Focal Hemorrhage Research Articles

CK7+/CD117- low grade oncocytic tumor of the kidney: a clinicopathological analysis

Objective: To investigate the clinicopathological, immunohistochemical and molecular characteristics of low grade oncocytic tumors (LOT) of the kidney with CK7+/CD117- staining pattern for enhancing the understanding of renal LOT. Methods: The clinical data, histological morphology and immunophenotypes of seven renal LOT cases diagnosed at the Department of Pathology, the First Affiliated Hospital, Zhejiang University School of Medicine from January 2017 to April 2021 were analyzed. The patients were followed up. Among the seven patients, five underwent high-throughput DNA targeted sequencing, and their molecular characteristics were analyzed. Results: The patients' age ranged 59-82 years, with an average of 70 years. There were 2 males and 5 females. The boundary of the tumor was clear. The tumor cells had homogeneous eosinophilic cytoplasm and round or oval nuclei, with a perinuclear halo. Small basophilic nucleoli were conspicuous (WHO/International Society of Urological Pathology grade 2). In the hypercellular areas, the tumor cells were mainly arranged in dense solid or nest. In the stroma, there were dilated veins, thick-walled arterioles and thick collagen fiber bundles that divided the cells into pseudonodules. In the sparsely cellular area, the tumor cells were arranged in the so-called "tissue culture" fashion. In addition, the stroma contained fresh hemorrhagic foci and lymphoid aggregates. High-throughput sequencing of 5 cases revealed that one case harbored mTOR gene missense mutation and another case harbored TSC1 frameshift mutation. Conclusions: LOT of the kidney is an indolent tumor with an overall good prognosis. Pathologists should not misdiagnose it as renal oncocytoma and chromophobe renal cell carcinoma.

S3041 Hepatic Artery Dissection – A Case Report

Introduction: Visceral artery aneurysms are rare pathologies with reported incidence rates between 0.01% to 0.2%; even rarer are hepatic artery dissections (HAD). Most aneurysms rupture or are incidentally found on autopsy, but imaging advancements has enabled earlier identification of aneurysms; in this case, a HAD. Case Description/Methods: A 77-year-old female with medical history pertinent for sickle cell trait, acquired factor VIII inhibitor coagulopathy, history of type 2 thoracic aortic dissection, and hypertension presented to the emergency room with a week of mild fatigue, postprandial epigastric burning pain, and intermittent stabbing right upper quadrant pain. Right upper quadrant ultrasound demonstrated a hypervascularized right hepatic lobe mass with large tortuous internal vessels. CT abdomen & pelvis without contrast showed a large hypodensity in the right liver with curvilinear density. MRI demonstrated large arteriovenous malformation (AVM) within the right hepatic lobe and focal hepatic parenchymal hemorrhage centered within AVM nidus. Gastroenterology was consulted and CT angiogram findings were suspicious for common HAD, proper hepatic & intrahepatic pseudoaneurysms, and intrahepatic rupture. Interventional radiology was consulted. Hepatic angiogram showed a large defect in the proximal hepatic artery with brisk opacification, thought to represent a pseudoaneurysm. This prompted framing coil placement across the large defect and coils extending from the proper hepatic artery to the common hepatic artery with significant reduction in forward flow & pseudoaneurysm opacification. Per hepatobiliary & vascular surgery, no need for additional surgical intervention. Postoperative course was complicated by fever & leukocytosis, worsening kidney injury, and anemia; attributed to the procedure and resolved with supportive care. Patient discharged on postoperative day 8 with outpatient follow-up. (Figure) Discussion: This case highlights the importance of imaging for earlier detection of hepatic artery aneurysms (HAA) in minimizing risk of catastrophic hemorrhage. HAA are rare but clinically important given they are associated with high incidence of rupture and mortality up to 20%. Although surgery is preferred for extrahepatic findings, endovascular interventions are favored for intrahepatic findings depending on size and presence of pseudoaneurysms, such as this case. They have led to more favorable short & longer-term outcomes and lower mortality & morbidity rates, particularly in poor surgical candidates.Figure 1.: Hepatic angiography and embolization was performed. A large defect with brisk opacification of the proper and common hepatic arteries were seen (A), prompting deploy of a framing coil. (B) Embolization was then performed on the hepatic artery with three coils (5mm, 6mm, & 8mm). Coils were examined from proper hepatic artery to the common hepatic artery. (C) Following placement of the coils, significant reduction in flow and opacification of the pseudoaneurysm was seen.

S2294 Endoscopic Management of Esophageal Cancer in a Patient with Decompensated Cirrhosis: The Importance of Multidisciplinary Collaboration and Peri-Procedure Planning in Complex Clinical Scenarios

Introduction: Endoscopic therapy is effective for management of early esophageal cancer (EC), however serious complications such as bleeding and perforation can occur. Patient selection, optimization of co-morbidities and peri-procedure management help mitigate risk and improve patient outcomes. We present a patient with decompensated cirrhosis who required complex peri-procedure planning prior to endoscopic treatment of early EC. Case Description/Methods: A 71-year male with decompensated cirrhosis (portal hypertension, esophageal varices, ascites) and recent DVT on apixaban was found to have a 1cm raised focal lesion at the GEJ; biopsies revealed high-grade dysplasia (HGD). He was referred for endoscopic mucosal resection (EMR). After extensive discussion with hematology, patient was admitted for anticoagulation management with intravenous (IV) heparin. EGD confirmed an 8mm nodule at the GEJ (Figure 1A,B,C). Grade 3 non-bleeding esophageal varices were noted at the GEJ and in the distal esophagus, prohibiting safe EMR. Biopsies again showed HGD. After multidisciplinary tumor board discussion, a transjugular portosystemic shunt (TIPS) was performed to decompress the portal system and reduce bleeding risk from the planned EMR. Doppler ultrasound a few weeks later confirmed patent TIPS. Repeat diagnostic EGD showed decompression of varices. EUS revealed a mucosal lesion with no lymphadenopathy. Biopsy revealed intramucosal adenocarcinoma. Based on this evaluation and after detailed discussion with the patient, EMR was planned with appropriate anticoagulation management. En-bloc multiband mucosectomy was performed (Figure 1D,E). Intraprocedural bleeding was controlled with band ligation and hemostatic spray (Figure 1F). Patient remained inpatient for observation on octreotide and IV pantoprazole drip without further bleeding. Apixaban 2.5mg was resumed on day 3 and he was discharged home on acid suppression. Pathology confirmed well-differentiated adenocarcinoma, pT1a. Tumor board discussion recommended continued endotherapy (cryotherapy) to the residual dysplastic Barrett’s mucosa which he is tolerating well. Discussion: Endoscopic treatment is effective for the management of early EC. However, when complex scenarios present in an elderly frail patient, multidisciplinary collaborative management and stepwise risk-mitigation strategies need to be in place to minimize morbidity and maximize success (Table). Tumor board and shared decision making are key patient centric strategies that reflect best practice.Figure 1.: A: Nodular distal esophageal lesion; B: Lesion in high-definition white light endoscopy (HDWLE); C: Lesion in narrow band imaging (NBI), D: Band placed at the base of the lesion, E: EMR defect, F: Hemostatic spray was used to achieve hemostasis of an area of focal bleeding after EMR. Table 1. - Risk Mitigation Strategies in Complex Endoscopy Practice – Best Practice Principles Pre-procedure consultation (nonemergent diagnostic/elective procedures) Pre-procedure planning (labs, imaging) Optimization of treatment for co-morbidities Anesthesia consultation Detailed high-risk informed consent Shared decision making Multidisciplinary GI tumor board discussion Medical record documentation Guideline-based anti-thrombotic management Appropriate procedure back-up and support (IR, surgery, radiology, critical care)

PRESENTATION OF ACUTE CEREBROVASCULAR ACCIDENT IN A YOUNG ADULT WITH THROMBOTIC THROMBOCYTOPENIA PURPURA (TTP)

PRESENTATION OF ACUTE CEREBROVASCULAR ACCIDENT IN A YOUNG ADULT WITH THROMBOTIC THROMBOCYTOPENIA PURPURA (TTP)

Difference in characteristics and lesion reactivation between type 3 macular neovascularization with and without subretinal fluid at baseline.

To compare the characteristics and incidence rates of lesion reactivation after anti-vascular endothelial growth factor (VEGF) treatment in type 3 macular neovascularization (MNV) with and without subretinal fluid (SRF) at baseline. This retrospective study included 95 patients diagnosed with type 3 MNV. After the initial loading injections, re-treatment was performed when lesion reactivation occurred defined as the re-accumulation of subretinal or intraretinal fluid or the new development of a retinal/subretinal hemorrhage. The differences in the baseline characteristics and the incidence rates of lesion reactivation were compared between patients with SRF (SRF group, n = 42) and those without SRF (non-SRF group, n = 53). At diagnosis, the mean visual acuity was worse (0.68 ± 0.41 vs 0.50 ± 0.36; P = 0.032), mean central retinal thickness was greater (515.4 ± 145.9μm vs 383.8 ± 105.5μm; P < 0.001), and the incidence of focal retinal hemorrhages was higher (90.5% vs 66.0%; P = 0.005) in the SRF group than in the non-SRF group. In the SRF group, the first lesion reactivation was noted in 89.7% at a mean of 5.8 ± 4.4months after the third injection. In the non-SRF group, the first lesion reactivation was noted in 70.6% at a mean of 6.1 ± 3.8months. There was a significant difference in lesion reactivation between the two groups (P = 0.019). The difference in the baseline characteristics and incidence of lesion reactivation between type 3 MNV with and without SRF suggests that the presence of SRF may be indicative of more advanced disease with a high risk of visual deterioration. This result also suggests the need for more active treatment to preserve vision in patients with SRF.

Fourth Nerve Paresis plus Crossed Horner Syndrome in Acute Leukemia

A 29-year-old patient with diplopia showed a unilateral fourth nerve palsy combined with a Horner syndrome on the opposite side. Magnetic resonance images disclosed a focal hemorrhage in the left dorsal midbrain, affecting the nucleus of the fourth nerve and adjacent oculosympathetic fibers. Further evaluations including a bone marrow biopsy confirmed acute lymphoblastic leukemia. The combination of ocular motor and oculosympathetic palsy has a distinct localizing value. Fourth nerve palsy ipsilateral to Horner syndrome locates lesion in the cavernous sinus, while contralateral fourth nerve palsy locates the lesion in the midbrain.

The Uncancerous Helix-Benign Fibrous Histiocytoma

Benign fibrous histiocytoma occurs as an exceptional, painless, subcutaneous, mesenchymal, fibrohistiocytic neoplasm devoid of dermal incrimination. Additionally designated as deep dermatofibroma, deep seated benign fibrous histiocytoma commonly emerges within subcutaneous tissue, deep seated soft tissue or parenchymal organs. Generally, benign fibrous histiocytoma arises in adult males &gt; 25 years and appears between 6 years to 84 years with a median age of disease emergence at 40 years. A male predominance is observed. Commonly, benign fibrous histiocytoma emerges within lower or upper extremities, head and neck or trunk. Neoplasms confined to deep soft tissue of retroperitoneum, mediastinum or pelvis are infrequently discerned [1,2]. Deep seated benign fibrous histiocytoma emerges as a painless, gradually progressive, well circumscribed or encapsulated tumefaction [1,2]. Grossly, firm, yellow to tan, well circumscribed tumefaction encompassed with a pseudo-capsule is discerned. Pseudo-capsule may be absent where tumefaction extends to the cutis [1,2]. Characteristically, tumour magnitude is ~ 4 centimetres and varies from 0.5 centimetres to 25 centimetres. Cut surface exhibits variable foci of haemorrhage [1,2]. Upon microscopy, neoplasm exhibits a prominent storiform pattern configured of uniform, spindle-shaped cells imbued with eosinophilic cytoplasm with ill defined cellular perimeter and bland, elongated or plump nuclei with vesicular chromatin and delicate nucleoli. Tumour nuclei are devoid of nuclear atypia [1,2]. tumefaction is admixed with disseminated lymphocytes, plasma cells multinucleated giant cells, osteoclastic giant cells or foamy macrophages [1,2]. Frequently, prominent vascular articulations may configure a hemangiopericytoma-like pattern. Mitotic figures appear ≤5 mitosis per 10 high power fields [1,2]. Intervening stroma is myxoid or hyaline. Focal necrosis or tumour infiltration of lymphatic and vascular configurations is exceptional. Tumour perimeter is non-infiltrative and peripheral entrapment of adipose tissue is absent. Focal entrapment of collagen fibres may occur [1,2].

Predictors of local recurrence of renal cell cancer. Our experience

Risk factors for renal cell cancer (RCC) recurrence, including its local form, include stage and high Fuhrman grading system score, regional lymph node involvement, microvascular invasion, tumor necrosis, positive surgical margin, and sarcomatoid or rhabdoid tumor differentiation. Objective. The study analyzes data from Moscow Research Oncological Institute named by PA Herzen to determine the predictors of local recurrence of kidney cancer based on the data from surgically treated patients with local recurrent RCC. Material and methods. We analyzed retrospectively data from 87 patients who were divided into 2 groups: 1-st, patients with detected local recurrence of kidney cancer (n=43), and 2-nd, control group (n=44). The following predictors were evaluated: tumor size, tumor histotype, tumor stage, Fuhrman grading system, surgical margin status, tumor necrosis, sarcomatoid and rhabdoid changes, microvascular invasion, hemorrhage and invasion of collecting system components (CSS), renal capsule, and perirenal cellular tissue and primary treatment. Results. The risk of local recurrence was higher in the primary tumor, over 40 mm in diameter (OR=5.8, p&lt;0.001), as well as microvascular invasion and focal hemorrhage (OR=15.1, p=0.001 and OR=3.3, p=0.008, respectively). Both univariate and multivariate analyses showed a negative effect on the risk of local RCC recurrence only for tumor necrosis (OR=15.4, p&lt;0.001 and OR=53.6, p=0.002, respectively) and high Fuhrman grade (OR=10.9, p=0.042 and OR=5.7, p=0.032, respectively). The most significant predictors of local renal cancer recurrence are tumor necrosis (p&lt;0.001), microvascular invasion (p=0.019), positive surgical margin (p=0.009), and high Fuhrman grade (p=0.04). High Fuhrman grade (3–4) of malignancy (HR=1.9, p=0.042), tumor diameter (HR=1.0, p=0.054), positive surgical margin (HR=3.5, p=0.001), and tumor necrosis (HR=2.3, p=0.029) were found to be the most significant factors influencing 5-year local recurrence-free survival rate. Conclusion. The course of renal cell cancer is determined by multiple interrelated and independent prognostic factors.

An autopsy case of cerebral arterial thrombosis after vaccination with ChAdOx1 nCOV-19

We present a fatal case of cerebral arterial thrombosis after corona virus disease 19 (COVID-19) vaccination with ChAdOx1 nCOV-19. The deceased was a 63-year-old woman with no relevant medical history. She presented symptoms of nausea, fatigue, and headache immediately after vaccination. Ten days after vaccination, she suddenly started vomiting and developed high blood pressure. The patient eventually died 23 days after vaccination. Autopsy findings showed that the cerebral arteries and internal carotid arteries were fully enlarged and were compacted with thrombi. The brain stem showed ischemic necrosis, and extravasation from this necrotic lesion led to focal subarachnoid hemorrhage around the brain stem where large blood clots still remained. No aneurysms or atherosclerotic changes were found in these arteries. We note the following three facts. Firstly, all symptoms occurred immediately after vaccination; secondly, the main cause of death was consistent with known side effects of the vaccine; and lastly, the mechanism of thrombus formation in this case goes beyond the general category of thrombogenesis known so far. While the authors know that this case does not fall into known categories of vaccine side effects, we presenting this case to demonstrate that a comprehensive review of various possibilities related to vaccine side effects is needed to establish a COVID-19 defense system.

MPR-Specific Actions Influence Maintenance of the Blood-Brain Barrier (BBB).

Cerebral cavernous malformations (CCMs) are characterized by abnormally dilated intracranial microvascular sinusoids that result in increased susceptibility to hemorrhagic stroke. It has been demonstrated that three CCM proteins (CCM1, CCM2, and CCM3) form the CCM signaling complex (CSC) to mediate angiogenic signaling. Disruption of the CSC will result in hemorrhagic CCMs, a consequence of compromised blood–brain barrier (BBB) integrity. Due to their characteristically incomplete penetrance, the majority of CCM mutation carriers (presumed CCM patients) are largely asymptomatic, but when symptoms occur, the disease has typically reached a clinical stage of focal hemorrhage with irreversible brain damage. We recently reported that the CSC couples both classic (nuclear; nPRs) and nonclassic (membrane; mPRs) progesterone (PRG)-receptors-mediated signaling within the CSC-mPRs-PRG (CmP) signaling network in nPR(−) breast cancer cells. In this report, we demonstrate that depletion of any of the three CCM genes or treatment with mPR-specific PRG actions (PRG/mifepristone) results in the disruption of the CmP signaling network, leading to increased permeability in the nPR(−) endothelial cells (ECs) monolayer in vitro. Finally, utilizing our in vivo hemizygous Ccm mutant mice models, we demonstrate that depletion of any of the three CCM genes, in combination with mPR-specific PRG actions, is also capable of leading to defective homeostasis of PRG in vivo and subsequent BBB disruption, allowing us to identify a specific panel of etiological blood biomarkers associated with BBB disruption. To our knowledge, this is the first report detailing the etiology to predict the occurrence of a disrupted BBB, an indication of early hemorrhagic events.

Leptolysin, a Leptospira secreted metalloprotease of the pappalysin family with broad-spectrum activity.

Extracellular proteolytic enzymes are produced by a variety of pathogenic microorganisms, and contribute to host colonization by modulating virulence. Here, we present a first characterization of leptolysin, a Leptospira metalloprotease of the pappalysin family identified in a previous exoproteomic study. Comparative molecular analysis of leptolysin with two other pappalysins from prokaryotes, ulilysin and mirolysin, reveals similarities regarding calcium, zinc, and arginine -binding sites conservation within the catalytic domain, but also discloses peculiarities. Variations observed in the primary and tertiary structures may reflect differences in primary specificities. Purified recombinant leptolysin of L. interrogans was obtained as a ~50 kDa protein. The protease exhibited maximal activity at pH 8.0 and 37°C, and hydrolytic activity was observed in the presence of different salts with maximum efficiency in NaCl. Substrate specificity was assessed using a small number of FRET peptides, and showed a marked preference for arginine residues at the P1 position. L. interrogans leptolysin proteolytic activity on proteinaceous substrates such as proteoglycans and plasma fibronectin was also evaluated. All proteins tested were efficiently degraded over time, confirming the protease´s broad-spectrum activity in vitro. In addition, leptolysin induced morphological alterations on HK-2 cells, which may be partially attributed to extracellular matrix (ECM) degradation. Hemorrhagic foci were observed in the dorsal skin of mice intradermally injected with leptolysin, as a plausible consequence of ECM disarray and vascular endothelium glycocalyx damage. Assuming that leptospiral proteases play an important role in all stages of the infectious process, characterizing their functional properties, substrates and mechanisms of action is of great importance for therapeutic purposes.

INTRAOSSEOUS CHOLESTEROL GRANULOMA IN MAXILLA AND MANDIBLE—RARE CASE REPORT

Cholesterol granuloma is a rare lesion resulting from a granulomatous reaction containing cholesterol crystals. Such injury is often associated with sinus diseases, surgeries, and local trauma that can cause focal bleeding. This case refers to 2 lesions in the left maxilla and mandible in a 38-year-old female patient. The lesions were not related to sinus alterations; moreover, one was located in the mandible. Sagittal and axial tomographic sections showed a periapical hypodense area between teeth 24 and 25 and between teeth 34 and 35. Surgery was performed for total enucleation of both lesions. Histopathologic examination showed peripheral dense fibrous connective tissue and cracks compatible with regions of accumulation of cholesterol crystals in needle shapes, surrounded by macrophages and giant foreign-body cells. The case has 15 months of observation, with no recurrence and complete bone repair in the regions.

AN EXTENSIVE SIMPLE BONE CYST OF THE MANDIBLE: A CASE REPORT

Simple bone cyst (SBC) is a pathologic cavity of uncertain origin without lining epithelium commonly located in the mandibular marrow space. A 14-year-old White boy presented with an asymptomatic lesion in the right mandible that extended from the root of the canine to the first premolar. Radiographic examination revealed a radiolucent and unilocular lesion affecting the right mandible. Cone beam computed tomography showed slight expansion and thinning of the cortical margin with well-defined borders and scalloping contour among roots of involved teeth. No root resorption or tooth displacement was detected. After exploratory surgery, a nonpurulent fluid was aspirated, and curettage was performed. Microscopic examination revealed the presence of fibrous connective tissue, fibrinous exudate, and hemorrhagic foci neighboring fragments of dystrophic calcification. The final diagnosis of SBC was confirmed. The patient remains in follow-up without evidence of recurrence. Simple bone cyst (SBC) is a pathologic cavity of uncertain origin without lining epithelium commonly located in the mandibular marrow space. A 14-year-old White boy presented with an asymptomatic lesion in the right mandible that extended from the root of the canine to the first premolar. Radiographic examination revealed a radiolucent and unilocular lesion affecting the right mandible. Cone beam computed tomography showed slight expansion and thinning of the cortical margin with well-defined borders and scalloping contour among roots of involved teeth. No root resorption or tooth displacement was detected. After exploratory surgery, a nonpurulent fluid was aspirated, and curettage was performed. Microscopic examination revealed the presence of fibrous connective tissue, fibrinous exudate, and hemorrhagic foci neighboring fragments of dystrophic calcification. The final diagnosis of SBC was confirmed. The patient remains in follow-up without evidence of recurrence.

Comparative Effectiveness of Management by Surgical Resection vs Observation for Cerebral Cavernous Malformations: A Matched Propensity Score Analysis

BACKGROUND: Despite increasing incidental identification of cerebral cavernous malformations (CCMs), uncertainty remains about how to best manage CCM patients. OBJECTIVE: To compare the outcomes of patients with surgically resected vs observed CCMs after adjusting for indication bias through propensity score matching. METHODS: Single-center retrospective chart review was performed on individuals treated for CCMs between 1995 and 2016 at Washington University and Barnes-Jewish Hospital. Participants underwent surgical resection (n = 54) or were observed without surgery (n = 203). Propensity score matching was used to match observed to surgical cases on characteristics at first observation or initial surgery. Time to first focal neurological deficit and mortality postinitial visit or postsurgery was estimated using a Cox proportional hazards model with robust sandwich estimators. Differences in the presence of specific follow-up symptoms were estimated using exact logistic regression. RESULTS: After propensity score matching, 34 matched pairs were created. The median (IQR) follow-up duration was 1.5 (0, 5) years for surgical cases and 3 (0, 5) years for observed cases. After matching, no significant differences were found for time to first focal neurological deficit (P = .37, hazard ratio [HR]: 0.76, 95% CI: 0.41, 1.39) or mortality (P = .91, HR: 0.85, 95% CI: 0.06, 12.24). No significant differences were found between the groups for seizure (P = .15, odds ratio: 0.33, 95% CI: 0.06, 1.34) or hemorrhage (P = 1.00, odds ratio 1.00, 95% CI: 0.07, 13.80). CONCLUSION: In this propensity scored–matched analysis, there were no significant differences between surgical or observed cases in time to focal neurological deficit, mortality, recurrent hemorrhage, or seizure.

Reversible cerebral vasoconstriction syndrome: review of neuroimaging findings.

Reversible cerebral vasoconstriction syndrome (RCVS) is a group of disorders characterized by segmental narrowing and dilatation of medium-to-large cerebral arteries, clinically presenting with recurrent episodes of sudden-onset thunderclap headaches, with or without focal neurological deficits. Cerebral vasoconstriction is typically reversible, with spontaneous resolution within 3 months. Although the syndrome has generally a benign course, patients with neurological deficits may experience worse outcome. The main imaging finding is segmental constriction of intracranial arteries, which can be associated with subarachnoid hemorrhage and/or ischemic foci. Other possible findings are intracranial hemorrhage, subdural bleeding and cerebral edema. The latter may have a pattern which can resemble that of posterior reversible encephalopathy syndrome, a condition that can overlap with RCVS. New imaging techniques, such as vessel wall imaging and arterial spin labeling, are proving useful in RCVS and are giving new insights into the pathophysiology of this condition. In this paper, we aim to review neuroimaging findings of RCVS.

Multiple Surgical Treatments for Recurrent Retroperitoneal Hemorrhage in a COVID-19 Patient with Respiratory Failure on Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) may be required in patients with corona virus disease-19 (COVID-19) and respiratory failure. Anticoagulation is the standard treatment to prevent complications of ECMO and COVID-19 coagulopathy, however, there is a risk of bleeding. Some patients with retroperitoneal hemorrhage (RPH) have been treated with angiography-embolization. We report on a patient with COVID-19 on ECMO who underwent multiple operations (×5) for recurrent RPH. A 46-year-old man was admitted with COVID-19 pneumonia. ECMO with anticoagulation therapy was initiated. The patient developed RPH, caused by external compression of the inferior vena cava interrupting the ECMO inflow, and surgical hematoma evacuation was performed, with no obvious bleeding focus during the multiple surgeries. Following the patient’s recovery, a follow-up computed tomography scan showed the hematoma had been resolved, but there was a dilemma regarding anticoagulation. Lowering the threshold for surgical treatment, enabled treatment of a patient with serious RPH.

The Use of Non-targeted Lipidomics and Histopathology to Characterize the Neurotoxicity of Bifenthrin to Juvenile Rainbow Trout (Oncorhynchus mykiss).

Due to the detection frequencies and measured concentrations in surface water, the type I pyrethroid insecticide, bifenthrin, has been of particular concern within the Sacramento-San Joaquin Delta in California. Concentrations have been detected above levels previously reported to impair neuroendocrine function and induce neurotoxicity to several species of salmonids. Metabolomic and transcriptomic studies indicated impairment of cellular signaling within the brain of exposed animals and potential alteration of lipid metabolism. To better understand the potential impacts of bifenthrin on brain lipids, juvenile rainbow trout (Oncorhynchus mykiss) were exposed to mean bifenthrin concentrations of 28 or 48 ng/L for 14 days, and non-targeted lipidomic profiling in the brain was conducted. Brain tissue sections were also assessed for histopathological insult following bifenthrin treatment. Bifenthrin-exposed trout had a concentration-dependent decrease in the relative abundance of triglycerides (TGs) with levels of phosphatidylcholines (PCs) and phosphatidylethanolamines (PEs) significantly altered following 48 ng/L bifenthrin exposure. An increased incidence of histopathological lesions, such as focal hemorrhages and congestion of blood vessels, was noted in the brains of bifenthrin-treated animals, suggesting an association between altered lipid metabolism and neuronal cell structure and integrity.

Magnetic resonance imaging characteristics of polypoid endometriosis and review of the literature.

Polypoid endometriosis is a rare variant of endometriosis and may mimic malignancy. The purpose of this study is to evaluate magnetic resonance (MR) imaging characteristics of polypoid endometriosis for the differential diagnosis with malignancy. MR imaging findings of four histologically proven polypoid endometriosis were retrospectively evaluated with the review of the literature. All polypoid endometriosis exhibited high signal intensity on T2-weighted images reflecting abundant dilated endometrial glands. Peritoneal lesions were surrounded by low signal intensity rim represented the "black rim sign" reflecting endometriotic fibrous adhesion. Two cases arising from endometriotic cysts showed transmural extension (peritoneal extension and myometrial infiltration). Endometriotic hemorrhagic foci were demonstrated in four lesions as high signal intensity on T1-weighted images and/or susceptibility-induced signal voids on susceptibility-weighted MR sequence. Diffusion-weighted images showed high signal intensity with relatively high apparent diffusion coefficient (ADC) due to T2 shine-through effect but no diffusion restriction, and dynamic contrast-enhanced (DCE) MR imaging showed gradually increasing contrast-enhancement pattern like benign pathologies. Polypoid endometriosis may mimic malignancy; however, black rim sign may be a characteristic MR imaging finding for the peritoneal lesions, and no diffusion restriction and gradually increasing contrast-enhancement pattern may reflect its benign nature.

Demonstration of a new entity of non-perforated appendicitis through studying cluster of appendicitis

Differential diagnosis and management for perforated appendicitis and non-perforated appendicitis are current hot topics. The aim of this study is to demonstrate a new entity of non-perforated appendicitis, “acute hemorrhagic appendicitis” through studying cluster of acute appendicitis among Tibetan students at a high school in central China. Over the 11-year period, there were 120 patients with more female patients (102 of 499, 20.4%) than male patients (18 of 474, 3.8%) among 973 Tibetan students. 117 patients’ clinical data were available. Clinical manifestations were identical to classic appendicitis. However, axilla temperature, white blood cell counts and neutrophil level were elevated mildly in 12 (10.3%), 19 (16.2%) and 12 (10.3%) patients respectively. Pathologically, the resected appendices exhibited focal or diffuse hemorrhages in mucosa and/or submucosa, and infiltration by eosinophil and by lymphocytes. No patients had perforated appendicitis. The median time from the onset to surgery was 3 days (IQR, 2–4). All patients were discharged with full recovery. In conclusion, “acute hemorrhagic appendicitis” represented a new entity of non-perforated appendicitis with unique cause and pathogenesis, which might be treated with antibiotics alone or self-limited. Studying the cluster is a reliable method to find new entity of appendicitis.

Primary retroperitoneal perirenal CIC rearrangement sarcoma: A case report.

Primary retroperitoneal perirenal CIC rearrangement sarcoma is rare. The current case report presents a 69-year-old male patient with this pathology, including the clinical features, pathomorphology and immunohistochemistry, and CIC gene rupture detected by fluorescence in situ hybridization (FISH). Furthermore, the relevant literature was reviewed. Histologically, the tumor was composed of diffuse nests of small- to medium-sized juvenile round blue cells with hyperchromatic nuclei, prominent nucleoli and occasional mitotic signs. The tumor involved adipose tissue with no obvious hemorrhagic necrotic foci. Immunohistochemistry indicated scattered expression of CD99 in tumor cells. FISH examination suggested that the CIC gene was fragmented and translocated.