prescribed.